Can we improve the morbidity and mortality associated with the associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) procedure in the management of colorectal liver metastases?

Hernandez‐Alejandro, Roberto; Bertens, Kimberly A.; Pineda-Solís, Karen; Croome, Kristopher P.

doi:10.1016/j.surg.2014.08.041

Cited by 120 publications

(125 citation statements)

References 36 publications

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“…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. 4 The largest available studies reporting on short-term outcomes of ALPPS are analyses of the International ALPPS Registry, with a published 90-day mortality of 9% and a severe complication (Clavien-Dindo ≥ IIIb) rate of 27%.…”

Section: Discussionsupporting

confidence: 63%

“…We reported our initial experience with ALPPS, which had an overall complication rate of 36%, a severe complication rate of 14% and no deaths within 90 days. 10 Recently, Alvarez and colleagues 11 reported high oncological feasibility with adequate patient safety. The morbidity in their series according to the Clavien-Dindo classification was 53% (43% for grade IIIa or higher and 31% for grade IIIb or higher) and mortality was 6.6%.…”

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confidence: 99%

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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: 63%

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confidence: 99%

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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“…8,9 Three methods to enlarge FLR are possible in this situation before ERH: (1) surgical right-sided portal vein ligation (PVL), 10,11 (2) portal vein embolization (PVE) as an interventional approach used by various centres [12][13][14] and (3) the surgical approach of "associating liver partition with PVL for staged hepatectomy". [15][16][17] However, as hypertrophy following PVE is necessary but highly variable, we retrospectively analyzed data from our patient cohort for differences in those with good hypertrophy (increase to .25% of the sFLR) and those with a less beneficial increase in size of sFLR.…”

Section: Introductionmentioning

confidence: 99%

Identification of cofactors influencing hypertrophy of the future liver remnant after portal vein embolization—the effect of collaterals on embolized liver volume

Zeile¹,

Bakal

Volkmer³

et al. 2016

The British Journal of Radiology

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Objective: The purpose of this retrospective study was to monitor hypertrophy of future liver remnant following portal vein embolization (PVE) before planned extended right hepatectomy. However, because individual responses to PVE are highly variable, our focus was to identify cofactors of successful hypertrophy. Methods: 28 patients with primary or secondary liver tumours, mean age 64.1 6 12.9 years, underwent PVE. Volumetric analysis of hypertrophy before and after PVE (median 39.0 6 15.7 days) was performed. The embolized liver segments were investigated for occurrence of reperfusion of their portal branches. Blood parameters before PVE were additionally investigated. Results: Patients were divided into responders (21/28) and non-responders (7/28) by post-PVE standardized future liver remnant being above or below 25%, respectively. No significant differences between the groups were found regarding biometric and volumetric parameters before PVE. In the entire group after PVE, the mean absolute increase of Segments 2 and 3 was 196.0 6 84.7 cm 3 and the median relative increase was 46.6 6 98.8%. The formation of left to right hepatic portoportal collaterals exhibited a negative correlation to successful hypertrophy (p 5 0.004) as well as low plasma total protein (p 5 0.019). Successful embolization of Segment IV showed only a trend to significance (p 5 0.098). Conclusion: Cofactors associated with a favourable outcome regarding hypertrophy were the absence of collaterals in the control CT scans and high plasma total protein. Advances in knowledge:Portoportal collaterals negatively influence hypertrophy after PVE. On the other hand, plasma total protein is a positive prognostic indicator on hypertrophy of the liver in our cohort.

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“…Unfortunately, the rates of major mortality were almost 40% in most studies, and the postoperative mortality rates ranged between 8 and 12% (109)(110)(111)(112). Due to these poor short-term outcomes, the association of the primary tumor resection during the first stage of the ALPPS seems to be hazardous.…”

Section: Associating Liver Partition and Portal Vein Ligation For mentioning

confidence: 99%

Surgical Options in Synchronous Liver Metastases from Colorectal Cancer

Alexandrescu¹,

Diaconescu²,

Popescu³

2017

JTMR

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Currently, the treatment of liver metastases of colorectal cancer (CRC) requires a multidisciplinary approach and should be individualized for each patient. Liver resection provides 5 years survival rates ranging between 30 and 58% in patients with liver metastases of CRC. The optimal timing of liver resection, resection of the primary tumor and neoadjuvant chemotherapy has not been fully established, yet, neither for initially resectable synchronous liver metastases, nor for those initially unresectable which could be converted to resectability. Advocates of simultaneous resection and those of staged resection (delayed liver resection or "liver first approach"), both presented theoretical arguments in favor of each of these therapeutic strategies. Progresses in liver surgery, anesthesia, intensive care and oncology caused a paradigm shift regarding the approach of synchronous colorectal liver metastases, with simultaneous resection (SR) becoming a safer procedure in the last decade. As well, the oncologic outcomes of SR are similar to those achieved by staged resection. In this review we present the literature data concerning the results achieved by each of the currently available therapeutic approaches. Abbreviations: CLMs -colorectal liver metastases, SCLMs -synchronous colorectal liver metastases, CRC -colorectal cancer, PVL-portal vein ligation, PVE -portal vein embolization, SR -simultaneous resection, DR -delayed liver resection, SgR -staged resections, FLR -future liver remnant, CHT -chemotherapy, OS -overall survival, DFS -disease-free survival, ETS -early tumor shrinkage

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Can we improve the morbidity and mortality associated with the associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) procedure in the management of colorectal liver metastases?

Cited by 120 publications

References 36 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?

Identification of cofactors influencing hypertrophy of the future liver remnant after portal vein embolization—the effect of collaterals on embolized liver volume

Surgical Options in Synchronous Liver Metastases from Colorectal Cancer

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