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Two-stage liver surgery and ALPPS: removing tumours in two steps | CION Cancer Clinics
A two-stage hepatectomy removes tumours from both sides of the liver in two separate operations, with time in between for the healthy part to grow. ALPPS is a faster version that divides the liver in the first operation, so the second comes sooner but with higher risk. Both are used when one operation would leave too little liver. This page explains each route, the risks and its limits. CION Cancer Clinics’ surgical oncologists in Hyderabad can talk this through with you.
MI
Medically reviewed by Dr. Mohammed ImaduddinConsultant Surgical Oncologist · MBBS, MS (General Surgery), MCh (Surgical Oncology) · last reviewed September 2026, next review due September 2027
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On this page
- What are a two-stage hepatectomy and ALPPS?
- What happens in a standard two-stage hepatectomy?
- How do a two-stage hepatectomy and ALPPS compare?
- Who might be considered, and who is it not for?
- What are the risks, and what can this page not tell you?
- What do families misunderstand about staged liver surgery?
- Common questions about two-stage hepatectomy and ALPPS
The short answer
What are a two-stage hepatectomy and ALPPS?
Both are ways of removing tumours from both sides of the liver when a single operation would leave too little healthy liver behind. The liver is cleared in two operations, with time in between for the part that stays to grow.
Why it is split in two
Your liver cannot manage if too much is taken in one go. Splitting the work lets the surgeon clean up one side first, then let that side grow, and only then remove the other side. It is mostly used for cancer that has spread to the liver from the bowel, where tumours often sit on both sides.
What the gap between operations is for
The gap does two jobs. It lets the cleared side of the liver grow large enough to cope alone. It also gives the team a chance to watch how the cancer behaves. If new tumours appear elsewhere during the wait, a second large operation may not help, and that is better known before it is done than after.
How ALPPS differs
ALPPS stands for associating liver partition and portal vein ligation for staged hepatectomy. In the first operation, the surgeon divides the liver along the planned line and ties off the blood supply to the side that will go. The remaining liver grows much faster, so the second operation comes sooner. That speed comes with a higher risk, which is why it is used selectively.
Not every centre performs ALPPS. If it has been mentioned, ask your centre how often they do it.The classic route
What happens in a standard two-stage hepatectomy?
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Chemotherapy, often first
Many people have chemotherapy before surgery to shrink the tumours and check how the cancer responds.
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The first operation
The surgeon removes the smaller tumours from the side of the liver that will stay. Very small spots may be destroyed with heat instead.
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Blocking blood to the other side
Blood flow to the side that still holds tumours is blocked, either by tying the vein during the first operation or by portal vein embolisation soon after.
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The waiting period
Over some weeks the cleared side grows. You recover at home. Chemotherapy is sometimes given during this time.
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Scans before the second step
A repeat scan checks the growth and makes sure the cancer has not spread. This decides whether the second operation goes ahead.
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The second operation
The side holding the remaining tumours is removed. Recovery from this step is usually longer than from the first.
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Follow-up afterwards
Regular scans and blood tests continue after both stages are done. Further chemotherapy is sometimes advised, depending on what the pathology report shows.
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How do a two-stage hepatectomy and ALPPS compare?
Two-stage hepatectomy
ALPPS
Weeks between the two operations
A much shorter gap, usually counted in days
Liver grows more slowly
Liver grows faster
More time for the cancer to progress in the gap
Less time for the cancer to progress
Widely used and well studied
Higher risk of complications in reported studies, done in fewer centres
Suitability
Who might be considered, and who is it not for?
These are big undertakings. Your team weighs each of these before suggesting either route.
May be considered
People with tumours on both sides of the liver, often from bowel cancer, whose cancer has responded to chemotherapy and who are fit for two operations.
Usually not suitable
People with cancer that has spread outside the liver and cannot be treated, cirrhosis, or heart and lung problems that make repeated anaesthetics unsafe.
Where ALPPS is used with more caution
Early reports showed higher risks in some groups. Teams are more careful about it in these situations.
Often including
- Older people
- Cancers that start in the liver or bile ducts
Questions to ask your centre
Ask which route they suggest and why, how often they perform it, and what happens if the second stage cannot be done.
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Being straight with you
What are the risks, and what can this page not tell you?
Two operations mean two recoveries. The second is often the harder one, because a large part of the liver is removed.
Not everyone reaches the second stage
Some people do not go on to the second operation. The liver may not grow enough, or the cancer may progress during the wait. This is hard to hear, and knowing it is possible from the start helps families prepare. Other treatments are then discussed.
The main risks
These include bleeding, bile leaks, infection and liver failure after the second operation. With ALPPS, the risks of serious complications are generally described as higher, which is why careful selection matters. Your surgeon should explain the risks as they apply to you.
Preparing as a family
Staged surgery can stretch over several months when chemotherapy is included. Plan who will stay with the patient in hospital, who will help at home between the stages, and how travel from your district will work for scans. Keep every report in one folder. Ask the team for one contact number for questions during the gap.
What this page cannot tell you
It cannot tell you which route is right for you, or whether you should have surgery at all. Your treating team makes that recommendation with your scans, and you make the decision with them.
Commonly believed
What do families misunderstand about staged liver surgery?
"Needing two operations means the cancer is too advanced to treat."
Staging the surgery is a way of making removal possible when one operation would be unsafe. It is a sign the team sees a surgical route, not that they have given up.
"The faster route is always better."
ALPPS shortens the wait but raises the risk of the operations. For many people, the slower classic route is the safer choice.
"After the first stage, the hard part is over."
The second stage is usually the bigger operation, with a longer recovery. Plan for support at home for both.
"If the second stage is cancelled, the first was pointless."
The first stage still removed tumours and gave the team information about how the cancer behaves. That shapes what is offered next.
Did you know
Every case at CION is discussed at a tumour board, with surgeons, radiologists and medical oncologists together, before a plan for major liver surgery is confirmed.
Questions we are asked
Common questions about two-stage hepatectomy and ALPPS
How long is the gap between the two operations?
In a classic two-stage hepatectomy, usually some weeks, to allow the liver to grow. With ALPPS the gap is much shorter, because growth is faster. Your team sets the timing after a repeat scan or blood tests, and it can move depending on how you recover.
Will I go home between the two stages?
In a classic two-stage plan, usually yes. You recover at home, keep up light activity and return for scans. With ALPPS, many people stay in hospital between the two operations because the gap is short. Ask your team what to expect.
Is ALPPS available everywhere?
No. It is a specialised operation done in a limited number of liver surgery centres. If it has been suggested, ask how often the team performs it, what their complication record is, and why they prefer it over the classic two-stage route for you.
Will I have chemotherapy as well?
Very often. Many people have chemotherapy before the first operation, and some during the gap or after the second. Your medical oncologist and surgeon plan the timing together, allowing time for the liver to recover. Do not skip or delay a cycle on your own.
What happens if the second operation is not possible?
Your team will explain why and discuss other treatments, such as further chemotherapy, targeted medicines, ablation or radiotherapy. The options depend on what the scans show. It is reasonable to ask for time to think and to bring family to that conversation.
How long is recovery overall?
Longer than for a single liver operation, because there are two. Tiredness often lasts months after the second stage. Your surgeon can give a rough idea based on the size of each operation and your fitness. Plan for someone to help at home through both.
Can the operations be done by keyhole surgery?
Sometimes the first stage can, depending on where the tumours sit and the centre's experience. The second stage is more often open. Ask your centre what approach they plan for each step and why, rather than assuming either way.
Is staged liver surgery covered by schemes or insurance?
It is often covered when it is part of an approved cancer treatment plan. Aarogyasri, CGHS, ECHS and EHS are accepted, and most cashless insurers are empanelled. Because there are two admissions, call the helpline early so the team can check your cover for both.
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Sources
- American Cancer Society — Surgery for liver cancer
- National Cancer Institute — Colon cancer treatment (PDQ), patient version
- Cancer.Net — Liver cancer: types of treatment
- Cancer Research UK — Bowel 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 Before Liver SurgeryThe procedure often used between the two stagesLiver Resection for Colorectal Liver MetastasesThe situation where staged surgery is most usedFuture Liver Remnant ExplainedWhy the liver left behind decides the planLiver Failure After ResectionThe main risk after the second operation
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