Improving the safety of associating liver partition and portal vein ligation for staged hepatectomy

Liver resection is the only potential curative treatment option in patients with colorectal liver metastases (CRLM). Between 15–25% of the patients are primarily resectable, whereas in the majority of patients, the extent of and biological behavior of the disease, anatomical proximity to vital hepatic structures and insufficient future liver remnant (FLR) precludes resection. Modern chemotherapy has provided vast improvement by providing downsizing of tumors and various methods like portal vein embolization (PVE) and two stage hepatectomy have been established as standard practice in order to increase the number of patients that can be offered resection (1,2). Association liver partitioning and portal vein ligation for staged hepatectomy was first reported in a small case series from Germany in 2010, and was more formally published and described in 2012 as a novel technique to induce rapid volume growth of FLR (3). The method has, however, been regarded as controversial and evoked debates due to high procedure related morbidity and mortality rates, that does not seem to be merely related to lack of experience, since it has also been reported from experienced referral HPB centers (4,5). The mortality risk associated with associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) by far exceeds the standards commonly associated with liver resection for metastatic disease. Cause of perioperative death has in particular been attributed to liver failure and infectious complications.