title: ALPPS: challenging the concept of unresectability--a systematic review.
abstract: BACKGROUND
  Hepatic resection for malignancy is limited by the amount of liver parenchyma left behind. As a result, two-staged hepatectomy and portal vein occlusion (PVO) have become part of the treatment algorithm. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been recently described as a method to stimulate rapid and profound hypertrophy.
  
  
  METHODS
  A systematic review of the literature pertaining to ALPPS was undertaken. Peer-reviewed articles relating to portal vein ligation (PVL) and in situ split (ISS) of the parenchyma were included.
  
  
  RESULTS
  To date, ALPPS has been employed for a variety of primary and metastatic liver tumors. In early case series, the perioperative morbidity and mortality was unacceptably high. However with careful patient selection and improved technique, many centers have reported a 0% 90-day mortality. The benefits of ALPPS include hypertrophy of 61-93% over a median 9-14 days, 95-100% completion of the second stage, and high likelihood of R0 resection (86-100%).
  
  
  CONCLUSIONS
  ALPPS is only indicated when a two-stage hepatectomy is necessary and the future liver remnant (FLR) is deemed inadequate (<30%). Use in patients with poor functional status, or advanced age (>70 years) is cautioned. Discretion should be used when considering this in patients with pathology other than colorectal liver metastases (CRLM), especially hilar tumors requiring biliary reconstruction. Biliary ligation during the first stage and routine lymphadenectomy of the hepatoduodenal ligament should be avoided.
  
  
  CONCLUSIONS
  A consensus on the indications and contraindications for ALPPS and a standardized operative protocol are needed.
authors.affiliation: Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, 339 Windermere Road, London, ON, Canada N6A 5A5.
authors.forename: Kimberly A
authors.initials: KA
authors.lastname: Bertens
authors.affiliation: Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, 339 Windermere Road, London, ON, Canada N6A 5A5.
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Hawel
authors.affiliation: Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, 339 Windermere Road, London, ON, Canada N6A 5A5.
authors.forename: Kalvin
authors.initials: K
authors.lastname: Lung
authors.affiliation: Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, 339 Windermere Road, London, ON, Canada N6A 5A5.
authors.forename: Suzana
authors.initials: S
authors.lastname: Buac
authors.affiliation: Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, 339 Windermere Road, London, ON, Canada N6A 5A5; Multi-Organ Transplant Program, London Health Sciences Centre, 339 Windermere Road, London, ON, Canada N6A 5A5.
authors.forename: Karen
authors.initials: K
authors.lastname: Pineda-Solis
authors.affiliation: Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, 339 Windermere Road, London, ON, Canada N6A 5A5; Multi-Organ Transplant Program, London Health Sciences Centre, 339 Windermere Road, London, ON, Canada N6A 5A5. Electronic address: roberto.hernandezalejandro@lhsc.on.ca.
authors.forename: Roberto
authors.initials: R
authors.lastname: Hernandez-Alejandro
mesh_terms: D006498:Hepatectomy / Q000379:methods*; D006801:Humans; D006984:Hypertrophy; D008026:Ligation / Q000379:methods; D008099:Liver / Q000473:pathology; D008113:Liver Neoplasms / Q000601:surgery*; D008115:Liver Regeneration / Q000502:physiology; D018579:Patient Selection; D011169:Portal Vein / Q000601:surgery; D014656:Vascular Surgical Procedures / Q000379:methods
keywords: ALPPS; Hepatectomy; In situ split; Portal vein occlusion; Two-stage hepatectomy