Conventional Two-Stage Hepatectomy or Associating Liver Partitioning and Portal Vein Ligation for Staged Hepatectomy for Colorectal Liver Metastases? A Systematic Review and Meta-Analysis

Abstract

Background: Pushing the surgical limits for initially unresectable colorectal liver metastases (CRLM) are two approaches for sequential liver resection: two-stage hepatectomy (TSH) and associating liver partitioning and portal vein ligation for staged hepatectomy (ALPPS). However, the role of each treatment modality remains ill-defined. The present meta-analysis was designed to compare the safety, efficacy, and oncological benefits between ALPPS and TSH in the management of advanced CRLM. Methods: A systematic literature search was conducted from online databases through to February 2020. Single-arm synthesis and cumulative meta-analysis were performed. Results: Eight studies were included, providing a total of 409 subjects for analysis (ALPPS: N = 161; TSH: N = 248). The completions of the second stage of the hepatectomy [98 vs. 78%, odds ratio (OR) 5.75, p < 0.001] and R0 resection (66 vs. 37%; OR 4.68; p < 0.001) were more frequent in patients receiving ALPPS than in those receiving TSH, and the waiting interval was dramatically shortened in ALPPS (11.6 vs. 45.7 days, weighted mean difference = −35.3 days, p < 0.001). Nevertheless, the rate of minor complications was significantly higher in ALPPS (59 vs. 18%, OR 6.5, p < 0.001) than in TSH. The two treatments were similar in 90-day mortality (7 vs. 5%, p = 0.43), major complications (29 vs. 22%, p = 0.08), posthepatectomy liver failure (PHLF; 9 vs. 9%, p = 0.3), biliary leakage (11 vs. 14%, p = 0.86), length of hospital stay (27.95 vs. 26.88 days, p = 0.8), 1-year overall survival (79 vs. 84%, p = 0.61), 1-year recurrence (49 vs. 39%, p = 0.32), and 1-year disease-free survival (34 vs. 39%, p = 0.66). Cumulative meta-analyses indicated chronological stability for the pooled effect sizes of resection rate, 90-day mortality, major complications, and PHLF. Zhang et al. ALPPS for Colorectal Liver Metastases Conclusions: Compared with TSH, ALPPS for advanced CRLM resulted in superior surgical efficacy with comparable perioperative mortality rate and short-term oncological outcomes, while this was at the cost of increased perioperative minor complications.

Is the extent of functional liver remnant increase truly “functional”? A single-institution case series of patients with associating liver partition and portal vein ligation for staged hepatectomy (ALPPS)

“…We also demonstrated the feasibility and safety of ALPPS in a low-volume centre. Our overall morbidity was 60%, which is comparable to overall minor complications of 59% reported in a meta-analysis on 161 patients who underwent ALPPS [3]. Our results were also similar to results reported by other low-volume centres (overall post-operative complication rate 66.7%) [23].…”

“…To reduce this risk, guidelines state a minimum of future liver remnant (FLR) > 20-25% in healthy patients without underlying liver disease prior to extended hepatectomy [ 2 ]. Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) is a two-staged procedure aimed to induce rapid hypertrophy of the FLR to reduce risk of PHLF, with higher successful completion of second stage of hepatectomy (98% vs. 78%, odds ratio [OR] = 5.75, p < 0.001), R0 resection (66% vs. 37%, OR = 4.68, p < 0.001) and shorter waiting time between the first and second stage of hepatectomy (11.6 vs. 45.7 days, weighted mean difference [MD] = −35.3 days, p < 0.001) compared to conventional two-stage hepatectomy (TSH) [ 3 ].…”

Oncological Outcomes after Liver Venous Deprivation for Colorectal Liver Metastases: A Single Center Experience

“…In the same paper, oncological outcomes after ALPPS procedure seem to be likewise comparable to LVD results, with a 3-year OS of 37% and a median DFS of 19 months [ 35 ]. Similarly, a very recent meta-analysis comparing ALPPS with a traditional two-stage hepatectomy found a 1-year OS of 79 vs. 84% respectively for ALPPS and PVE [ 36 ]. A recent meta-analysis by Giglio et al has also reported that PVE does not negatively affect oncological outcomes after major liver resections in patients with CRLM [ 37 ].…”

Ligation of the middle hepatic vein to increase hypertrophy induction during the ALPPS procedure

“…Considering this within the context of the literature, several papers show similar results. For example, Vicente et al found an SFSS rate of 22.2% [ 35 ], and Zhang et al indicated that 75% of ALPPS-associated mortality was due to post hepatectomy liver failure [ 36 ]. In addition, a recent review by Chan et al from 2020 highlights that the main complications of ALPPS are high morbidity (Clavien-Dindo ≥ Grade IIIB complications) and 90-day mortality.…”