How should liver hypertrophy be stimulated? A comparison of upfront associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) and portal vein embolization (PVE) with rescue possibility

Abstract

Background: The role of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in comparison to portal vein embolization (PVE) is debated. The aim of this study was to compare successful resection rates (RR) with upfront ALPPS vs. PVE with rescue ALPPS on demand and to compare the hypertrophy of the liver between ALPPS and PVE plus subsequent rescue ALPPS.Methods: A retrospective analysis of all patients treated with PVE for colorectal liver metastasis (CRLM)or ALPPS (any diagnosis, rescue ALPPS included) at five Scandinavian university hospitals during the years 2013-2016 was conducted. A Chi-square test and a Mann-Whitney U test were used to assess the difference between the groups. A successful RR was defined as liver resection without a 90-day mortality.Results: A total of 189 patients were included. Successful RR was in 84.5% of the patients with ALPPS upfront and in 73.3% of the patients with PVE and rescue ALPPS on demand (P=0.080). The hypertrophy of the future liver remnants (FLRs) with ALPPS upfront was 71% (48-97%) compared to 96% (82-113%) after PVE and rescue ALPPS (P=0.010).Conclusions: Upfront ALPPS offers a somewhat higher successful RR than PVE with rescue ALPPS on demand. The sequential combination of PVE and ALPPS leads to a higher overall degree of hypertrophy than upfront ALPPS.

Portal Vein Embolization Using N-Butyl Cyanoacrylate-Glue: What Impact Does a Central Vascular Plug Have?

“…No patients were unable to be resected due to insufficient growth, but patients with an sFLR < 20% relatively more often needed an additional volume-expanding procedure prior to resection. This is in line with earlier reports [ 20 ], and it might be a useful cutoff for considering more invasive strategies upfront such as ALPPS or liver venous deprivation–simultaneous hepatic and portal vein embolization (double vein embolization) [ 22 , 23 ].…”

“…In case of insufficient FLR growth (post-PVE sFLR < 30% and/or limited hypertrophy from pre-PVE volumetry) on the follow-up CT, the multidisciplinary team (MDT) decided either to refer the patient to re-PVE where obvious missed branches were seen on post-PVE CT, wait for additional growth or to perform a rescue ALPPS (Associating Liver Partition and Portal vein Ligation for Staged hepatectomy–ALPPS) in order to stimulate further growth [ 19 , 20 ].…”

Safety and efficacy of right portal vein embolization in patients with prior left lateral liver resection

“…In fact, results of a recent study by Sparrelid et al. (18) suggest that a lower sFLR baseline is associated with a significant higher need of rescue ALPPS after PVE.…”

“…Additionally, combined portal and hepatic vein embolization or "associating liver partition with portal vein ligation for staged hepatectomy" (ALPPS) are other options for patients who are at risk for insufficient hypertrophy (17). In fact, results of a recent study by Sparrelid et al (18) suggest that a lower sFLR baseline is associated with a significant higher need of rescue ALPPS after PVE.…”

Establishment of a Rat Model of Liver Venous Deprivation: Simultaneous Portal and Hepatic Vein Ligation

“…7,8 PVE has become a widely used but inefficient approach to stimulate hypertrophy of FLR, and the ALPPS procedure seems to be more aggressive and efficient but is accompanied by more complications. [1][2][3]9 The safety and efficacy of LVD remain unclear because of a relatively limited number of studies. A recent multicenter study compared LVD with PVE and reported that LVD achieved better FLR hypertrophy (59% vs. 48%; p=0.020) and resectability (90% vs. 68%; p=0.007) than PVE.…”