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Ricardo Robles from Murcia, Spain, published a paper in the August issue of the British Journal of Surgery about a new modification of the ALPPS approach to induce rapid hypertrophy.

An umbilical tape is placed around the liver parenchyma along the umbilical fissure using an extraglissonian approach ot exclude portal vein, artery and bile duct to the left lobe. After ligation and transection of the right portal vein they observed an 60% increase in liver volume within one week (similar, but not exactly the same as the 80% observed in ALPPS). 

The advantage of this approach clearly is the short operating time for stage 1 due to the small amount of surgery performed and the abiltiy to cut through parechyma in stage two that has been made ischemic and is easy to transect during stage 2. The authors report 2 mortalities in 22 patients, however a standardized reporting system for complications is not used.

The new method, called "ALTPS" by the authors, might also give suggestion about the physiology of rapid hypertrophy: it seems to be enough to prevent cross-circulation to induce rapid hypertrophy.

Plaese click on the PubMed link below to access Ricardo's contribution:

Tourniquet modification of the associating liver partition and portal ligation for staged hepatectomy procedure.
Robles R, Parrilla P, López-Conesa A, Brusadin R, de la Peña J, Fuster M, García-López JA, Hernández E.
Br J Surg. 2014 Aug;101(9):1129-34. PubMed PMID: 24947768.

I am sure this will become an important modification of ALPPS: less surgery, less blood loss, shorter operating time by just performing a hanging maneuver and a "parenchymal ligation" in stage 1. 

Even more interesting is  the contribution to explain the physiology of rapid hypertrophy without resection: obliterating the cross-circulation suffices to induce rapid hypertrophy.  Like Dejong in his editorial in BJS states, it will could now be interesting to test different methods of rapid hypertrophy without resection against each other, as long as they are shown to be as safe as the gold standard PVE and PVL. Unfortunately that still remains somewhat unclear.




We often do laparoscopic staging in gallbladder cancers before proceeding to ALPPS, so conceivably performing the "parenchymal ligation" using the tourniquet can be done laparoscopically as in the hanging maneouvre for standard hemihepatectomy. We use the Goldfinger dissector to do this and this can be followed by laparoscopic portal vein ligation & transection.

Dear Prakash,

I think this is an excellent idea and one of the advantages of the ALTPS approach. I have to admit I have not performed ALTPS myself, but I thought about this and disucssed with with Ricardo Robles a few weeks ago in Madrid. it would be great if somebody would go ahead and demonstrate that this works. Please let us know if you do and publish it as a report. It would help the community to know that this is feasible



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