A better route to ALPPS: minimally invasive vs open ALPPS

Abstract

Background Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has gained both interest and controversy, as an alternative to portal vein embolisation (PVE) by inducing future liver remnant hypertrophy in patients at risk of liver failure following major hepatectomy. Open ALPPS induces more extensive hypertrophy in a shorter timespan than PVE; however, it is also associated with higher complication rates and mortality. Minimally invasive surgery (MIS), with its known benefits, has been applied to ALPPS in the hope of reducing the surgical insult and improving functional recovery time while preserving the extensive FLR hypertrophy. Methods A search of the PubMed, Medline, EMBASE and Cochrane Library databases was conducted on 10 July 2019. 1231 studies were identified and screened. 19 open ALPPS studies, 3 MIS ALPPS and 1 study reporting on both were included in the analysis. Results 1088 open and 46 MIS-ALPPS cases were included in the analysis. There were significant differences in the baseline characteristic: open ALPPS patients had a more diverse profile of underlying pathologies (p = 0.028) and comparatively more right extended hepatectomies (p = 0.006) as compared to right hepatectomy and left extended hepatectomy performed. Operative parameters (time and blood loss) did not differ between the two groups. MIS ALPPS had a lower rate of severe Clavien-Dindo complications (≥ IIIa) following stage 1 (p = 0.063) and significantly lower median mortality (0.00% vs 8.45%) (p = 0.007) compared to open ALPPS. Conclusion Although MIS ALPPS would seem to be better than open ALPPS with reduced morbidity and mortality rates, there is still limited evidence on MIS ALPPS. There is a need for a higher quality of evidence on MIS ALPPS vs. open ALPPS to answer whether MIS ALPPS can replace open ALPPS.

Synchronous Two-Stage Hepatectomy With Associated Liver Partition and Portal Vein Ligation in Addition to Low Anterior Resection for Metastatic Rectal Cancer

“…Patient selection may represent one of the major biases to standardize this practice. Further randomized control studies are needed to better define the patient population that may benefit from this approach [13][14][15].…”

Impact of sarcopenia on the future liver remnant growth after portal vein embolization and associating liver partition and portal vein ligation for staged hepatectomy in patients with liver cancer: A systematic review

“…Its incidence is even greater than that of insufficient liver growth contributing to a “failed” PVE, 19% vs 11%, as reported in the international DRAGON trial ( 42 ). This may be partly due to the slow growth after PVE, approximately 4-8 weeks to induce an FLR growth of 12-38% ( 9 , 43 ). During this long waiting interval, the tumor is likely to progress, leaving the patient not eligible for surgery anymore.…”

Laparoscopic ICG-guided ralpps procedure for HCC on cirrhosis with 3D reconstruction implementation: a case report

“…This allows an increase in the FLR blood flow and the disruption of all cross-exchanges between neoplastic and healthy liver segments. These advantages add up to the benefits of a laparoscopic approach, which produces a lower inflammatory response (reducing the development of adhesions, thus facilitating the second stage), less postoperative pain and shorter length of stay [26,27] .…”