ALPPS: A New Surgical Technique for Metastatic Liver Cancer

January 1, 2015

Separation of liver into left lateral segment and right lobe. The right portal vein is ligated and left segment has hypertrophied,

Novel approach may lead to increased survival rates
 Innovations in Digestive Health - Winter 2015 - View Full PDF 

Christopher Siegel, MD, PhD

Division Chief, Hepatobiliary and Transplant Surgery, UH Case Medical Center; Surgical Director, Liver Center, UH Digestive Health Institute; and Associate Professor of Surgery, Case Western Reserve University School of Medicine

Surgeons at University Hospitals Case Medical Center and University Hospitals Seidman Cancer Center are pioneering a new approach to treating metastatic cancer in the liver, having performed one of only four cases done in the United States to date. With the new technique, tumors previously considered unresectable using conventional staged hepatectomy may now be resectable.

The procedure - known as Associating Liver Partition with Portal Vein Ligation for Staged Hepatectomy, or ALPPS - was first reported in 2011 and described at length the next year in the March 2012 issue of Annals of Surgery. It opens doors to patients who may have had too little healthy liver tissue to undergo surgery by taking advantage of the organ's ability to regenerate, says Christopher Siegel, MD, PhD, Division Chief of Hepatobiliary and Transplant Surgery at UH Case Medical Center.

"Even though it's one organ, the liver has separate segments. Each of those eight segments can function independently and has its own blood flow. You're not limited by the anatomy of the liver but by the size of what you leave behind," Dr. Siegel explains, noting that much research has gone into understanding the minimum amount of liver tissue needed. "Because the liver can grow and regenerate - a process driven by portal flow and pressures - if we take a liver and ligate or tie off a branch of the portal vein, that part of the liver once served by the vein will get smaller and the rest of the liver hypertrophies."

A PROMISING NEW TOOL

The ALPPS procedure occurs in two stages. In the first, surgeons "isolate the segment they want to remove by dividing the liver and ligating the portal vein to those segments, but they leave the artery and the bile duct intact, so that the hepatic cells on that side survive and function," Dr. Siegel says. "Patients have larger liver volume, while ensuring the remnant meant to stay behind has increased portal flow and will grow." The collaterals inside the liver tissue are shifted away from the part of the liver to be removed, he says, and the diseased portion of the liver remains in place temporarily. It is also possible in some cases to remove tumors in the remaining segment during the same ALPPS procedure.

Then, patients recover over the course of 10 to 14 days, during which the liver tissue to be kept has time to grow. "You reach a critical mass of liver tissue so that you can remove the side you want to remove," Dr. Siegel notes.

Proper patient selection for ALPPS is crucial, Dr. Siegel stresses, noting that decisions are made on an individual basis after considering the size of the liver and locations of tumors, among other factors, ALPPS appears to be most appropriate for patients with metastatic colon cancer, It may also be suitable for those with bile duct, gall bladder, liver cell or neuroendocrine cancers.

Contraindications to ALPPS include cirrhosis of the liver or scar tissue, It is also possible that liver growth after the first step of ALPPS may be insufficient, making the second step of the procedure impossible, Another issue considered is whether the patient is resilient enough to undergo two surgeries within a relatively short timespan.

More common in Europe than in the United States, ALPPS "is a fairly new procedure and still controversial because of the risk of complications and difficulty to perform," Dr, Siegel notes, Possible consequences include prolonged cholestasis and death, However, recent reports, such as a 14-patient series published in the journal Surgery in October 2014, demonstrate that the procedure is evolving,

Even with the challenges, ALPPS is a welcome addition, Dr, Siegel says, "Every patient we see, we look at everything we can offer to treat their cancer, This is one more tool we have,"

Results for the new technique are being tracked in the international ALPPS registry, which has enrolled more than 200 patients thus far, According to Dr, Siegel, UH Case Medical Center is gearing up to take part in an ongoing randomized controlled trial of ALPPS versus classic two-stage hepatectomy. That trial was initiated in 2012, More information on the two studies is available online at www.ALPPS.net.

Separation of liver into left lateral segment and right lobe. The right portal vein is ligated and left segment has hypertrophied.

MOVING BEYOND CONVENTIONAL METHODS

Before ALPPS was developed, the best option for patients with metastatic liver cancer was classic two- stage hepatectomy with portal vein embolization, Dr, Siegel says. Radiologists would insert coils into the veins of the liver segment needing removal, thereby causing clots to form and block portal flow. "One of the problems with this approach is that there can be collaterals in the liver that will keep branches of the portal vein open, even with the coils, and thus prevent complete clotting of that side," he notes.

Research shows that, compared with earlier methods, the desired portion of the liver grows larger and more quickly using ALPPS.

Studies also suggest that ALPPS and other recent developments lead to better patient outcomes. According to Dr, Siegel, five-year survival rates for patients with stage IV colon cancer and liver metastases had previously hovered at 15 to 20 percent. Now, with the combination of advanced surgical techniques such as ALPPS and newer chemotherapy drugs, he says, some patients can potentially be cured.

CONTACT OUR EXPERTS. To learn more about options for patients with liver tumors, contact Dr. Siegel at 216-844-0489.

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