Staged Liver Resection for Perihilar Liver Tumors Using a Tourniquet in the Umbilical Fissure and Sequential Portal Vein Embolization on the Fourth Postoperative Day (a Modified ALTPS)

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) achieves the hypertrophy of the future liver remnant in seven days. We achieved the same hypertrophy placing a tourniquet in the parenchimal transection line associating a right portal vein ligation (associating liver tourniquet and right portal vein ligation for staged hepatectomy-ALTPS). In perihiliar tumors a “non touch” technique should be performed. ALPPS and ALTPS do not comply with this technical aspect because a dissection of the hilum is carried out in both procedures during the portal dissection. To avoid this problem we devised a new method called sequential ALTPS. It consists of placing a tourniquet in the umbilical fissure without ligation of the right portal vein during the first stage. Subsequently, on the 4th postoperative day we performed a percutaneous right portal vein embolization. We present the first case of this new technique in which we have obtained a hypertrophy of 77% of the future liver remnant seven days after portal vein embolization. In the second stage a right trisectionectomy was performed with inferior vena cava resection with a goretex graft replacement.

ResumenAssociating liver partition and portal vein ligation for staged hepatectomy (ALPPS) consigue la hipertrofia en 7 días del futuro remanente hepático. Nosotros conseguimos la misma hipertrofia colocando un torniquete en la línea de sección parenquimatosa con ligadura portal derecha (associating liver tourniquet and right portal vein occlusion for staging). En tumores perihiliares se debe realizar la técnica «non-touch», que las técnicas ALPPS Y ALTPS no cumplen al manipular el hilio hepático en la disección portal. Por ello, diseñamos este nuevo método que consiste en realizar la técnica ALTPS de forma secuencial, realizando en el primer tiempo la colocación del torniquete en la cisura umbilical sin ligadura portal derecha, y al 4° día postoperatorio la embolización portal derecha. En este caso el incremento del futuro remanente hepático fue del 77% al 7° día tras la embolización portal percutánea. En el segundo tiempo se realizó triseccionectomía derecha con resección de la vena cava inferior siendo sustituida por un injerto de goretex anillado de 2 cm de diámetro.