High mortality after ALPPS for perihilar cholangiocarcinoma: case-control analysis including the first series from the international ALPPS registry

Abstract

Introduction Resection of perihilar cholangiocarcinoma (PHC) entails high-risk surgery with substantial postoperative mortality reported up to 18%, even in specialized centers. The aim of this study was to compare outcomes of PHC patients who underwent associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) to patients with a small functional liver remnant who underwent resection without ALPSS. Methods All patients who underwent ALPPS for PHC were identified from the international ALPPS registry and matched controls were selected from a standard resection cohort from two centers based on future remnant liver size. Outcomes included morbidity, mortality, and overall survival. Results Of the 37 patients who had undergone ALPPS for PHC in the registry, 29 had sufficient data for analyses. ALPPS for PHC was associated with a 48% (14/29) 90-day mortality and median OS of 6 months. A total of 257 patients underwent major liver resection for PHC without ALPPS. The 90-day mortality was 13% and median OS 46 months. The 29 ALPPS patients were matched to 29 patients resected without ALPPS, with similar future liver remnant volume (P=0.480). Mortality in the matched control group was 24% (P=0.100) and median OS was 27 months (P = 0.064). Discussion Outcomes of ALPPS for PHC appear inferior when compared to standard extended resections in high-risk patients. Considering these outcomes, portal vein embolization should remain the preferred method to increase future remnant liver volume in PHC patients. ALPPS is not recommended for PHC due to the 48% 90-day mortality in expert centers.

Percutaneous radiofrequency-assisted liver partition versus portal vein embolization before hepatectomy for perihilar cholangiocarcinoma

“…Major morbidity was seen in only three of 11 patients, compared with 13 of 29 patients with PHCC who underwent conventional ALPPS in one series 9 . Major morbidity was seen in only three of 11 patients, compared with 13 of 29 patients with PHCC who underwent conventional ALPPS in one series 9 .…”

“…This was considered inferior to standard extended resections, leading the authors to recommend that ALPPS should not be performed for PHCC 9 . This was considered inferior to standard extended resections, leading the authors to recommend that ALPPS should not be performed for PHCC 9 .…”

‘In-Situ Split' Liver Resection/ALPPS - Historical Development and Current Practice

“…Interestingly, the indication for the novel procedure in the first patient turned out to be rather suboptimal, and it has rarely been used for this indication since (including our center) [15,16,17]. However, a broad range of other indications in which the technique is useful have emerged and include many primary (predominantly hepatocellular carcinoma and iCCC) [18] as well as secondary liver tumors, i.e.…”

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

“…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].…”

“…Clavien and de Santibañes [8] established a now commonly used descriptive name for this new procedure: associating liver partition and portal vein ligation for staged hepatectomy, the so-called ALPPS procedure. However, just as most innovations suffer from initial throwbacks, the exploration phase of ALPPS also unveiled relevant morbidity in patients as well as unacceptable high mortality rates, especially in unselected patient cohorts and in certain indications such as perihilar cholangiocarcinoma [9][10][11]. Driven by the ALPPS registry, certain recommendations have been made concerning indications, surgical-technical modifications, and patient management, discussed and worded during the 1st international ALPPS consensus meeting in Keywords ALPPS · Portal vein embolization, PVE · Liver resection · Small-for-size setting · Pre-completion pitfalls · Failure Summary 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.…”