Medical Oncologist
CION Cancer Clinics
Two-stage liver surgery and ALPPS: why some operations are split in two | CION Cancer Clinics
Two-stage liver surgery removes cancer in two planned operations because one would leave too little healthy liver behind. Between them, the part that will stay is made to grow. ALPPS is a faster version with higher risk. Most people offered either have bowel cancer that spread to the liver. This page explains how both work, and who they do not suit. At CION Cancer Clinics, a multidisciplinary tumour board weighs your liver function and your scans before recommending any treatment.
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Medically reviewed by Dr. Muralidhar MuddusettyConsultant Surgical Oncologist · MBBS (AIIMS), MS (Surgery, AIIMS), DNB (Surgical Oncology), MRCS (Edinburgh) · last reviewed October 2026, next review due October 2027
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On this page
- What is two-stage liver surgery, and why would anyone need it?
- How do surgeons decide a staged plan is needed?
- What happens in a standard two-stage operation?
- How is ALPPS different from the standard two-stage approach?
- Who is two-stage surgery or ALPPS not suitable for?
- What this page cannot tell you
- Common questions about two-stage liver surgery
The short answer
What is two-stage liver surgery, and why would anyone need it?
Two-stage liver surgery removes the cancer in two planned operations instead of one. It is used when taking everything out at once would leave too little healthy liver for you to live on safely.
The idea is simple. The first operation clears some of the tumours, or prepares the liver, and the part that will stay behind is given time to grow. Once it has grown enough, the second operation removes the rest of the cancer. The liver is the one organ that can regrow itself, and this plan uses that.
Who this page is mostly about
Most people offered two-stage surgery have cancer that spread to the liver from the bowel, not cancer that started in the liver. If that is your situation, the colon cancer pages on liver surgery eligibility are the right place to read in detail. Primary liver cancer, called hepatocellular carcinoma (HCC), usually grows in a liver already scarred by cirrhosis, and a scarred liver regrows poorly. That is why this approach is used far less often for HCC.
Two-stage surgery is a way to reach an operation that would otherwise be unsafe. It is not a stronger operation.What the team weighs
How do surgeons decide a staged plan is needed?
The question is never only how big the cancer is. It is how much good liver will be left once it is gone.
The liver that will stay behind
Surgeons measure, on a CT scan, the part of the liver that would remain after the operation. This is called the future liver remnant. If it is too small, the liver can fail after surgery, which is the danger the whole plan is built to avoid.
How healthy that liver is
A liver damaged by cirrhosis, heavy chemotherapy or fat needs a larger share left behind than a healthy one. Blood tests and sometimes a scan of liver stiffness help judge this.
Where the tumours sit
Cancer on both sides of the liver is the usual reason. One side can be cleared first while the other side grows.
Typical picture
- Several tumours spread across both halves
- A large tumour needing most of one side removed
- Cancer that has responded well to chemotherapy
Whether you can face two operations
Your heart, lungs, nutrition and strength all count. Two operations close together ask a lot of the body.
Not sure whether this applies to you?
Ask an oncologistThe classic route
What happens in a standard two-stage operation?
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Chemotherapy first, in many cases
For cancer that spread from the bowel, treatment often starts with chemotherapy to shrink the tumours and show how the cancer behaves.
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The first operation clears the side that will stay
The surgeon removes the smaller tumours from the half of the liver that will be kept, so that the half is clean before it grows.
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The liver is made to grow
The blood supply to the diseased side is blocked, usually by portal vein embolisation. The portal vein is the main vessel bringing blood to the liver. With that flow redirected, the clean side enlarges over the following weeks.
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A repeat scan checks the growth
The team measures the remaining liver again and checks that the cancer has not spread elsewhere while waiting.
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The second operation removes the rest
If the liver has grown enough and the cancer is still contained, the diseased side is removed. Some people never reach this step, and that is an expected part of the plan, not a failure on their part.
Side by side
How is ALPPS different from the standard two-stage approach?
Standard two-stage surgery
ALPPS
Growth is triggered by blocking the portal vein, often through a needle by an interventional radiologist
The surgeon ties the portal vein and divides the liver tissue during the first operation
The remaining liver grows over several weeks
The remaining liver grows much faster, often within a couple of weeks
A longer gap, so more people stop before the second operation
More people complete both stages
Lower risk at each step
Higher risk of serious complications, especially in older or frailer people
Widely used and well studied
Done in a smaller number of specialist liver units, with evidence still growing
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Not for everyone
Who is two-stage surgery or ALPPS not suitable for?
It does not suit most people with cirrhosis. A scarred liver grows back slowly and unpredictably, and leaving it smaller can tip it into failure. For HCC in a cirrhotic liver, the team more often weighs ablation, TACE, a transplant assessment or medicines. The page on why surgery is often impossible in cirrhosis explains this in full.
Other situations where it is usually not offered
It is not offered when the cancer has spread beyond the liver in a way surgery cannot clear. It is not offered when the cancer keeps growing during chemotherapy, because a second operation is unlikely to come in time. It may also be ruled out by portal hypertension, which is raised pressure in the liver's blood vessels, or by serious heart or lung disease.
When ALPPS in particular is avoided
Many surgeons avoid ALPPS in older people, in people with a damaged liver, and in bile duct cancer near the liver's centre, where early reports showed high risk. In those cases a slower standard two-stage plan, or no surgery, is usually safer.
Being straight with you
What this page cannot tell you
It cannot tell you whether your liver is large enough, healthy enough or clear enough for a staged plan. That depends on measurements taken from your own scans, your blood results and how your cancer has responded to treatment. Only a liver surgical team looking at those can answer it.
It cannot tell you which approach is right
Standard two-stage surgery, ALPPS, a single operation combined with ablation, or no operation at all can each be the sensible answer for a different person. At CION, the tumour board of surgical, medical and radiation oncologists reviews the scans together. CION's surgical oncologists assess and plan the operation, and portal vein embolisation is coordinated through accredited partner hospitals. Your team will tell you where the operation takes place.
It cannot predict your outcome
Nobody can promise that both stages will happen. Families should hear that clearly at the start, so a stop after the first stage does not feel like a broken promise.
If you have been told your cancer is "too big to remove", it is reasonable to ask whether a staged plan was considered.Questions we are asked
Common questions about two-stage liver surgery
Why not remove all the cancer in one operation?
Because the liver left behind would be too small to keep you alive. After a very large removal, the liver can fail, and that can be fatal. Staging the surgery gives the remaining liver time to grow first, so the final operation is safer.
What does ALPPS stand for?
It stands for Associating Liver Partition and Portal vein ligation for Staged hepatectomy. In plain words, the surgeon splits the liver and ties off the vein feeding the diseased side in the first operation. The healthy side then grows quickly before the second operation.
How long is the gap between the two operations?
With ALPPS the gap is usually short, often a couple of weeks. With the standard route it is longer, because the liver grows more slowly after the vein is blocked. Your team decides the timing from repeat scans, not from a fixed date.
What if the second operation never happens?
Some people do not reach the second stage, either because the liver did not grow enough or the cancer spread. Treatment does not stop there. The team will discuss medicines, ablation or other options, depending on what the scans show.
Is this used for liver cancer that started in the liver?
Sometimes, but less often. It is mainly used for cancer that spread from the bowel. HCC usually comes with cirrhosis, and a scarred liver does not regrow well. In a liver without cirrhosis, a staged plan may still be considered for HCC.
Is ALPPS riskier than the standard approach?
Yes, the risk of serious complications is higher. In exchange, more people complete both operations. Whether that trade is worth it depends on your age, your liver and how quickly the cancer is moving. Ask your surgeon to explain the choice in your own case.
Will I have chemotherapy between the two operations?
It depends on the cancer. For bowel cancer that spread to the liver, chemotherapy is often given before, and sometimes between or after, the operations. For HCC it is used far less. Your medical oncologist will explain what is planned and why.
Should I get a second opinion before agreeing?
It is reasonable for any major liver operation, and especially for a staged one. Bring your scans and reports. Call the CION helpline and the team will tell you how to have them reviewed by the tumour board.
Your Specialists
Meet CION's liver cancer specialists. Bring your scan reports and liver blood tests.
Our medical and surgical oncologists plan liver cancer care together, weighing the tumour and how well your liver works before choosing surgery, a liver-directed procedure or medicines.
Medical Oncologist
Dr. C. Raghavendra Reddy
MBBS(Gold Medal), DNB(General Medicine), DM(Medical Oncology)(Gold Medal)
Medical Oncologist
Dr. Bharati Devi Gorantla
MBBS, MD(General Medicine), DM(Medical Oncology)(Adyar,Chennai), ECMO, MRCP SCE(UK)
Medical Oncologist
Dr. Owais Mohammed
MBBS, MD (General Medicine), DrNB (Medical Oncology), ECMO, MRCP SCE (Medical Oncology) (UK)
Medical Oncologist
Medical Oncologist
Surgical Oncologist
Dr. Muralidhar Muddusetty
MBBS (AIIMS), MS (Surgery) (AIIMS), DNB (Surgical Oncology), MRCS (Edinburgh)
Surgical Oncologist
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Sources
- American Cancer Society — Surgery for Liver Cancer
- Cancer Research UK — Surgery for liver cancer
- American Cancer Society — Embolization Therapy for Liver Cancer
- National Cancer Institute — Surgery for Cancer
This page is general information, not a prescription. Do not change or stop any treatment based on what you read here. If anything is worrying you, contact your own treating team — or call our helpline and we will help you reach the right specialist.
Keep reading
Related pages
Portal Vein Embolisation to Grow the Remaining LiverThe step that makes the liver grow between operationsFuture Liver Remnant: The Number Surgeons CalculateHow surgeons decide whether enough liver will be leftWhy a Small Tumour Sometimes Cannot Be RemovedWhen cirrhosis, not size, rules surgery outTwo-Stage Hepatectomy and ALPPS ExplainedThe operative detail of both procedures
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Were you told the cancer is too big to remove?
Send us your scans and reports and the tumour board can review whether a staged plan, or another route, fits your liver. One helpline serves every CION centre.