ALPPS Procedure for Extended Liver Resections: A Single Centre Experience and a Systematic Review

Abstract

AimTo report a single-centre experience with the novel Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) technique and systematically review the related literature.MethodsSince January 2013, patients with extended primary or secondary liver tumors whose future liver remnant (FLR) was considered too small to allow hepatic resection were prospectively assessed for the ALPPS procedure. A systematic literature search was performed using PubMed, Scopus and the Cochrane Library Central.ResultsUntil July 2014 ALPPS was completed in 9 patients whose mean age was 60±8 years. Indications for surgical resection were metastases from colorectal cancer in 3 cases, perihilar cholangiocarcinoma in 3 cases, intrahepatic cholangiocarcinoma in 2 cases and hepatocellular carcinoma without chronic liver disease in 1 case. The calculated FLR volume was 289±122 mL (21.1±5.5%) before ALPPS-1 and 528±121 mL (32.2±5.7%) before ALLPS-2 (p<0.001). The increase in FLR between the two procedures was 96±47% (range: 24–160%, p<0.001). Additional interventions were performed in 4 cases: 3 patients underwent Roux-en-Y hepaticojejunostomy, and one case underwent wedge resection of a residual tumor in the FLR. The average time between the first and second step of the procedure was 10.8±2.9 days. The average hospital stay was 24.1±13.3 days. There was 1 postoperative death due to hepatic failure in the oldest patient of this series who had a perihilar cholangiocarcinoma and concomitant liver fibrosis; 11 complications occurred in 6 patients, 4 of whom had grade III or above disease. After a mean follow-up of 17.1±8.5 months, the overall survival was 89% at 3–6 and 12 months. The recurrence-free survival was 100%, 87.5% and 75% at 3-6-12 months respectively. The literature search yielded 148 articles, of which 22 articles published between 2012 and 2015 were included in this systematic review.ConclusionThe ALPPS technique effectively increased the resectability of otherwise inoperable liver tumors. The postoperative morbidity in our series was high in accordance with the data from the systematic review. Age, liver fibrosis and presence of biliary stenting were predisposing factors for postoperative morbidity and mortality.

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

“…8,9 This morbidity and mortality is further attenuated in patients with CRLM and in those older than 60 years. 24 This finding supports our centre's recommendation that selection criteria for ALPPS are the cornerstone of successfully improving perioperative outcomes, and, in addition to age and CRLM, we reiterate the importance of good functional status.…”

“…The first published cohort described a 12% perioperative mortality, 2 with other studies reporting similarly high perioperative mortality as well as severe morbidity in up to two-thirds of patients. 24 Our group has previously reported an early experience with ALPPS, showing no deaths within 90 days in a pilot series of 14 patients. 10 In the present series, we again report no deaths within 90 days in 32 patients, which to our knowledge makes this study the largest single-centre cohort with no perioperative mortality.…”

Hypertrophy and Liver Function in ALPPS: Correlation with Morbidity and Mortality

“…methacetin has been administered. It has so far only been published in 1 single case report which demonstrated a dramatic decrease in global liver function between stage-1 and stage-2 ALPPS [42].…”

Asociación de Partición Hepática y Ligadura Portal para Hepatectomía por Etapas (ALPPS)

“…Sin embargo, existen otras indicaciones mucho menos frecuentes como metástasis de tumores de Wilms, ovario, cérvix uterino, estómago. GISTs y melanoma (Nadalin et al, 2014;Schadde et al, 2014a;Ratti et al;Rochet et al;Zhang et al, 2014;Hasselgren et al, 2015;Lang et al, 2015;Truant et al, 2015;Vivarelli et al, 2015;Buac et al;Björnsson et al, 2016a;Røsok et al, 2016); todo lo cual, debe estar en relación con la existencia de un hígado remanente menor de 25 % a 30 % (hígados sanos) y menor de 40 % (hígados colestásicos, esteatósicos, con fibrosis, o con cambios patológicos secundarios a quimioterapia (Nadalin et al; Ratti et al; Zhang et al; Buac et al).…”