Risk Adjustment in ALPPS Is Associated With a Dramatic Decrease in Early Mortality and Morbidity

Abstract

Risk adjustment of patient selection and technique in ALPPS resulted in a continuous drop of early mortality and major postoperative morbidity, which has meanwhile reached standard outcome measures accepted for major liver surgery.

Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy in the Treatment of Colorectal Liver Metastases: Current Scenario

“…The data confirm that even after chemotherapy there is a low perioperative complication and mortality rate possible in ALPPS [44]. Two most recent publications of the ALPPS Registry in 2016 and 2017 noted a continuous drop in risk-adjusted early mortality and morbidity [46, 47]. While a meta-analysis by Moris et al [48] still accounted a higher morbidity and mortality in ALPPS but with no difference in liver-related mortality data of the first, and so far only randomized controlled trial (RCT), the most definite way to compare ALPPS versus TSH/PVE, showed no difference in the perioperative complication (Clavien-Dindo grade III–IV) and the 90-day-mortality rate.…”

Dealing with insufficient liver remnant: Associating liver partition and portal vein ligation for staged hepatectomy

“…Colorectal liver metastases (CRLM) have turned out to be the prime indication for ALPPS (Figure ) . Colorectal cancer is the third most frequent cancer worldwide and nearly half of these patients are confronted with liver metastases either already at the time of diagnosis (synchronous) or later (metachronous).…”

“…This unfavorable safety profile of ALPPS has led to skepticism in the pioneer phase of this procedure and even some experienced hepatobiliary centers stopped performing this procedure. Over time, various risk factors for procedure‐related morbidity and mortality have been identified and the perioperative outcome of ALPPS has significantly improved . Tumor entities other than CRLM and advanced age (≥67 years) appear to elevate the risk of early mortality, which theoretically might be avoided upfront .…”

“…Although the excessive application of chemotherapy in CRLM can also lead to chemotherapy‐associated liver injury (CALI), the most likely explanation for the better tolerability of ALPPS in CRLM is the absence of chronic underlying liver disease as observed in hepatocellular carcinoma or biliary complications in cholangiocarcinoma. Another important factor, which led to improved safety of ALPPS is the increased utilization of ALPPS variants minimizing the impact of stage 1 surgery …”

Ex vivo liver resection coupled with associated liver partition and portal vein ligation: Combining existing techniques to achieve surgical resectability

“…2,3 Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has expanded the treatment armamentarium for extensive hepatic resection by addressing the function and size of the future liver remnant (FLR), particularly when percutaneous portal vein embolization (PVE) is unfeasible. [5][6][7] A 73-yearold patient with cholangiocarcinoma faced challenging R0 resection secondary to tumor involvement of major hepatic vasculature, inadequate FLR, and inability to undergo PVE. Minimizing concerns associated with traditional two-staged hepatectomy, and with risk adjustment, ALPPS results in acceptable morbidity and mortality rates.…”