title: Inverting the ALPPS paradigm by minimizing first stage impact: the Mini-ALPPS technique.
abstract: OBJECTIVE
  The current associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) approach is represented by an aggressive first surgical procedure followed by a shorter and less aggressive second procedure. This paradigm has been associated with high morbidity and mortality. Inverting the aggressiveness of the surgical stages might be beneficial in order to facilitate patient recovery during interval period. We propose a new technical paradigm for the ALPPS approach.
  
  
  METHODS
  During the first stage, partial parenchymal transection combined with intraoperative portal vein embolization (PVE) was performed. Liver mobilization was kept at minimum while hilar plate or hilum dissection was strictly avoided. The completion surgery by means of the anterior approach was carried out once sufficient future liver remnant (FLR) hypertrophy and function were certified.
  
  
  RESULTS
  We applied this technique in four patients (hepatocellular carcinoma in a cirrhotic liver = 1 and colorectal liver metastases = 3). The mean FLR hypertrophy was 62.6 % (range 49-79). All the four patients underwent the completion surgery with R0 margins, and neither one developed liver failure nor major complications.
  
  
  CONCLUSIONS
  The technique proposed inverts the current ALPPS strategy, minimizing the first stage impact to promote rapid patient recovery and leaving the main surgical procedure for the second stage. The combination of evidence-based facts such as partial parenchymal transection, intraoperative PVE, and "non-touch" oncological rules was feasible and safe, allowing complete tumor resection in highly selected candidates with extensive liver disease.
authors.affiliation: Hepato-Pancreato-Biliary and Liver Transplant Sections, General Surgery Service, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1181ACH, Buenos Aires, Argentina. eduardo.desantibanes@hospitalitaliano.org.ar.|, Esmeralda 1319, 4to piso, 4to cuerpo CP 1007, Buenos Aires, Argentina. eduardo.desantibanes@hospitalitaliano.org.ar.
authors.forename: Eduardo
authors.initials: E
authors.lastname: de Santibañes
authors.affiliation: Hepato-Pancreato-Biliary and Liver Transplant Sections, General Surgery Service, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1181ACH, Buenos Aires, Argentina.
authors.forename: Fernando A
authors.initials: FA
authors.lastname: Alvarez
authors.affiliation: Hepato-Pancreato-Biliary and Liver Transplant Sections, General Surgery Service, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1181ACH, Buenos Aires, Argentina.
authors.forename: Victoria
authors.initials: V
authors.lastname: Ardiles
authors.affiliation: Hepato-Pancreato-Biliary and Liver Transplant Sections, General Surgery Service, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1181ACH, Buenos Aires, Argentina.
authors.forename: Juan
authors.initials: J
authors.lastname: Pekolj
authors.affiliation: Hepato-Pancreato-Biliary and Liver Transplant Sections, General Surgery Service, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1181ACH, Buenos Aires, Argentina.
authors.forename: Martin
authors.initials: M
authors.lastname: de Santibañes
mesh_terms: D000328:Adult; D000368:Aged; D006528:Carcinoma, Hepatocellular / Q000473:pathology / Q000601:surgery*; D015179:Colorectal Neoplasms / Q000473:pathology; D005260:Female; D006498:Hepatectomy / Q000379:methods; D006801:Humans; D008113:Liver Neoplasms / Q000473:pathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D011169:Portal Vein / Q000601:surgery*
keywords: ALPPS; Hepatectomy/methods; Liver/neoplasm