How much liver needs to be transected in ALPPS? A translational study investigating the concept of less invasiveness

Linecker, Michael; Kambakamba, Patryk; Reiner, Cäcilia S.; Nguyen-Kim, Thi Dan Linh; Stavrou, Gregor A.; Jenner, R.; Oldhafer, Karl J.; Björnsson, Bergþór; Schlegel, Andrea; Györi, Georg; Schneider, Marcel; Lesurtel, Mickaël; Clavien, Pierre‐Alain; Petrowsky, Henrik

doi:10.1016/j.surg.2016.08.004

Cited by 59 publications

(57 citation statements)

References 31 publications

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“…Improvements have been achieved by proper patient selection and in particular by refining the surgical technique mainly aiming at reducing post-stage 1 morbidity [35-39]. Main advances have been attributed to the preservation of the middle hepatic vein during first-stage hepatectomy, leading to the concept of an only partial hepatic transection named “partial ALPPS”.…”

mentioning

confidence: 99%

“…Main advances have been attributed to the preservation of the middle hepatic vein during first-stage hepatectomy, leading to the concept of an only partial hepatic transection named “partial ALPPS”. Most important, the transection of only 50–80% of liver parenchyma is associated with a significant reduction of perioperative morbidity but does not appear to compromise the extent of the hypertrophy induced [39-40]. Complete transection of the liver parenchyma during stage 1 is now left to those situations where tumor invasion into the FLR in between stages is to be avoided.…”

mentioning

confidence: 99%

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Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy in the Treatment of Colorectal Liver Metastases: Current Scenario

Lang¹,

Baumgart²,

Mittler³

2018

Dig Surg

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Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) has expanded the surgical armamentarium for patients with advanced and bilateral colorectal liver metastases. However, the enthusiasm that the medical fraternity had about ALPPS was hampered by a high mortality rate and early and frequent tumor recurrence. While surgical safety has improved, mainly due to technical refinements and a better patient selection, the oncological value in the face of early tumor recurrence remains unclear. The only randomized controlled trial on ALPPS versus two-stage hepatectomy (TSH) so far confirmed that ALPPS led to higher resectability with comparable perioperative complication rate, but oncological outcome was not measured. Robust data regarding long-term outcome are still missing. TSH and ALPPS might be complementary strategies for the resection of colorectal liver metatsases (CRLM) with ALPPS being reserved for patients with no other surgical option, that is, after failed portal vein embolization or those with an extremely small future liver remnant. In other words, ALPPS can be considered a supplementary tool and a last resort in the liver surgeon’s hand to offer resectability in otherwise nonresectable CRLM. In these individual cases, and always embedded into a multimodal treatment setting, ALPPS may offer a chance of complete tumor removal and prolonged survival and even a chance for cure.

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confidence: 99%

mentioning

confidence: 99%

Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy in the Treatment of Colorectal Liver Metastases: Current Scenario

Lang¹,

Baumgart²,

Mittler³

2018

Dig Surg

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“…Giving that the starting sFRL was equivalent in the 2 groups (below 20%) before step 1, patients did not experience the same amount of growth with partial ALPPS (79 vs. 59%) in their FLR; nevertheless, there was enough volume to go on to step 2. The effectiveness of partial ALPPS was also studied multi-institutionally with the results leading to the same conclusion [39]. Gaining systemic control of the tumor upfront in patients with CRLM seems logical in these borderline resectable cases.…”

Section: Discussionmentioning

confidence: 93%

Did the International ALPPS Meeting 2015 Have an Impact on Daily Practice The Hamburg Barmbek Experience of 58 Cases

et al. 2017

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Background: ALPPS (associating liver partition and portal vein ligation for staged hepatectomy) was introduced only 10 years ago and has gained wide acceptance as a variation of staged procedures in liver surgery. It has been criticized for its high morbidity and mortality, which all centers reported in their initial series. Methods: After a world expert meeting in Hamburg in 2015 where all experts in the field met to discuss this method, caveats were extracted and formulated. We researched our complete prospective ALPPS database to see if the recommendations had any impact on outcome. Results: In total, we performed 58 ALPPS procedures in our center. 33 patients were operated on before, 25 after the meeting. Results in terms of morbidity and mortality were significantly better after the meeting, as were patient selection and strategy. Conclusion: In our own center's experience, the implementation of the meetings' recommendations and the information gathered through this valuable exchange had a dramatic impact on results. Having performed 58 ALPPS procedures in total, we can now conclude that ALPPS has become much safer in our hands since the 2015 meeting and that morbidity and mortality are no longer the issue to be discussed. Future research must focus on oncologic outcomes in these patients.

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“…In detail, 21 of 28 patients with liver failure after stage 1 died within 90 days after stage 2, especially in the case of a MELD score >10 (odds ratio 3.9-4.9). Surgery-related fatal liver failure was finally confirmed in the publication by Linecker et al [16]. Extracted data for all analyzed publications are displayed in table 1.…”

Section: Pitfalls Detected After Alpps Stage 1 That Led To Adverse Oumentioning

confidence: 89%

“…Reports on ALPPS failure after the stage 1 operation are still very rare. Manuscripts focusing on reasons for failure after ALPPS have so far only been published by Truant et al [14], Schadde et al [15], and Linecker et al [16]. ALPPS still results in a very high in-house mortality and thus also impairs the oncologic outcome of the patients; however, mortality has somewhat improved with better patient selection along with the adherence to the recommended avoidance of certain indications such as perihilar cholangiocarcinoma [11,17].…”

Section: Discussionmentioning

confidence: 99%

A Comparison of Pitfalls after ALPPS Stage 1 or Portal Vein Embolization in Small-for-Size Setting Hepatectomies

Schnitzbauer¹

2017

Visc Med

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Background: Portal vein embolization (PVE) followed by resection and associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) are tools to enable liver resections in small-for-size settings. Methods: A systematic review of the literature and comparison of pitfalls between PVE and resection and after ALPPS stage 1 were performed. Results: Evidence levels were as low as 4 for both procedures. 20 publications were identified with reports on post-PVE or post-ALPPS stage 1 pitfalls. A total of 2,758 patients treated with PVE followed by resection and 698 patients undergoing ALPPS were analyzed. Pitfalls identified were failure to advance to resection (PVE: high (20%)/ALPPS: low (1%); p = 0.0001), tumor progression (PVE: high/ALPPS: low); insufficient hypertrophy (PVE: frequent/ALPPS: rare), and inter-stage liver failure (PVE: rare/ALPPS: frequent). However, in-house mortality was still very high after ALPPS (7 vs. 3%, p = 0.0001) in a pooled analysis. Conclusion: PVE is a well-established technique to induce hypertrophy in small-for-size settings. The weakness of PVE is that it may fail to advance to resection. Inter-stage liver failure in ALPPS triggers post-stage 2 mortality. Prolongation of the inter-stage interval to overcome liver failure or cancellation of the resection stage combined with adherence to defined indications has the potential to make ALPPS much safer and decrease mortality rates. Level of evidence is low for both techniques.

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How much liver needs to be transected in ALPPS? A translational study investigating the concept of less invasiveness

Cited by 59 publications

References 31 publications

Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy in the Treatment of Colorectal Liver Metastases: Current Scenario

Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy in the Treatment of Colorectal Liver Metastases: Current Scenario

Did the International ALPPS Meeting 2015 Have an Impact on Daily Practice The Hamburg Barmbek Experience of 58 Cases

A Comparison of Pitfalls after ALPPS Stage 1 or Portal Vein Embolization in Small-for-Size Setting Hepatectomies

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