Associating liver partition and portal vein ligation for staged hepatectomy for Klatskin tumours:<i>hinc sunt leones</i>!

Donati, Marcello; Stavrou, Gregor A.; Gulik, Thomas M. van; Oldhafer, Karl J.

doi:10.1111/ans.12893

Cited by 12 publications

(7 citation statements)

References 9 publications

(18 reference statements)

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“…Theoretically, ALPPS is highly suitable for treatment of hilar cholangiocarcinoma. Donati et al [105] summarized the reasons for this: pre-PVE that predetermines the side of the liver to be resected can be avoided, hepaticojejunostomy is performed during the first step to drain the cholestatic biliary tree, and the impact of small-for-size syndrome is reduced and the surgeon can check the liver remnant at the site of the hepaticojejunostomy and control a possible bile leak. However, indications for treatment of Klatskin's tumor are debated since the procedure is technically demanding and it has a high mortality.…”

Section: Discussionmentioning

confidence: 99%

An updated systematic review of the evolution of ALPPS and evaluation of its advantages and disadvantages in accordance with current evidence

et al. 2016

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The main obstacle to achieving an R0 resection after a major hepatectomy is inability to preserve an adequate future liver remnant (FLR) to avoid postoperative liver failure (PLF). Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a novel technique for resecting tumors that were previously considered unresectable, and this technique results in a vast increase in the volume of the FLR in a short period of time. However, this technique continues to provoke heated debate because of its high mortality and morbidity.The evolution of ALPPS and its advantages and disadvantages have been systematically reviewed and evaluated in accordance with current evidence. Electronic databases (PubMed and Medline) were searched for potentially relevant articles from January 2007 to January 2016.ALPPS has evolved into various modified forms. Some of these modified techniques have reduced the difficulty of the procedure and enhanced its safety. Current evidence indicates that the advantages of ALPPS are rapid hypertrophy of the FLR, the feasibility of the procedure, and a higher rate of R0 resection in comparison to other techniques. However, ALPPS is associated with worse major complications, more deaths, and early tumor recurrence.Hepatobiliary surgeons should carefully consider whether to perform ALPPS. Some modified forms of ALPPS have reduced the mortality and morbidity of the procedure, but they cannot be recommended over the original procedure currently. Portal vein embolization (PVE) is still the procedure of choice for patients with a tumor-free FLR, and ALPPS could be used as a salvage procedure when PVE fails. More persuasive evidence needs to be assembled to determine whether ALPPS or two-stage hepatectomy (TSH) is better for patients with a tumor involving the FLR. Evidence with regard to long-term oncological outcomes is still limited. More meticulous comparative studies and studies of the 5-year survival rate of ALPPS could ultimately help to determine the usefulness of ALPPS. Indications and patient selection for the procedure need to be determined.

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Section: Discussionmentioning

confidence: 99%

An updated systematic review of the evolution of ALPPS and evaluation of its advantages and disadvantages in accordance with current evidence

et al. 2016

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“…(15) However, in the subgroup of 11 patients with PHC, ALPPS resulted in 27% mortality. (15) Although these figures fueled the discussion whether ALPPS should be contraindicated in PHC patients,(16, 17, 24) ALPPS is employed in patients with very small FLRs, usually in connection with extended right hemihepatectomy. (15) The latter two factors have also been associated with substantial mortality following resection of PHC.…”

Section: Discussionmentioning

confidence: 99%

“…right to left hepatectomy or right to left depending on intra-operative findings. (24) ALPPS has the advantage that the ultimate decision to proceed can be taken during the operation. However, the functional value of the rapid increase in liver volume seen after stage 1 in ALPPS needs furher clinical assessment.…”

Section: Discussionmentioning

confidence: 99%

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

Olthof

Coelen

Wiggers

et al. 2017

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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.

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“…Still, a dropout rate of 16% is half that reported for PVE cases. On the other hand, we have found a new concept for the treatment of Klatskin tumors, as we still see ALPPS as an option in selected cases [46]. In 2 Klatskin tumor patients (Bismuth IIIa type), PVE extended to segment 4 was followed by laparoscopic partial ALPPS because hypertrophy of the sFLR was insufficient.…”

Section: Discussionmentioning

confidence: 99%

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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Associating liver partition and portal vein ligation for staged hepatectomy for Klatskin tumours:hinc sunt leones!

Cited by 12 publications

References 9 publications

An updated systematic review of the evolution of ALPPS and evaluation of its advantages and disadvantages in accordance with current evidence

An updated systematic review of the evolution of ALPPS and evaluation of its advantages and disadvantages in accordance with current evidence

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

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

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