Staged resection for small liver remnants (PVE vs. ALPPS)
Liver has a remarkable ability to regenerate to meet the metabolic needs of the human body. The growth factors needed for regeneration travel to the liver via the portal vein. If the portal flow is reduced or stopped the liver will atrophy. This knowledge has been used successfully in the treatment of patients who require an extensive liver resection but would not have enough remaining liver to survive. The threat of liver failure is real. Two options are available for to increase the safety:
1. portal vein embolization/ligation
2. ALPPS procedure.
Both procedures have pros and cons.
Portal vein ligation can be done in the operating room at the same time as removing tumors from the future liver remnant. If the future liver remnant is free of tumors but is just too small, then portal vein ligation can be performed percutaneously in interventional radiology. The liver remnant will grow approximately 1-2%/week. The liver is volume is reassessed 8 weeks later. If the liver fails to grow >5%, then the liver is not healthy and a resection should not be attempted. approximately 1 in 3 patients fail to have adequate regeneneration to allow a safe resection. The FLRV considered safe in healthy liver is 20%, diseased livers 30% and cirrhosis 40%.
Given the high failure rate for portal vein embolization/ligation and the length of time need to see an adequate regeneration and more effective surgical technique was developed: The ALPPS procedure. The liver partition is added to the portal vein ligation to allow rapid regeneration in 1-2 weeks. The liver may double in size over this time frame. Unlike portal vein emboliztion, almost all the patients get to the second stage. Since there is a very short waiting time between the two surgical stages, the tumor does not progress but the patient will be in the hospital 3-4 weeks. If the first stage can be done minimally invasively, then patient may be discharged and readmitted for the second stage.
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