Can we improve the morbidity and mortality associated with the associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) procedure in the management of colorectal liver metastases?

doi:10.1016/j.surg.2014.08.041

Surgery

Volume 157, Issue 2, February 2015, Pages 194-201

https://doi.org/10.1016/j.surg.2014.08.041 Get rights and content

Background

Meticulous selection of patients who can undergo the associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) procedure safely will be paramount to minimize the associated morbidity and mortality.

Methods

We collected data prospectively on 14 consecutive patients who underwent the ALPPS procedure for planned resection of colorectal liver metastases at London Health Sciences Centre, Canada, between April 2012 and November 2013.

Results

The median relative increase of the standardized future liver remnant after the ALPPS procedure was 93 ± 28%. The standardized future liver remnant rate of volume increase was 35 ± 13 mL/day. Biopsies of the FLR were taken during stage 1 and 2. These biopsies showed a mean preregeneration Ki-67 index of 0% and a postregeneration index of 14 ± 3%. All 14 ALPPS patients completed the 2-stage hepatectomy. No complications occurred after ALPPS stage 1. After ALPPS stage 2, 5 patients had complications (36%), with 2 patients (14%) having a severe complication (Clavien-Dindo ≥ IIIB). Median follow-up was 9 months. Overall survival at the time of follow-up was 100%. Recurrence developed in 2 patients. One patient had recurrence in the liver and lungs 5 months after stage 2 and was offered more chemotherapy. The other patient developed recurrence in the liver remnant 9 months after stage 2 and underwent additional chemotherapy with a possible future resection of the recurrence.

Conclusion

Low morbidity and negligible mortality can be achieved with the ALPPS procedure, and the high rates published in previous reports can be improved with refinements in technique and patient selection. The ALPPS approach may be a valid option to enable resection in selected patients with colorectal liver metastases considered unresectable previously by standard techniques.

Section snippets

Materials and methods

All patients who underwent an ALPPS procedure for CRLM between April 2012 and November 2013 at London Health Sciences Centre were followed prospectively as part of an institutional pilot study. This was a single-center study conducted in London, Ontario, Canada. All 14 consecutive patients who underwent an ALPPS procedure during this time period are included in the analysis. All patients in this study were reviewed by a multidisciplinary tumor board and were deemed unresectable in a

Results

We performed 14 ALPPS procedures all for CRLMs between the dates of April 2012 and November 2013. Mean patient age was 57 ± 12 years (range 31–66, Table I). The proportion of male patients was 64%.

Patients had 9 ± 3 (range 4–15) lesions, and all of the patients had bilobar liver metastases. There were 4 patients who underwent simultaneous colon resection with the ALPPS procedure. In all 4 cases, the colon resection was performed during the ALPPS stage 1. Two patients underwent a reverse

Discussion

As surgeons continue to perform extensive liver resections, various strategies have been used to induce FLR hypertrophy in an attempt to minimize the risk of postoperative liver failure. PVE to induce hypertrophy of FLR has become the gold standard, with many centers demonstrating excellent results.23, 24, 25 Despite these excellent results, however, PVE has a 20–30% failure rate attributable to inadequate hypertrophy or disease progression.6, 7 Recently, the ALPPS approach has been proposed as

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Cited by (106)

Liver volumetry and liver-regenerative interventions: history, rationale, and emerging tools
2024, Journal of Gastrointestinal Surgery
Postoperative hepatic insufficiency (PHI) is the most feared complication after hepatectomy. Volume of the future liver remnant (FLR) is one objectively measurable indicator to identify patients at risk of PHI. In this review, we summarized the development and rationale for the use of liver volumetry and liver-regenerative interventions and highlighted emerging tools that could yield new advancements in liver volumetry.
A review of MEDLINE/PubMed, Embase, and Cochrane Library databases was conducted to identify literature related to liver volumetry. The references of relevant articles were reviewed to identify additional publications.
Liver volumetry based on radiologic imaging was developed in the 1980s to identify patients at risk of PHI and later used in the 1990s to evaluate grafts for living donor living transplantation. The field evolved in the 2000s by the introduction of standardized FLR based on the hepatic metabolic demands and in the 2010s by the introduction of the degree of hypertrophy and kinetic growth rate as measures of the FLR regenerative and functional capacity. Several liver-regenerative interventions, most notably portal vein embolization, are used to increase resectability and reduce the risk of PHI. In parallel with the increase in automation and machine assistance to physicians, many semi- and fully automated tools are being developed to facilitate liver volumetry.
Liver volumetry is the most reliable tool to detect patients at risk of PHI. Advances in imaging analysis technologies, newly developed functional measures, and liver-regenerative interventions have been improving our ability to perform safe hepatectomy.
Mini-ALPPS
2024, Safe Major Hepatectomy after Preoperative Liver Regeneration: Preopearative PVE, Two-Satage Hepatetomy, ALPPS and Hepatic Vein Deprivation
Surgical resection is the mainstay of treatment among patients with primary and metastatic tumors in the liver, especially when extrahepatic disease is absent. Modern liver surgery has been accompanied by a change in the surgeon's perspective, which was previously focused on “what is resected” to focus on “what is left after resection.” This paradigm shift in terms of the concept of resectability has generated greater attention in the future liver remnant (FLR), also giving rise to new strategies for the treatment of these tumors. Currently, a tumor is considered resectable when the potential resection margin is negative and the FLR volume is sufficient to maintain liver function, preserving at least two contiguous segments with adequate afferent and efferent bile and vascular flow (Charnsangavej et al. 2006). However, the possibility of achieving an R0 resection is often limited by the quantity and quality of FLR, being posthepatectomy liver failure (PHLF) the most feared and serious complication after major liver resections (Rahbari et al. 2011).
Evolution of associating liver partition and portal vein ligation for staged hepatectomy from 2012 to 2021: A bibliometric analysis. Review
2022, International Journal of Surgery
Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has become increasingly popular during the past few decades, and its indications have extended from patients with normal liver to post-chemotherapy patients and even patients with cirrhosis. However, few studies have assessed the publications in relation to ALPPS.
Web of Science was searched to identify studies related to ALPPS published from 2012 to 2021. The analysis was performed using the bibliometric package (Version 3.1.0) in R software.
In total, 486 publications were found. These articles were published in 159 journals and authored by 2157 researchers from 694 organizations. The most prolific journal was Annals of Surgery (24 articles and 1170 citations). The most frequently cited article was published in Annals of Surgery (average citations, 72.7; total citations, 727). China was the most productive country for ALPPS publications but had comparatively less interaction with other countries. Both thematic evolution and co-occurrence network analysis showed low numbers of topics such as failure, resection, and safety among the publications but large numbers of highly cited papers on outcomes, prediction, mechanisms, multicenter analysis, and novel procedures such as liver venous deprivation. A total of 196 studies focused the clinical application of ALPPS, and most studies were IDEAL Stages I and II. The specific mechanism of ALPPS liver regeneration remains unclear.
This is the first bibliometric analysis offering an overview of the development of ALPPS research publications. Our findings identified prominent studies, countries, institutions, journals, and authors to indicate the future direction of ALPPS research. The role of ALPPS in liver regeneration and the long-term results of ALPPS need further study. Future research directions include comparison of ALPPS with portal vein embolization, liver venous deprivation, and other two-stage hepatectomies as well as patients’ quality of life after ALPPS.
Variation in complications and mortality following ALPPS at early-adopting centers
2021, HPB
Citation Excerpt :
In contrast, the former finding from the LIGRO trial, that ALPPS does not result in a higher complication or mortality rate compared to two-staged hepatectomy is unexpected because, during the first several years of ALPPS adoption, various case series were published reporting high morbidity and mortality,4–7 with larger, multi-center and registry based, studies also raising concerns about perioperative outcomes.8,15,16 However, much lower perioperative morbidity and mortality rates were reported by institutions at which ALPPS was generally only offered to patients with colorectal liver metastases.2,3,9–11 More recently, due to more careful patient selection – particularly, exclusion of patients with primary hepatobiliary cancers – the initially high morbidity and mortality has appeared to improve over time.16,37
Various, often conflicting, estimates for post-operative morbidity and mortality following ALPPS have been reported in the literature, suggesting that considerable center-level variation exists. Some of this variation may be related to center volume and experience.
Using data from seventeen centers who were early adopters of the ALPPS technique, we estimated the variation, by center, in standardized 90-day mortality and comprehensive complication index (CCI) for patients treated between 2012 and 2018.
We estimated that center-specific 90-day mortality following treatment with ALPPS varied from 4.2% (95% CI: 0.8, 9.9) to 29.1% (95% CI: 13.9, 50.9), and that center-specific CCI following treatment with ALPPS varied from 17.0 (95% CI: 7.5, 26.5) to 49.8 (95% CI: 38.1, 61.8). Declines in estimated 90-day mortality and CCI were observed over time, and almost all individual centers followed this trend. Patients treated at centers with a higher number of ALPPS cases performed over the prior year had a lower risk of post-operative mortality.
Despite considerable center-level variation in ALPPS outcomes, perioperative outcomes following ALPPS have improved over time and treatment at higher volume centers results in a lower risk of 90-day mortality. Morbidity and mortality remain concerningly high at some centers.
ALPPS in neuroendocrine liver metastases not amenable for conventional resection – lessons learned from an interim analysis of the International ALPPS Registry
2020, HPB
Surgery is the most effective treatment option for neuroendocrine liver metastases (NELM). This study investigated the role of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) as a novel strategy in treatment of NELM.
The International ALPPS Registry was reviewed to study patients who underwent ALPPS for NELM.
From 2010 to 2017, 954 ALPPS procedures from 135 international centers were recorded in the International ALPPS Registry. Of them, 24 (2.5%) were performed for NELM. Twenty-one patients entered the final analysis. Overall grade ≥3b morbidity was 9% after stage 1 and 27% after stage 2. Ninety-day mortality was 5%. R0 resection was achieved in 19 cases (90%) at stage 2. Median follow-up was 28 (19–48) months. Median disease free survival (DFS) was 17.3 (95% CI: 7.1–27.4) months, 1-year and 2-year DFS was 73.2% and 41.8%, respectively. Median overall survival (OS) was not reached. One-year and 2-year OS was 95.2% and 95.2%, respectively.
ALPPS appears to be a suitable strategy for inclusion in the multimodal armamentarium of well-selected patients with neuroendocrine liver metastases. In light of the morbidity in this initial series and a high rate of disease-recurrence, the procedure should be taken with caution.
Chance and challenge of associating liver partition and portal vein ligation for staged hepatectomy
2019, Hepatobiliary and Pancreatic Diseases International
The associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) was first performed in 2007. The critical patient selection, timing to perform the second stage operation, and minimally invasive technique are three key factors for patient outcomes. The aim of this review is to summarize published data on these three aspects.
Studies were identified by searching PubMed for articles published from January 2007 to October 2018, using the keywords “associating liver partition and portal vein ligation for staged hepatectomy” or “ALPPS” or “in situ split”. Studies on colorectal liver metastasis (CRLM), perihilar cholangiocarcinoma (PHC), and hepatocellular carcinoma (HCC) indicated for ALPPS, cutoff values to determine the timing of stage 2, as well as modifications of ALPPS were included.
The mortality of ALPPS for CRLM is declining, for PHC is high. In patients with HCC, essential hypertrophy makes the ALPPS safer. However, the degrees of fibrosis affect the hypertrophy. The future liver remnant volume is still the gold standard to start the second stage. Hepatobiliary scintigraphy plays an important role in quantitatively assessing liver function, whereas cutoff values need to be further calibrated. Less-invasive ALPPS modifications have increased and led to a decreased mortality.
ALLPS improved the CRLM outcomes; ALPPS is feasible in patients with PHC after failure of portal vein embolization; ALPPS may be an option for HCC patients with major vascular invasion and thrombosis. The simplified and less-invasive ALPPS is the trend.

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HPBCan we improve the morbidity and mortality associated with the associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) procedure in the management of colorectal liver metastases?

Background

Methods

Results

Conclusion

Section snippets

Materials and methods

Results

Discussion

Eur J Surg Oncol

J Gastrointest Surg

J Gastrointest Surg

Eur J Surg Oncol

J Am Coll Surg

Liver Transpl

Surgery

J Am Coll Surg

Eur J Cancer

J Gastrointest Surg

Strategies for safer liver surgery and partial liver transplantation

N Engl J Med

Preoperative portal embolization to increase safety of major hepatectomy for hilar bile duct carcinoma: a preliminary report

Surgery

A two-stage hepatectomy procedure combined with portal vein embolization to achieve curative resection for initially unresectable multiple and bilobar colorectal liver metastases

Ann Surg

Two-stage hepatectomy: a planned strategy to treat irresectable liver tumors

Ann Surg

Two-step surgery for synchronous bilobar liver metastases from digestive endocrine tumors: a safe approach for radical resection

Ann Surg

Long-term results of two-stage hepatectomy for irresectable colorectal cancer liver metastases

Ann Surg

Right portal vein ligation combined with in situ splitting induces rapid left lateral liver lobe hypertrophy enabling 2-staged extended right hepatic resection in small-for-size settings

Ann Surg

Our initial experience with ALPPS technique: encouraging results

Updates Surg

How to avoid postoperative liver failure: a novel method

World J Surg

HPB
Can we improve the morbidity and mortality associated with the associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) procedure in the management of colorectal liver metastases?