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Chapter • ALPPS (Associating Liver Partition with Portal Vein Ligation for Staged Hepatectomy)
Procedure: ALPPS Stage 1
Step1
Intraoperative ultrasound and planning
A bilateral subcostal incision is performed and the round and falciform ligaments are transected
as described in previous chapters. Tumor extension, number, and relation to intrahepatic vascular structures are established by intraoperative ultrasound. Lesions that will have to be removed from the FLR with nonanatomical resections are marked by electrocautery on the liver
surface (
(
. Fig. 52.3a). e line of transection is marked, with careful attention to a safe margin
. Fig. 52.3b).
. Fig.52.3
Section III • Liver: Nontransplant Procedures
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Step2
Portal vein ligation
For right portal vein ligation, the infundibulum of the gallbladder is followed to the cystic duct and
cystic artery. Both are ligated and the right hepatic artery and common hepatic duct are identied
as described in ▶
with a lid hook to dissect the portal bifurcation. e right portal vein is dissected free and ligated
proximally and distally (
Chap. 46
. Fig. 52.4).
, “Right Hemihepatectomy.” e hepatic artery is retracted carefully
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. Fig.52.4
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Chapter • ALPPS (Associating Liver Partition with Portal Vein Ligation for Staged Hepatectomy)
Step3
Preparation of the hepatic veins
If the right and middle hepatic veins are isolated together to preserve middle hepatic vein outow
for the FLR, the right lobe of the liver is mobilized from the diaphragm and segment1 is taken o
the vena cava as described in ▶ Chap. 46 “Right Hemihepatectomy”. e space between middle
and right hepatic veins is dissected from below with a right angle dissector. e tip of the right
angle is found between the caudate lobe and vena cava and an umbilical tape is pulled through to
establish the superior part of the hanging maneuver, if a hanging maneuver is used. e umbilical tape is then pulled down to the hilar structures (
to be excluded from the FLR, the space between middle and le hepatic vein may be isolated for
the hanging maneuver.
Anterior approach to ALPPS. Anterior approach with or without the additional hanging maneuver may be used as well. Mobilization of the right lobe and dissection of the triangular ligament
are not necessary when the anterior approach is used.
. Fig. 52.5). If the middle hepatic vein needs
Step4
. Fig.52.5
Transection of the hepatic parenchyma
e transection line previously marked with the help of ultrasound is incised with electrocautery,
and the parenchyma is transected using one of the techniques described in ▶ Chap. 44, “ Techniques of Liver Parenchyma Dissection.” In Zurich, we use clamp crush technique. e Pringle maneuver for intermittent or continuous inow occlusion is performed, as described in ▶ Chap. 41.
Once the umbilical tape is encountered at the end of the parenchymal transection, the split of the
liver in situ is complete (
In the early days of ALPPS many groups used to suture a plastic cover is sutured to the FLR
(.
Fig. 52.6b
and the abdomen is closed.
). Now we use absorbable hemostatic patches or eece instead. Drains may be placed,
. Fig. 52.6a).
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Section III • Liver: Nontransplant Procedures
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. Fig.52.6
Chapter • ALPPS (Associating Liver Partition with Portal Vein Ligation for Staged Hepatectomy)
Procedure: ALPPS Stage 2: Hepatectomy of the Deportalized Lobe
Native MRI or CT is performed for volumetry rst on day6 and then weekly until the volume is
sucient to go to stage2. Once the FLR volume exceeds 30 %, the deportalized lobe may be removed. e previous subcostal incision is reopened and retractors are placed. e artery and bile
duct of the deportalized lobe are found and suture ligated (
then transsected using the laparoscopic endovascular stapler (
been mobilized and the small liver veins of the right lobe have been ligated during stage1, the
liver may now be removed
If the anterior approach is being used, transsection of the short hepatic veins by ligatures and
clips, suture ligatures and of the respective hepatic veins by placement of clamps and oversewing
is performed through the parenchymal split of the liver. e triangular ligament on the right side
is then taken down and the deportalized lobe is removed and the abdomen closed. We do not use
drains aer the second step of ALPPS.
. Fig. 52.7a). e right hepatic vein is
. Fig. 52.7b). If the right lobe has
. Fig.52.7
Section III • Liver: Nontransplant Procedures
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Tricks of the Senior Surgeon:
ALPPS is a powerful surgical tool to induce hypertrophy and has the highest feasibility
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among Two-Stage Hepatectomies because of its profound and robust eect on liver hypertrophy but also has a high morbidity and mortality when used non-selectively
Consider alternative techniques like partial transection (vs. complete transection) or delayed
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portal vein embolization (vs. portal vein ligation) or tourniquet ALPPS in patients with contraindications to classic ALPPS
Familiarize yourself with the split techniques in liver transplantation before embarking on
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ALPPS resections
Delay the second stage when bilirubin and INR are not normal and perform the second stage
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only if the MELD score is less than 10
Perform liver function testing like ICG, HIDA or other test and do not perform stage two until
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liver function has normalized after stage 1.
Do not feel compelled to perform stage 2 resections if there are any doubts about volume or
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function of the liver remnant.
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Ablation Therapy of Liver Tumors
Michael A. Choti, MichelleL. de Oliveira
Thermal Ablation
Indications and Contraindications
Indications
Contraindications
Unresectable malignant tumors of the liver (e. g., hepatocellular carcinoma, colorectal me-
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tastases, neuroendocrine tumors, selected other types of metastases)
Tumors < 5 cm in size (most eective for lesions < 3 cm)
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Palliative treatment of symptomatic tumors (e. g., neuroendocrine metastases)
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Bridge to liver transplantation (hepatocellular carcinoma)
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z Open approach
In combination with resection
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When resection is planned, but unresectability is found at time of laparotomy
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In dicult locations or in selected cases when multiple ablations are required
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z Laparoscopic approach
Patient fullls basic requirements to undergo surgery
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Lesion(s) amenable to laparoscopic approach
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z Percutaneous approach (not discussed in this atlas)
Extrahepatic disease (unless extrahepatic sites are resectable or when there is palliative
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indication for symptoms)
Perihilar tumor localization
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Signicant coagulopathy or thrombocytopenia
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Ascites
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Previous bilio-enteric anastomosis such as pancreaticoduodenectomy (relative contraindi-
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cation because of increased risk of hepatic abscess following ablation)
Preoperative Investigation and Preparation for the Procedure
CT or MRI: Assessment to rule out resectability and determine if lesions are candidates for ablation
Consider PET/CT: Evaluation for presence of extrahepatic disease (e. g., colorectal metastases)
In operating room:
Place grounding pads if needed (for radiofrequency ablation)
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Prepare the patient for surgery as usual
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Helpful to have the cross-sectional imaging of the lesion(s) viewable in the operating room
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during the procedure
Guidance Imaging Modality
Imaging is used for lesion localization, probe guidance, and ablation monitoring. e following
features of each imaging modality must be considered:
P.-A. Clavien, M. G. Sarr, Y. Fong, M. Miyazaki (Eds.), Atlas of Upper Gastrointestinal and Hepato-Pancreato-Biliary Surger y,
DOI 10.1007/978-3-662-46546-2_53, © Springer-Verlag Berlin Heidelberg 2016
Section III • Liver: Nontransplant Procedures
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z Ultrasound
Method most commonly used, regardless of approach
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Intraoperative US (IOUS) typically utilizes a low/mid frequency range probe (4–8 MHz)
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Real-time feedback
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Sometimes dicult to visualize lesion adequately
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Increased echogenicity from microbubbles during thermal ablation
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Microbubbles are not a true representation of zone of coagulation necrosis
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Altered echogenicity may obscure further needle positioning
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z Alternatives: CT or MRI (percutaneous approach)
Transaxial needle track required
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CT uoroscopy is a useful adjunct
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For MRI, a compatible ablation needle is required
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Ablation Methods
Radiofrequency ablation
Radiofrequency ablation (RFA) is currently the most commonly used method of ablation. It uses
alternating current to induce active tissue heating around a probe, resulting in coagulative necrosis.
A number of dierent probes are commercially available for performing RFA (. Fig. 53.1a–d).
Probes are typically 14 to 17.5gauge, 15 to 25 cm long, insulated cannulas straight needle electrodes or deployable multi-tine probes. Some probes have a closed cooled-tip system (Covidien;
Manseld, MA) or local saline infusion (Angiodynamics).
Problems with RFA include susceptibility to heat sink in proximity to major vasculature. A
single application of RFA is less eective for tumors larger than 3 cm.
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. Fig.53.1
Microwave ablation
Microwave ablation (MWA) is the most recent thermal ablation development with increasing
favorable preference. It uses microwave energy to induce active tissue heating around a microwave
antenna, resulting in coagulative necrosis. Advantages of MWA include more rapid ablation times
and no need for grounding pads. In addition, MWA relies less on conductive heating for tumor
ablation, which theoretically results in more predictable burns with less heat sink eect.
ere are two distinct MWA systems: 915 MHz and 2.45 GHz. e rst employs between one
to three 13-guage antennae with multi-antenna conguration, but with independent connection
to the generator. e 2.45 GHz system uses a single-antenna connected to a generator capable of
delivering 100watts of power. Both systems can be used in open, laparoscopic, and percutaneous
approaches. Although both MWA systems provide equivalent tumor ablation, the 2.45 GHz seems
to achieve a faster and more predictable ablation zone through a single antenna.
MWA antennas usually consist of a single-needle electrode with the active microwave-emitting
part at the tip (Acculis-Angiodynamics, Evident/Emprint-Covidien). e MWA presents a nonconductive stainless steel sha, a 16 mm ceramic tip and a feed point which is the center of ablation
area. is feed point is visible under IOUS/CT guidance as a dark band. e MWA 2.45 GHz system oers ablation volume estimation based on power (30–100 W) and time settings (up to 8min).
Chapter • Ablation Therapy of Liver Tumors
guidance until the feed point is central located in the tumor. e MWA generator is set up according to the coagulation size. e extent of the ablation is visualized as hypoechoic area with acoustic
shadow. For large lesions, the overlapping ablation area is used to provide adequate margin.
Other ablation methods
Ethanol injection: Technique using ethanol instead of heat to ablate tumors as hepatocellular
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Cryoablation: Induces necrosis by freezing and thawing tissue around probe. e most
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Irreversible electroporation: Induces cell apoptosis by irreversibly increasing the permeability
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Procedures
Open technique
Step1
Access and assessment of tumors
Incision, evaluation, palpation, and mobilization of the liver are performed as for a liver resection.
e abdomen is explored for the presence of extrahepatic disease, and the evaluation is completed
by IOUS to identify/conrm the location and the size of the lesions (. Fig. 53.2a). e feasibility
of the ablation is determined and the number of needed ablations is calculated.
Once the tumor is identied (see ▶ Step1–Procedures), the probe is inserted under image
More details about minimal invasive approach are provided below in
carcinoma (2–3 cm). Less eective than thermal ablation such as RFA and MWA.
common complications are myoglobinuria and myoglobinuria, acute tubular necrosis and
pleural eusions. Cryoshock phenomenon occurs in 1 % of the cases with 18 % mortality.
erefore, cryoablation should not exceed 30 % volume of cryo-tissue destruction.
of the cell membrane. As this method does not rely on thermal tissue destruction, it is less
susceptible to variable ablation volumes due to heat sink eects.
. Fig. 53.4.
Step2
Placement of the probe and ablation of tumors
e probe is aligned so that its trajectory lies in the plane of the ultrasound image and does not
intersect vital structures such as blood vessels and bile ducts. It is advanced under IOUS guidance
until the tip is either close to the proximal edge of the tumor or near the distal edge, depending on
the probe type (. Fig. 53.2b). e (deployed) probe is visualized in perpendicular view to conrm
adequate tip position and deployment (. Fig. 53.2a). e probe tines are deployed and thermal
energy is applied according to the manufacturer’s directions (
. Fig. 53.2c,d).
. Fig.53.2
Section III • Liver: Nontransplant Procedures
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Step3
Ablation of large or irregularly shaped lesions and tract ablation
For large or irregularly shaped lesions, multiple ablations may be needed (Step2 is repeated as
necessary). A pattern of overlapping spheres or cylinders is used to cover the lesion while maintaining adequate margins.
With some devices, tract ablation is performed to cauterize the tract and to minimize seeding.
e probe is withdrawn 1 cm at a time in tract ablation mode on the radiofrequency generator,
allowing the temperature to reach > 70 °C at each step. is process is continued until the probe
is completely removed (
. Fig. 53.3).
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. Fig.53.3
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