Complete tumor resection in the liver is the only chance to obtain long-term survival in patients with hepatic tumor or metastasis from other primary cancers. In patients with a large load of tumor within the liver, multiple strategies have been employed to improve resection, especially when a small liver remnant is expected. Staged hepatectomies, in which the surgeon perform partial resection in one side of the liver, and after four to six weeks proceed with the resection of the other side, and strategies to induce hypertrophy of the future liver remnant that include percutaneous portal vein embolization or intraoperative portal vein ligation, have also been largely employed by specialized liver surgery teams.
Hans Schlitt from Regensburg, Germany developed a new procedure, called liver bi-partition, for the first time by chance, in 2007. Planning to perform an extended right hepatectomy in a patient with hilar cholangiocarcinoma - being the future cholestatic liver remnant too small to sustain the patient postoperatively - he decided to perform intraoperatively only a selective hepatico-jejunostomy on the left biliary system, dividing the liver parenchyma along the falciform ligament, thereby completely devascularizing segment 4. Finally, the right portal vein was ligated to induce hypertrophy on segments 2 and 3. On the 8th postoperative day was performed a CT scan and observed a huge hypertrophy of the remnant liver. Recently, de Santibanes and Clavien2 proposed the acronym "ALPPS" for Associating Liver Partition and Portal vein Ligation for Staged hepatectomy. The ALPPS procedure has become an advance that represents an important tool to surgically induce fast liver hypertrophy.1 2 3
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