ALPPS Offers a Better Chance of Complete Resection in Patients with Primarily Unresectable Liver Tumors Compared with Conventional‐Staged Hepatectomies: Results of a Multicenter Analysis

Schadde, Erik; Ardiles, Victoria; Slankamenac, Ksenija; Tschuor, Christoph; Sergeant, Gregory; Amacker, Nadja; Baumgart, Janine; Croome, Kris P.; Hernandez‐Alejandro, Roberto; Lang, Hauke; Santibañés, Eduardo de; Clavien, Pierre Alain

doi:10.1007/s00268-014-2513-3

Cited by 254 publications

(272 citation statements)

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“…22 Second, the completion rate of ALPPS significantly eclipses that of conventional 2-staged hepatectomy, with few patients failing to reach stage 2 of the procedure due to tumour progression. 23 Our results support the previous evidence of high feasibility of ALPPS. We found minimal interstage dropout, excellent FLR hypertrophy and a reduction in blood transfusion between stages in the late group without any compromise in perioperative outcomes.…”

Section: Discussionsupporting

confidence: 83%

Optimizing associated liver partition and portal vein ligation for staged hepatectomy outcomes: Surgical experience or appropriate patient selection?

Hasan

Tun-Abraham

Wanis

et al. 2017

CJS

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Background: Early reports of associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) outcomes have been suboptimal. The literature has confirmed that learning curves influence surgical outcomes. We have 54 months of continuous experience performing ALPPS with strict selection criteria. This study aimed to evaluate the impact of the learning curve on ALPPS outcomes. Methods:We retrospectively compared patients who underwent ALPPS between April 2012 and March 2016. Patients were grouped into 2 24-month (early and late) periods. All candidates had a high tumour load requiring staged hepatectomy after chemotherapy response, a predicted future liver remnant (FLR) less than 30% and good performance status. Results:Thirty-three patients underwent ALPPS during the study period: 16 in the early group (median age 65 yr, mean body mass index [BMI] 27) and 17 in the late group (median age 60 yr, mean BMI 25). Bilobar disease was comparable in both groups (94% v. 88%, p > 0.99). Duration of surgery was not statistically different. Intraoperative blood loss and need for transfusion were significantly lower in the late group (200 ± 109 mL v. 100 ± 43 mL, p < 0.05). The late group had a higher proportion of monosegment ALPPS (4:1). There were no deaths within 90 days in either cohort. Rates of postoperative complications were not statistically significant between groups. The R0 resection rate was similar. The entire 1-year disease-free and overall survival were 52% and 84%, respectively. Conclusion:Excellent results can be obtained in innovative complex surgery with careful patient selection and good technical skills. Additionally, the learning curve brought confidence to perform more complex procedures while maintaining good outcomes.Contexte : Les premiers résultats sur l'association de la partition hépatique et de la ligature portale pour l'hépatectomie en 2 temps (ALPPS) sont sous-optimaux. La littérature a confirmé que les courbes d'apprentissage influencent les résultats des interventions chirurgicales. Notre étude reposait sur 54 mois consécutifs d'utilisation de la technique ALPPS selon des critères de sélection rigoureux. Elle visait à évaluer l'effet de la courbe d'apprentissage sur les résultats liés à l'ALPPS.Méthodes : Nous avons procédé à une comparaison rétrospective des patients traités par l'ALPPS entre avril 2012 et mars 2016. Nous avons divisé les patients en 2 groupes de 24 mois (précoce et tardif). Tous les candidats avaient une charge tumorale élevée nécessitant une hépatectomie en 2 temps après une réponse à la chimiothérapie, un volume estimé de futur foie résiduel (FFR) inférieur à 30 % et un indice fonctionnel favorable. Résultats :Trente-trois patients ont été traités par l'ALPPS pendant la période de l'étude : 16 dans le groupe précoce (âge médian 65 ans, indice de masse corporelle [IMC] moyen 27) et 17 dans le groupe tardif (âge médian 60 ans, IMC moyen 25). Le taux de maladie bilobaire était comparable entre les 2 groupes (94 % c. 88 %, p > 0,99). La durée de la chirurgie...

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Section: Discussionsupporting

confidence: 83%

Optimizing associated liver partition and portal vein ligation for staged hepatectomy outcomes: Surgical experience or appropriate patient selection?

Hasan

Tun-Abraham

Wanis

et al. 2017

CJS

Self Cite

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“…A multicentric analysis revealed an 11-fold faster hypertrophy after ALPPS than after PVE (28). As hypertrophy is achieved more rapidly after ALPPS, the complete resection of the tumor could be performed in a shorter period of time, which offers some benefits: 1. the risk of disease progression between the two stages of the operation decreases (25,29); 2. the patient recovers more rapidly, decreasing the length of hospital stay (25); 3. the postoperative chemotherapy could be delivered sooner than in patients undergoing "twostage" operations (25).…”

Section: Discussion Discussionmentioning

confidence: 99%

“…Thus, major morbidity (Dindo-Clavien III or more) rates after ALPPS ranged between 27 and 41% in series presented until now (24,26,28,30,31). Moreover, the high mortality rates (up to 12.5% in most series) raise concerns about the indications, limits and surgical technique used for ALPPS (26,28). These factors were assessed in some recent papers and the authors recommended avoiding ALPPS in patients older than 60 years-old and in patients with hilar cholangiocarcinoma (28,32).…”

Section: Discussion Discussionmentioning

confidence: 99%

“…Moreover, the high mortality rates (up to 12.5% in most series) raise concerns about the indications, limits and surgical technique used for ALPPS (26,28). These factors were assessed in some recent papers and the authors recommended avoiding ALPPS in patients older than 60 years-old and in patients with hilar cholangiocarcinoma (28,32). Other experts also recommended avoiding ligation of the right bile duct during the first operation (30) and revealed that obesity, post-stage one biliary fistula and ascites or infected/bilious peritoneal fluid at stage two operation were significantly associated with major morbidity and mortality (26).…”

Section: Discussion Discussionmentioning

confidence: 99%

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Primary Hepatic Lymphoma Resected by ALPPS Procedure (Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy)

Alexandrescu¹,

Stoica²,

Grigorie³

et al. 2016

JTMR

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Background: Primary hepatic lymphoma represents a very rare location of non-Hodgkin lymphomas, whose treatment consists of liver tumor resection followed by chemotherapy. In some cases, however, upfront hepatectomy is not feasible due to insufficient volume of the liver remnant. Case report: An ALPPS (Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy) procedure was performed in a patient with a large primary hepatic lymphoma, whose estimated liver remnant represented only 13% of total liver volume, it was performed. During the first stage, we performed right portal branch ligation and in situ splitting, without right bile duct ligation. After the first stage, the patient did not develop biliary fistula, ascites or sepsis. The volume of segments 2 and 3 increased by 98% after eleven days, making possible subsequent resection of the tumor by a right trisectionectomy. The patient did not develop any complication, being discharged 9 days after the second stage of ALPPS. Postoperatively, the patient underwent chemotherapy, being disease-free at 13 months following operation. Conclusion: This is the first patient presented in the literature who underwent ALPPS for resection of a primary hepatic lymphoma. This type of tumor could be managed by ALPPS, with low morbidity and mortality rates. Abbreviations: ALPPS -Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy, PHL -primary hepatic lymphoma, PVE -portal vein embolization, PVL -portal vein ligation, FLR -future liver remnant

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“…7 The ALPPS procedure has also been compared with the wellestablished technique of portal vein embolization/ ligation (PVE/PVL). 10 These comparisons have shown that 79% of patients undergoing ALPPS achieved cancer-free resection at three months compared with 58% in the PVE/PVL arm (odds ratio 2.80, confidence interval 1.12-6.98, p = 0.027). Volume increases per day were 11 times more rapid with ALPPS (34.…”

Section: Box 1: Case Descriptionmentioning

confidence: 99%

Two-stage hepatectomy for liver metastasis from colorectal cancer

Selby

Hernandez‐Alejandro

2014

CMAJ

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ALPPS Offers a Better Chance of Complete Resection in Patients with Primarily Unresectable Liver Tumors Compared with Conventional‐Staged Hepatectomies: Results of a Multicenter Analysis

Abstract: This study provides evidence that ALPPS offers a better chance of complete resection in patients with primarily unresectable liver tumors at the cost of a high mortality. The technique is promising but should currently not be used outside of studies and registries.

Cited by 254 publications

References 45 publications

Optimizing associated liver partition and portal vein ligation for staged hepatectomy outcomes: Surgical experience or appropriate patient selection?

Optimizing associated liver partition and portal vein ligation for staged hepatectomy outcomes: Surgical experience or appropriate patient selection?

Primary Hepatic Lymphoma Resected by ALPPS Procedure (Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy)

Two-stage hepatectomy for liver metastasis from colorectal cancer

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