BRIEF CLINICAL REPORT

A New Surgical Technique Variant of Partial ALPPS

(Tourniquet Partial-ALPPS)
Ricardo Robles-Campos, MD, PhD,  Y Roberto Brusadı́n, MD, PhD,  Vı́ctor López-López, MD, PhD, 
Asunción López-Conesa, MD, PhD,  Álvaro Navarro-Barrios, MD,  Paula Gómez-Valles, MD, 
Albert Caballero-Illanes, MD, y Valentı́n Cayuela-Fuentes, MD,  and Pascual Parrilla-Paricio, MD, PhD 
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aggressive variants were designed.3 –5 Tourniquet ALPPS (T-

Objective: We present a new variant of partial-ALPPS (p-ALPPS) ‘‘Tourni-
quet partial-ALPPS (Tp-ALPPS)’’, with the aim of reducing aggressiveness
during stage 1.
Summary Background Data: Associating liver partition and portal vein
ligation for staged hepatectomy (ALPPS) results in liver regeneration in only
9 days. Due to its high initial morbidity and mortality, less aggressive variants
were designed.
Methods: A new surgical variant of ALPPS was designed consisting in
introducing a Kelly forceps from the base of the liver, crossing the liver
parenchyma through an avascular area. A 3-mm Vicryl (V152; Ethicon,
Somerville, New Jersey, USA) tape is passed, and the tourniquet is
then knotted. Six patients operated on by this new Tp-ALPPS surgical
technique were compared to 6 patients operated on by Tourniquet ALPPS
(T-ALPPS).
Results: There were no differences in volume increase at 10 days. During stage
1, blood losses and transfusion rates tended to be lower in the Tp-ALPPS group,
without statistical differences. Surgical time was shorter in the Tp-ALPPS group
than in T-ALPPS (90 min versus 135 min) ( p < 0.023). In stage 2, blood losses
and transfusion were similar in both groups, but surgical time tended to be higher
in the Tp-ALPPS group, which could be related to the surgical technique
performed. There were no differences in morbidity and mortality.
Conclusions: Tp-ALPPS achieved a similar increase in volume as T-ALPPS
but with a shorter stage 1 surgical and similar morbidity and mortality.
Keywords: ALPPS, mini-ALPPS, p-ALPPS, R-ALPPS
(Ann Surg 2021;273:e22–e24)
A ssociating liver partition and portal vein ligation for staged
hepatectomy (ALPPS)1,2 results in liver regeneration in only
9 days. Due to its high initial morbidity and mortality, 1 less
From the Department of Surgery, HBP Unit, Virgen de la Arrixaca University
Hospital, Biomedical Research Institute of Murcia-Virgen de la Arrixaca
(IMIB-Arrixaca), Murcia, Spain; and yDepartment of Pathology, Virgen de
la Arrixaca University Hospital, Biomedical Research Institute of Murcia-
Virgen de la Arrixaca (IMIB-Arrixaca), Murcia, Spain.
rirocam@um.es.
Personal contribution of the authors:
Ricardo Robles-Campos: study design of the new surgical technique and writing.
Roberto Brusadin: patient selection and writing.
Victor López-López: patient selection and writing.
Asunción López-Conesa: patient selection and surgery.
Alvaro Navarro-Barrios: writing, patient selection, and control of data base.
Paula Gómez-Vallés: patient selection and control of data base.
Albert Caballero-Illanes: histology and inmunopathological studies.
Valentı́n Cayuela-Fuentes: patient selection and control of data base.
Pascual Parrilla-Paricio: study design and writing.
The authors have nothing to disclose and declare no conflicts of interest.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions of
this article on the journal’s Web site (www.annalsofsurgery.com).
Copyright ß 2020 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0003-4932/20/27301-0e22
DOI: 10.1097/SLA.0000000000004244
ALPPS)3 occludes intrahepatic circulation without liver partition
with similar regenerative results. We present a new variant of partial-
ALPPS (p-ALPPS) ‘‘Tourniquet partial-ALPPS (Tp-ALPPS)’’ mod-
ified using a tourniquet, with the aim of reducing aggressiveness
during stage 1.
METHODS
Study Design
Twelve patients were included in this prospective study that
compared T-ALPPS (n ¼ 6) and Tp-ALPPS (n ¼ 6). All patients
were informed about the risks of both procedures and signed an
informed consent form. Only patients with colorectal liver metasta-
ses and an insufficient future liver remnant (FLR) who required
ALPPS were included.
Volume increase of the FLR after stage 1 was the primary
endpoint. A ratio <0.5 for FLR volume/body weight was considered
insufficient. Secondary endpoints were morbidity (global and
IIIB),6 90-day mortality and 1-year overall survival (OS) and
disease-free survival (DFS). Liver failure was defined using the
International Study Group of Liver Surgery criteria.
Surgical Technique
T-ALPPS4: In stage 1,3 a tourniquet on the Cantlie line
(inserted using the hanging maneuver) or umbilical fissure is placed.
The tourniquet is knotted, under ultrasound control, tightly enough to
completely occlude the intrahepatic circulation. On the seventh
postoperative day, volumetric computed tomography is performed.
During stage 2, the tourniquet is used to perform the hanging
maneuver, and the liver bipartition is performed following the
ischemic line produced by the tourniquet.
Tp-ALPPS: After cleaning the liver metastases in the left lobe
(Fig. 1A–D), the right portal vein is ligated. Under ultrasound
control, a Kelly forceps is introduced from the base of the liver,
crossing the liver parenchyma through an avascular area (Supple-
mentary Fig. 1, http://links.lww.com/SLA/C376). If a right hepatec-
tomy is planned for stage 2, the forceps is introduced from the right
side of the base of segment 4b (Fig. 1E), crossing to segment 8,
between the right and middle hepatic veins (Fig. 1F). A 3-mm Vicryl
(V152; Ethicon, Somerville, NJ) tape is passed, and the tourniquet
(Fig. 1G) is then knotted (Fig. 1H). In case of right trisectionectomy
in stage 2, the forceps is introduced from the left side of the base of
segment 4b crossing to segment 4a, between the middle and left
hepatic veins. After stage 1, at 7 days, volumetric computed tomog-
raphy (Fig. 1C), determination of indocyanine green clearance, and
scintigraphy were carried out. In stage 2, the tourniquet can be used
as a hanging maneuver, and a right trisectionectomy or right hepa-
tectomy (including segment I in case of liver metastases in this
segment) is performed. Chemotherapy and follow-up were carried
out using our previously published criteria.

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Annals of Surgery  Volume 273, Number 1, January 2021 Tourniquet Partial ALPPS

FIGURE 1. CT scan of the first Tp-ALPPS patient, who presented with bilobar CRLM (3 in the left lobe and 5 in the right lobe), one of
which was in segment 1 (in the 3D reconstruction, an arrow points to the segment 1 metastasis), on the inferior vena cava,
impeding the hanging maneuver (A, B). The CT scan control at 7 d after stage 1 shows an 80% increase in volume. The arrow
indicates the occlusion of the circulation line (C). Last control CT-scan performed at 26 months with local recurrence of the disease
which was resected (D). Tp-ALPPS surgical technique: passing the Kelly forceps upon hilum bifurcation, on the left side of the right
portal pedicle, under ultrasonographic control (E). Clamp emerging in segment 8 through liver parenchyma (F). A tourniquet is
placed across the liver (G). A small, 1-cm groove is made on the liver surface to prevent displacement, and a tourniquet is knotted in
the future transection line (H). ALPPS indicates associating liver partition and portal vein ligation for staged hepatectomy; CRLM,
colorectal liver metastases; CT, computed tomography; Tp-ALPPS, tourniquet partial ALPPS.

Statistical Analysis morbidity and mortality. This technique could be an alternative to T-

Using SPSS Statistics 24.0 (SPSS Inc., Chicago, IL), a 1:1
prospective study was performed. Continuous variables are reported
as medians with ranges and were compared using the Mann-Whitney
U test. Categorical variables were compared using the x2 test or
Fisher exact test. OS and DFS curves in both groups were generated
using the Kaplan-Meier method and compared with the log-rank test.
RESULTS
No statistically significant differences (SSD) in demographic
data were found between the 2 groups (Supplementary Table 1,
http://links.lww.com/SLA/C374). The baseline %FLR was lower
than 25% (without SSD) and the increase in FLR was 68% in the
T-ALPPS group and 69% in the Tp-ALPPS group, with similar
kinetic growth. In stage 1, the blood loss and transfusion rates tended
to be lower in the Tp-ALPPS group, without SSD. Surgical time was
shorter in the Tp-ALPPS group (90 minutes vs 135 minutes) (P <
0.023). In stage 2, blood losses and transfusion were similar in both
groups, but surgical time tended to be higher in the Tp-ALPPS group,
which could be related to the surgical technique performed. Morbid-
ity was similar in both groups without postoperative mortality.
Hospital stay tended to be lower, only after stage 1, in patients in
the Tp-ALPPS group.
One-year DFS (67% in both groups; P ¼ 0.424) and 1-year OS
(T-ALPPS vs Tp-ALPPS, 83% vs 100%; P ¼ 0.439) were similar.
DISCUSSION
Tp-ALPPS achieved a similar increase in volume as T-ALPPS
but with a shorter stage 1 surgical time (as hanging maneuver and
extra-Glissonian passage of the tourniquet are avoided) and similar
ALPPS for cases of big liver metastasis in segment I (where pass the
tourniquet with a hanging maneuver is impossible) or even p-ALPPS
(as it achieved occlusion of 50%–60% of the liver parenchyma
without splitting).
Tp-ALPPS is based on the absence of large caliber vessels on
the right and left sides of the middle hepatic vein. For right
hepatectomy, the forceps is introduced on the left side of the right
portal pedicle, with low risk of hemorrhage. Then, progressing
without much pressure, the area between the middle and right hepatic
veins can be reached. For right trisectionectomy, the forceps is
introduced on the right side of the left portal pedicle, progressing
until bifurcation between the left and middle hepatic veins. This
maneuver must be performed under ultrasound control, first to
reference the exit point of the clamp in an avascular area and to
avoid injury to the hepatic veins or tributaries (hepatic veins of
segments 8 and 3, which sometimes drain into the middle). After
passing the tourniquet, mild bleeding occurs at the entry and exit
points, which can be resolved with local hemostats and adequate
compression.
The ALPPS stage 1 surgical time1,7 were 210 minutes and
327 minutes, respectively, noticeably higher than Tp-ALPPS. In
ALPPS stage 1, the high rates of transfusion, surgical time, Pringle
maneuver, and morbidity (site infected collections, etc) were associ-
ated with mortality in some series.1,7 Several publications8,9 have
managed to reduce mortality from 12%1 to 4%,9 by performing risk
assessments, better patient selection, and the less aggressive ALPPS
variants (including p-ALPPS, mini-ALPPS, T-ALPPS, R-ALPPS).3–
5,10
Hence, we present an ALPPS variant that is presumably less
aggressive than those described in the literature so far. Study
limitations include the short sample size.

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Robles-Campos et al
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Annals of Surgery  Volume 273, Number 1, January 2021
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ß 2020 Wolters Kluwer Health, Inc. All rights reserved.