Partial ALPPS versus complete ALPPS for staged hepatectomy

Abstract Background Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) can induce a stronger regenerative ability than traditional 2-stage hepatectomy (TSH). ALPPS has become popular for achieving fast hypertrophy in patients with an insufficient future liver remnant (FLR). However, ALPPS is associated with high morbidity and mortality. Partial ALPPS is a variation that may decrease the morbidity and mortality. The purpose of this study was to perform a meta-analysis comparing outcomes of ALLPS and partial ALLPS. Methods PubMed, Embase, and Cochrane Library databases were searched for studies comparing partial ALPPS and complete ALPPS up to April 2019. Included studies were assessed by the Newcastle-Ottawa Scale (NOS). Weighted mean difference (WMD)/standard mean difference (SMD) and odds ratios (OR) with 95% confidence intervals (CIs) were calculated to compare FLR, time interval between stages, postoperative complications, and mortality between partial and complete ALPPS. Results Four studies including 124 patients were included. FLR hypertrophy of partial ALPPS was comparable to complete ALPPS (p = 0.09). The time interval between stages was not different between the 2 procedures (p = 0.57). The postoperative complications rate of partial ALPPS was significantly lower than that of complete ALPPS (OR = 0.38; p = 0.03). The mortality rate of partial ALLPS (4.9%) was lower than that of complete ALLPS (18.9%), but the difference was not significant (OR = 0.37; p = 0.12). Conclusions Partial ALLPS is associated with similar FLR hypertrophy and time interval between stages as complete ALLPS, and a lower complication rate. Further studies are needed to examine patient selection and outcomes of the 2 procedures.

Download Full-text

ALPPS readdresses the management of advanced liver tumors

International Surgery Journal ◽

10.18203/2349-2902.isj20170842 ◽

2017 ◽

Vol 4 (3) ◽

pp. 846 ◽

Cited By ~ 1

Author(s):

Fa-guang Huang ◽

Jiang-Hua Xiao ◽

Jun Kong ◽

Jian Ping Gong

Keyword(s):

Portal Vein ◽

Liver Tumors ◽

Future Liver Remnant ◽

Oncological Outcome ◽

Morbidity And Mortality ◽

High Morbidity ◽

Portal Vein Ligation ◽

Liver Remnant ◽

Staged Hepatectomy

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been developed to induce rapid liver hypertrophy of the future liver remnant (FLR) prior to hepatectomy in primarily non-resectable or marginally resectable liver tumors. In recent years, this novel strategy has aroused interests of many liver surgeons. Its indications have been broadened gradually with more and more reported cases. Modified ALPPS is also developed to reduce morbidity and mortality. The authors searched Medline and PubMed to identify related articles published in English, using terms: “ALPPS, associating liver partition and portal vein ligation for staged hepatectomy, in situ split, in situ splitting, liver partition”. The authors summarized and analysed the superiority, indications, modifications, safety, mechanisms of regeneration of ALPPS. ALPPS was more effective than traditional portal vein embolization (PVE) or portal vein ligation (PVL). ALPPS obtained 80% volume increase of future liver remnant (FLR ) within 7 days in contrast to 10%-46% within 2 to 8 weeks by PVE or PVL. ALPPS opens a chapter in the history of liver surgery and readdresses the management of advanced primary and metastatic liver tumors. The high morbidity and mortality associated with ALPPS could be decreased remarkably if we carefully select patients and carry out the operation with experienced surgeons. In addition, the safety, mechanisms and oncological outcome of ALPPS are still not clear, which need further research and randomized controlled trials.

Download Full-text

Speciális májműtét (Associating Liver Partition and Portal vein ligation for Staged hepatectomy, ALPPS) morbiditásának csökkentése átértékelt betegkiválasztási elvek és műtéttechnikai módosítás révén

Orvosi Hetilap ◽

10.1556/650.2019.31440 ◽

2019 ◽

Vol 160 (32) ◽

pp. 1260-1269

Author(s):

Oszkár Hahn ◽

Dávid Bárdos ◽

Péter Kupcsulik ◽

Attila Szijártó ◽

András Fülöp ◽

...

Keyword(s):

Multivariate Analysis ◽

Surgical Technique ◽

Portal Vein ◽

Patient Selection ◽

Liver Tumors ◽

Morbidity And Mortality ◽

Red Blood Cell Transfusion ◽

Portal Vein Ligation ◽

Liver Remnant ◽

Staged Hepatectomy

Abstract: Introduction: Resecability of liver tumors is exclusively depending on the future liver remnant (FLR). The remnant can be hypertrophised using portal vein occlusion techniques. The latest hypertrophising method is Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS), which provides the most significant induced hypertrophy in the shortest time. Morbidity and mortality of this procedure were initially unacceptably high. Aim: Reducing complications by better patient selection and modified surgical technique. Method: The First Department of Surgery, Semmelweis University, Budapest, prefers the ‘no touch’ technique, instead of ‘complete mobilization’. For optimizing patient selection, an international registry (including our patients’ data) was established. In addition to the surgical, we collected demographic, disease, liver function, histology, morbidity (Clavien–Dindo) and mortality parameters. Volume and function measurements were performed by using CT-volumetry and 99mtechnecium-mebrofenin SPECT/CT. Data were analyzed by multivariate analysis (significance: p<0.05). Results: We performed 20 ALPPS procedures from 2012 to 2018. The relative volume increment and resectability in our department and among the 320 registry patients were 96% vs. 86% and 95% vs. 98%. Using ‘no touch’ technique, the Clavien–Dindo III–IV morbidity and mortality rates were significantly lower (22%–0%) than with ‘complete mobilization’ (63%–36%) (p<0.05). Based on the multivariate analysis of the registry patients, age over 60 years, liver macrosteatosis, non-colorectal liver tumor, >300 minutes operation time, >2 units of red blood cell transfusion, or insufficient FLR function before stage 2 were identified as independent factors influencing mortality (p<0.05). Conclusion: Mortality and morbidity of ALPPS can be reduced by proper patient selection and ‘no touch’ surgical technique. Orv Hetil. 2019; 160(32): 1260–1269.

Download Full-text

Comment on “Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy Versus Portal Vein Embolization for Hepatitis-related Hepatocellular Carcinoma. A Changing Paradigm in Modulation of Future Liver Remnant Before Major Hepatectomy” by A. Chan, et al

Annals of Surgery ◽

10.1097/sla.0000000000003687 ◽

2019 ◽

Vol Publish Ahead of Print ◽

Author(s):

Daniel Azoulay ◽

Chetana Lim ◽

Chady Salloum

Keyword(s):

Hepatocellular Carcinoma ◽

Portal Vein ◽

Portal Vein Embolization ◽

Major Hepatectomy ◽

Future Liver Remnant ◽

Portal Vein Ligation ◽

Liver Remnant ◽

Staged Hepatectomy

Download Full-text

First application of intraoperative MRI of the liver during ALPPS procedure for colorectal liver metastases

Langenbeck s Archives of Surgery ◽

10.1007/s00423-020-01890-3 ◽

2020 ◽

Vol 405 (3) ◽

pp. 373-379

Author(s):

Carina Riediger ◽

Verena Plodeck ◽

Johannes Fritzmann ◽

Alexander Pape ◽

Alexander Kohler ◽

...

Keyword(s):

Liver Metastases ◽

Colorectal Liver Metastases ◽

Intraoperative Ultrasound ◽

Intraoperative Mri ◽

Portal Vein Ligation ◽

Liver Remnant ◽

Enhanced Mri ◽

Contrast Enhanced ◽

Contrast Enhanced Mri ◽

Staged Hepatectomy

Abstract Purpose Intraoperative detection of intrahepatic lesions can be demanding. The use of preoperative contrast-enhanced magnetic resonance imaging (MRI) or computer tomography (CT) combined with intraoperative ultrasound of the liver is state of the art. Near totally regressed colorectal liver metastases (CRLM) after neoadjuvant chemotherapy or nodules in severely altered liver tissue as steatosis or cirrhosis are often hard to detect during the operative procedure. Especially differentiation between benign atypical nodules and malignant tumors can be very difficult. The intraoperative use of contrast-enhanced ultrasound or intraoperative navigation are helpful tools. However, both methods show relevant limitations. The use of intraoperative MRI (ioMRI) can overcome this problem. Relevant structures can be marked within the operative site or immediate control of complete tumor resection can be achieved. This might allow immediate surgical optimization in case of failure. Methods We report the intraoperative application of ioMRI in a case of a 61-year-old male patient suffering from rectal cancer with 10 synchronous bilobar CRLM who was treated stepwise by multimodal treatment and staged hepatectomy. Intraoperative contrast-enhanced MRI of the liver was used during completion procedure of an extended right hemihepatectomy performed as “Associating Liver Partition and Portal vein Ligation for Staged hepatectomy (ALPPS)”. Results ioMRI provided excellent images and showed absence of liver metastases in the liver remnant. Procedure of ioMRI was safe, fast and feasible. Conclusion To the best of our knowledge, we describe the first case of intraoperative application of a contrast-enhanced MRI during open liver surgery at the University Hospital of Dresden.

Download Full-text

Associating liver partition and portal vein ligation for staged hepatectomy versus portal vein embolization in staged hepatectomy for hepatocellular carcinoma: A randomized comparative study.

Journal of Clinical Oncology ◽

10.1200/jco.2020.38.15_suppl.4578 ◽

2020 ◽

Vol 38 (15_suppl) ◽

pp. 4578-4578

Author(s):

Gang Huang

Keyword(s):

Hepatocellular Carcinoma ◽

Overall Survival ◽

Portal Vein ◽

Comparative Study ◽

Risk Ratio ◽

Portal Vein Embolization ◽

Portal Vein Ligation ◽

Liver Remnant ◽

Staged Hepatectomy

4578 Background: Both Portal Vein Embolization (PVE) and Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) have been used in patients with unresectable hepatocellular carcinoma (HCC) due to insufficient volumes in future liver remnant (FLR). But it remains unclear for which thetapy has better long-term overall survival. Methods: This study was a single-center, prospective randomized comparative study. Patients were randomly assigned in a 1:1 ratio to the 2 groups. The primary endpoints was three-year overall survival rates. Results: Between November 2014 to June 2016, 76 patients with unresectable HCC due to inadequate volume of FLR were randomly assigned to ALPPS groups (n = 38) and PVE groups (n = 38). Thirty-seven patients (97.4%) in the ALPPS Group compared with 25 patients (65.8%) in the PVE Group were able to undergo staged hepatectomy (risk ratio 1.48, 95% CI 1.17-1.87, p < 0.001). The three-year overall survival (OS) rate of the ALPPS group (65.8%) (95% CI 50.7-80.9) was significantly better than the PVE Group (42.1%) (95% CI 26.4-57.8), (HR 0.50, 95% CI 0.26-0.98, two-sided p = 0.036). Major postoperative complications rates after the stage-2 hepatectomy were 54.1% in the ALPPS group and 20.0% in the PVE group ((risk ratio 2.70, 95% CI 1.17-6.25, p = 0.007). Conclusions: ALPPS resulted in significantly better long-term overall survival outcomes, at the expenses of a significantly higher perioperative morbidity rate compared with PVE in patients who had initially unresectable HCC. Clinical trial information: ChiCTR-IOC-14005646 .

Download Full-text