Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) as a double-edged sword: leveraging imaging evaluation to maximize benefits and mitigate risks

Surgical resection is the primary treatment option for patients with malignant liver tumors. However, not all patients can be treated by liver resection, primarily due to the critical limitation of insufficient remnant liver volume. The Associating Liver Partition and Portal vein Ligation for Staged Hepatectomy (ALPPS) has been explored as a treatment option for patients with insufficient future liver volume, owing to its ability to induce rapid liver growth. Though ALPPS has opened up opportunities for radical resection, it also presents challenges, including high morbidity and mortality. Therefore, a thorough preoperative evaluation of liver function is essential for patients scheduled for ALPPS. Medical imaging plays a crucial role in providing important information for patient selection and safety monitoring during the ALPPS process. This review outlines the current status of ALPPS, detailing its primary imaging evaluation workflow and the recommended modalities based on available clinical evidence. Where applicable, levels of evidence and strength of recommendations are provided to guide imaging-based decision-making throughout the ALPPS process. CRITICAL RELEVANCE STATEMENT: This review provides a comprehensive overview of the ALPPS and elucidates the pivotal role of medical imaging throughout the clinical pathway: (1) preoperative patient selection, (2) staged interoperative assessment, and (3) postoperative surveillance, to ultimately improve patient outcomes. KEY POINTS: ALPPS is a promising therapy for malignant liver tumors due to its characteristic of increasing the resectability. Highly selected patients and effective preoperative and interstage management will improve the outcomes and achieve an acceptable morbidity and mortality. Medical imaging offers accurate function and anatomy assessment for ALPPS.