Associating Liver Partition and Portal Vein Ligation Techniques in Hepatic Surgery

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a two‐stage surgical strategy designed to overcome the limitation of future liver remnant (FLR) insufficiency in patients requiring extensive hepatic resection. In the first stage, portal vein branches to the diseased portion of the liver are ligated and the parenchyma is transected along an anatomical plane, prompting rapid ipsilateral atrophy and contralateral hypertrophy. Within one to two weeks, the FLR may increase by up to 80–100 per cent, enabling a safe second‐stage completion hepatectomy. By contrast, selective portal vein ligation (PVL) or portal vein embolisation (PVE) induces slower FLR hypertrophy over four to six weeks and may be insufficient in patients with underlying fibrosis or heavy tumour burden. ALPPS has broadened resectability criteria for colorectal liver metastases, perihilar cholangiocarcinoma and large hepatocellular carcinomas, yet it carries higher morbidity and demands careful patient selection. Technical refinements—including partial parenchymal division, minimally invasive approaches and radiofrequency‐assisted variants—seek to balance regenerative stimulus against operative stress. Collectively, these techniques have global significance for improving curative options in hepatobiliary oncology, challenging conventional limits on resection and stimulating research into molecular drivers of liver regeneration.

Research from Nature Portfolio

Preclinical modelling in a rodent ALPPS protocol has elucidated key regenerative pathways. In a reproducible rat model, combined portal vein ligation and in situ hepatic transection doubled regenerative rates compared with PVL alone, with marked up-regulation of mitogenic cytokines (interleukin-6, hepatocyte growth factor, tumour necrosis factor-α) and activation of NF-κB, STAT3 and Yap signalling. These findings underscore a synergistic effect of mechanical partition and vascular deprivation in driving hepatocyte proliferation.

Hypoxia signalling in non‐parenchymal cells has also emerged as critical. Stabilisation of hypoxia-inducible factors in hepatic stellate cells triggers VEGF-dependent angiogenesis, promoting sinusoidal endothelial cell proliferation and enhanced vascular density in the regenerating lobe. This crosstalk between stellate cells and endothelial compartments offers potential targets to augment liver remodelling and optimise timing of staged resections.

Associating Liver Partition and Portal Vein Ligation Techniques in Hepatic Surgery publication trend

The graph below shows the total number of articles in associating liver partition and portal vein ligation techniques in hepatic surgery across all publications each year (not limited to Nature Index journals).

Technical terms

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS): A two‐stage procedure combining portal vein ligation with in situ hepatic parenchymal transection to induce rapid hypertrophy of the future liver remnant.

Portal vein ligation (PVL): Surgical ligation of portal vein branches to redirect flow towards the FLR, promoting gradual compensatory hypertrophy.

Future liver remnant (FLR): The portion of liver that remains after resection, whose volume and function determine postoperative safety.

Portal vein embolisation (PVE): Radiological occlusion of portal branches to induce preoperative hypertrophy of the FLR over several weeks.

Hypertrophy: The increase in liver volume driven by hepatocyte proliferation and tissue remodelling in response to altered portal flow and parenchymal signalling.

References

1. Case Report: The application of associating liver partition and portal vein ligation for staged hepatectomy in patients with hepatitis b virus-related hepatocellular carcinoma after undergoing treatment with an immune checkpoint inhibitor: a report of two cases. Frontiers in Immunology (2023).
2. Minimally Invasive ALPPS Procedure: A Review of Feasibility and Short-Term Outcomes. Cancers (2023).
3. Rapid Induction of Liver Regeneration for Major Hepatectomy (REBIRTH): A Randomized Controlled Trial of Portal Vein Embolisation versus ALPPS Assisted with Radiofrequency. Cancers (2019).
4. A preliminary study of ALPPS procedure in a rat model. Scientific Reports (2015).
5. Hypoxia sensing by hepatic stellate cells leads to VEGF-dependent angiogenesis and may contribute to accelerated liver regeneration. Scientific Reports (2020).
6. Partial ALPPS versus complete ALPPS for staged hepatectomy. BMC Gastroenterology (2019).