Modified ALPPS procedures avoiding division of portal pedicles

Objective: We describe a modified procedure associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) including portal pedicle preservation during parenchymal division, thus avoiding necrosis. Background: Although ALPPS recently has been advocated for treating advanced liver tumors, sepsis originating from the ischemic area produced by parenchymal division increases mortality, accounting for one-third of postoperative deaths. Methods: Our procedure differs from the original ALPPS technique by sparing portal pedicles at the transection plane, thus maintaining blood supply. The preserved pedicles are segment 4 (S4) in right lobectomy plus right portal vein ligation (PVL), S1 in extended right hepatectomy (extended to S1) plus right PVL, lateral portal pedicles of the right paramedian sector (RPS) in extended right lateral sectoriectomy plus lateral PVL, and both portal pedicles of the lateral RPS and S1 in extended right lateral sectoriectomy with S1 resection plus lateral PVL. Results: These procedures were performed in 5 patients. Morbidity rates at first- and second-stage operations were 0% and 80%, without mortality. Mean hypertrophy of the future liver remnant was 1.638 ± 0.384 a week after the first-stage procedure. Conclusions: Our technique stimulates rapid hypertrophy and may improve safety in ALPPS.