Gut and Liver is an international journal of gastroenterology, focusing on the gastrointestinal tract, liver, biliary tree, pancreas, motility, and neurogastroenterology. Gut atnd Liver delivers up-to-date, authoritative papers on both clinical and research-based topics in gastroenterology. The Journal publishes original articles, case reports, brief communications, letters to the editor and invited review articles in the field of gastroenterology. The Journal is operated by internationally renowned editorial boards and designed to provide a global opportunity to promote academic developments in the field of gastroenterology and hepatology. +MORE
Yong Chan Lee |
Professor of Medicine Director, Gastrointestinal Research Laboratory Veterans Affairs Medical Center, Univ. California San Francisco San Francisco, USA |
Jong Pil Im | Seoul National University College of Medicine, Seoul, Korea |
Robert S. Bresalier | University of Texas M. D. Anderson Cancer Center, Houston, USA |
Steven H. Itzkowitz | Mount Sinai Medical Center, NY, USA |
All papers submitted to Gut and Liver are reviewed by the editorial team before being sent out for an external peer review to rule out papers that have low priority, insufficient originality, scientific flaws, or the absence of a message of importance to the readers of the Journal. A decision about these papers will usually be made within two or three weeks.
The remaining articles are usually sent to two reviewers. It would be very helpful if you could suggest a selection of reviewers and include their contact details. We may not always use the reviewers you recommend, but suggesting reviewers will make our reviewer database much richer; in the end, everyone will benefit. We reserve the right to return manuscripts in which no reviewers are suggested.
The final responsibility for the decision to accept or reject lies with the editors. In many cases, papers may be rejected despite favorable reviews because of editorial policy or a lack of space. The editor retains the right to determine publication priorities, the style of the paper, and to request, if necessary, that the material submitted be shortened for publication.
Hauke Lang , Janine Baumgart
, Jens Mittler
Correspondence to: Hauke Lang
Department of General, Visceral, and Transplant Surgery, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
Tel: +49-6131-172730, Fax: +49-6131-173660, E-mail: hauke.lang@unimedizin-mainz.de
Gut Liver 2020;14(6):699-706. https://doi.org/10.5009/gnl19233
Published online February 12, 2020, Published date November 15, 2020
Copyright © Gut and Liver.
In 2007, the first associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure was performed in Regensburg, Germany. ALPPS is a variation of twostage hepatectomy to induce rapid liver hypertrophy allowing the removal of large tumors otherwise considered irresectable due to a too small future liver remnant. In 2012, the international ALPPS registry was created, and it now contains more than 1,000 cases. During the past years, improved patient selection and refinements in operative techniques, in particular, less invasive approaches such as Partial ALPPS, Tourniquet ALPPS, Ablation-assisted ALPPS, Hybrid ALPPS or Laparoscopic or Robotic approaches, have resulted in significant improvements in safety. The most frequent indication for ALPPS is colorectal liver metastases. In the first randomized controlled study, ALPPS provided a higher resectability rate than conventional two-stage hepatectomy, with similar complication rates. Long-term outcome data are still missing. The initial results of ALPPS for hepatocellular carcinoma and for perihilar cholangiocarcinoma were devastating, but with progress in surgical technic and better patient selection, ALPPS could serve as a treatment alternative in carefully selected cases, even for these tumors. ALPPS has enlarged the armamentarium of hepato-pancreato-biliary surgeons, but there is still discussion regarding how to use this novel technique, which may allow resection of tumors that are otherwise deemed irresectable.
Keywords: ALPPS, ALPPS registry, Two-stage hepatectomy, Carcinoma, hepatocellular, Perihilar cholangiocarcinoma
In 2007 Schlitt from Regensburg, Germany, performed somewhat by chance the first “associating liver partition and portal vein ligation for staged hepatectomy” (ALPPS) procedure. The original procedure consisted of a right portal vein ligation combined with simultaneous parenchymal transection during stage 1, followed by resection of the tumor-bearing extended right lobe 9 days later.1 A novel surgical concept–named “
With the introduction of ALPPS a milestone in liver surgery seemed to be reached offering patients with an even extensive hepatic tumor burden the chance of resection. However, the early enthusiasm was hampered as the procedure was associated with a high morbidity and mortality rate which was 68% and 12% in the initial series.3 It was assumed that the high early complication rates would lower with increasing experience. This was confirmed by the first major report of 202 ALPPS procedures from the registry, showing a decrease of Clavien-Dindo grade ≥3 morbidity and mortality to 27% and 9%, respectively.9 It became clear that patient age and tumor type were independent risk factors for a poor outcome.9,11 Morbidity and mortality rates for CRLM were lower than for primary hepatobiliary malignancies. Nevertheless, complication rates after ALPPS for CRLM still were higher than after conventional liver resection, but this was attributed to a selection bias in the ALPPS group. It was obvious that patients undergoing ALPPS, although there was no matched pair analysis, had more advanced disease and a higher tumor burden than those patients usually treated by extended hepatectomy after PVE and PVL (portal vein ligation).
At the same time reports from Belgium, France and Italy demonstrated that post stage 1 complications grade ≥3b were significant predictors of post stage 2 mortality.12,13 Potential risk factors for an unfavorable outcome were in particular post stage 1 biliary fistula or ascites, and infected and/or bilious peritoneal fluid at stage 2.
Due to these data and a better know how and based on a growing experience with the procedure´s pitfalls, continuous efforts were made aiming at a reduction of the surgical morbidity and mortality. Modifications addressed anatomical and diagnostic aspects as well as the surgical technique itself. Anatomically, special attention was paid to the vascularization and biliary drainage of segment 4 in order to avoid ischemia/necrosis or bile leakage. At the end of stage 1 and stage 2 procedure, a bile leak test in order to prevent bile leaks was strongly recommended, and bile duct ligation of the future specimen was considered absolutely contraindicated as it might cause cholestasis, cholangitis or bile leaks.5,6,13 In order to prevent or minimize adhesions and to reduce bleeding and trauma during stage 2, either placement of a silastic bag between the two liver parts or other surface sealing materials not necessarily requiring removal was suggested.13
Further on, the importance of the venous drainage of segment 4 became evident. The concept of preserving the middle hepatic vein during stage 1 operation finally led to the development of “partial ALPPS.” It could be shown that the transection of only 50% to 80% of liver parenchyma resulted in similar effects on the velocity and extent of hepatic hypertrophy but with a significant reduction in perioperative morbidity.14,15 Complete transection of the liver parenchyma during stage 1 seemed to be mandatory only in those cases with a risk of invasion of the tumor into the FLR in between both stages due to close proximity of the tumor to the FLR.
Parallel to anatomical considerations special emphasis was laid on preoperative diagnostics. The two main diagnostic issues in ALPPS are the evaluation of the FLR and the timing of the stage 2 operation. It became clear that there was no good correlation of the CT-scan volumetry with the liver function even when based on three-dimensional reconstruction.16,17 Hepatobiliary scintigraphy (HBS) using 99mTc-labeled iminodiacetic acid derivates could show that volumetry overestimated the liver function in ALPPS while in PVE it was the other way around.18 Although the mechanisms are not fully understood the discrepancy between volume increase and the high rate of liver failure in ALPPS may be attributed to initial edema and enlarged but still at least partially immature and not completely functioning hepatocytes within the first 2 weeks of regeneration.19 This warranted an assessment of both function and volume of the FLR during the interstage course of ALPPS. Combining HBS with SPECT-CT (single photon emission computed tomography-computed tomography) offers quantitative information regarding segmental liver function and therefore provides an accurate measure of the function of the FLR.20 In a preliminary report Kambakamba
Over the ensuing years manifold other technical variations have been introduced, for example the replacement of parenchymal transection by just applying a tourniquet around the liver in the future transection line or by using radiofrequency or microwave ablation to create a virtual liver partition through a “necrotic groove” (Fig. 2).22-24 Another technical modification aiming to reduce the trauma during stage 1 was to avoid surgical manipulation of the hepatic hilum by replacing the portal vein transection by portal vein embolization (Hybrid ALPPS), either in a simultaneous or a subsequent fashion.25 The combination of only partial parenchymal transection and simultaneous intraoperative portal vein embolization (instead of portal vein ligation) was named Mini ALPPS.26 With the introduction of Mini ALPPS not only a modification of the ALPPS procedure but an entire change of paradigm was accomplished. In contrast to classic ALPPS, the surgical extent and the associated trauma of the stage 1 operation were dramatically reduced while the main surgical steps were performed at stage 2.
Only shortly after the introduction of ALPPS the first reports on laparoscopic approaches appeared–initially mainly regarding the stage 1 procedure but to a lesser extent also stage 2.7,27 The first larger series on laparoscopic ALPPS from Brazil showed a stage 2 completion rate similar to the open approach with no mortality and no complication Clavien-Dindo grade ≥3a, and a significant shorter hospital stay compared to an open ALPPS group (11 days vs 14 days; p=0.011).27 These encouraging results could be confirmed in further series, and the above mentioned technical variations for the open procedure such as partial or Mini ALPPS were also applicable and successful in the laparoscopic setting.28,29 In the meantime first case reports on robotic ALPPS have appeared.30 Technically, the robotic approach is feasible but needs further evaluation. In order to allow comparability of data, a “consensus” terminology was suggested to harmonize reports.31 All these technical refinements and a better patient selection led to a stepwise reduction in the perioperative complication rate of ALPPS.32 In a subsequent paper from the ALPPS registry in 2017 a continuous drop in early mortality and morbidity was reported.33 These data clearly demonstrated a significant improvement of results of ALPPS. Although a recent meta-analysis by Moris
The second major concern in ALPPS was about its oncological benefit. The initial enthusiasm about increased resectability in patients with even extensive tumor load had cooled down with first reports on early and aggressive tumor recurrence in many cases.36 The assumed pathological mechanism was a simultaneous massive stimulation of hepatocellular hypertrophy as well as growth of tumor cells in the systemic circulation and in the liver. However, experimental and also clinical data were contradictory.37 While some authors described an earlier tumor recurrence in admittedly very small series the meta-analysis by Moris
In the initial report indications for ALPPS were CRLM (n=14), hepatocellular carcinoma (HCC; n=3), ICC (n=2), perihilar cholangiocarcinoma (PHC; n=2), gallbladder carcinoma (n=1), malignant epithelioid hemangioendothelioma (n=1), non-colorectal liver metastases (n=2). Looking at the ALPPS registry CRLM are by far the most frequent indication for ALPPS (Fig. 3). Although ALPPS has been performed for almost any primary and secondary liver tumor, there are some larger series only about ALPPS for HCC and, to a much lesser extent, for PHC.
ALPPS has expanded the treatment options for patients with CLRM which are currently by far the main indication for this procedure (about 2/3 of patients in the ALPPS registry).38 However, there seems to be a lack of hard criteria when ALPPS is necessary. In a recent analysis by Schnitzbauer
A recent case-match study from the ALPPS registry compared otherwise irresectable “ALPPS patients” to historic controls receiving palliative chemotherapy and concluded a non-superiority in early oncological outcome in the ALPPS group.42 It has to be pointed out that with a median of seven liver segments affected and a median of four lesions in the FLR the disease in the surgical group was very far advanced. Thus, the poor outcome (data) has to be regarded rather as a failure of patient selection than a failure of the concept of ALPPS.
So far, only a few series were published comparing ALPPS to TSH, showing all in all no survival difference. While Adam
Surgery for HCC is often challenging due to an underlying liver cirrhosis with concomitant portal hypertension and/or impaired hepatic function. As such, ALPPS seemed to be an attractive approach to increase resectability. However, a first report from the ALPPS registry with 35 ALPPS for intermediate-stage HCC revealed a 90-day mortality of 31%.50 Such a devastating result certainly called for abandoning the ALPPS procedure for this indication but careful analysis elucidated that ALPPS had been used with wide inclusion criteria and in a somewhat undifferentiated manner. Much better results came from the Hong Kong University and, with smaller numbers, from San Camillo Forlanini in Rome.51,52 In particular the Hong Kong group could outline strict criteria which patients with HCC were good candidates for ALPPS (FLR volume <30% estimated standard liver volume, Child A cirrhosis, indocyanine green clearance rate <20% at 15 minutes, platelet count >100/nL, and no total right portal vein thrombosis). Although the degree of FLR hypertrophy in fibrotic/cirrhotic livers appeared somewhat less than in non-cirrhotic livers–in the initial report there was a volume gain of the FLR of a little less than 50%–the 90-day mortality rate of 7.1% was encouraging.51-53 Of note, in chronic liver disease complete parenchymal transection seems to be associated with a more rapid hypertrophy of the FLR than partial ALPPS.54
A recent single-center study from Fudan University, China, analyzed their outcome of standard ALPPS in 45 HCC patients. The in-detail analysis revealed that the severity of liver disease was inversely correlated with the degree and velocity of hypertrophy. With overall 1- and 3-year survival rates of 64% and 60% the survival of patients undergoing ALPPS was significantly better than of those receiving TACE.55
The experiences from Hong Kong, Rome and Fudan show that in selected patients ALPPS seems to be an attractive approach to increase resectability in HCC patients otherwise left with palliative treatment options.54-56
The first study of the international ALPPS registry reported 11 patients with PHC with a 90-day mortality rate of 27%.9 In 2017, Olthof
Now, more than 10 years ago Schlitt from Regensburg, Germany, performed the first ALPPS procedure. In 2012, the first report on 25 so called “
The most frequent indication for ALPPS is CRLM. In a first randomized controlled study ALPPS could be shown to provide a higher resectability rate than conventional TSH but with similar complication rates. Long-term outcome data are still missing. First results of ALPPS for HCC and PHC were devastating but with technical refinements and better patient selection even in these tumors ALPPS could be a treatment alternative allowing resection of otherwise irresectable tumors.
As with every surgery in particular for ALPPS is true that the most essential decision is the indication when to use it. ALPPS certainly does not replace other techniques such as PVE or standard TSH, but may allow tumor resection in selected patients without any other surgical option left. As such, ALPPS is a welcome novel asset in the armamentarium in the hands of experienced hepatobiliary surgeons.
No potential conflict of interest relevant to this article was reported.
Survival after ALPPS for Colorectal Liver Metastases-Literature Review
Author | Year | No. of patients | Year, % | Median survival, mo | |||
---|---|---|---|---|---|---|---|
1 | 2 | 3 | 5 | ||||
Schadde |
2014 | 141 | 76 | 63 | - | - | - |
Oldhafer |
2014 | 7 | 57 | - | - | - | - |
Lang |
2015 | 7 | - | - | 64 | - | - |
Ratti |
2015 | 12 | 92 | - | - | - | - |
Adam |
2016 | 17 | - | 42 | - | - | - |
Björnsson |
2016 | 23 | 83 | 59 | - | - | - |
Kambakamba |
2016 | 41 | - | - | - | - | 24.7±2.3 |
Olthof |
2017 | 70 | - | 62 | - | - | - |
Wanis |
2018 | 58 | 93 | 66 | 50 | - | - |
Robles-Campos |
2019 | 21 | 76 | - | 57 | 23 | 36 |
Baumgart |
2019 | 8 | 75 | - | 40 | - | 36.2 |
ALPPS, associating liver partition and portal vein ligation for staged hepatectomy.
Gut and Liver 2020; 14(6): 699-706
Published online November 15, 2020 https://doi.org/10.5009/gnl19233
Copyright © Gut and Liver.
Hauke Lang , Janine Baumgart
, Jens Mittler
Department of General, Visceral, and Transplant Surgery, University Medical Center, Mainz, Germany
Correspondence to:Hauke Lang
Department of General, Visceral, and Transplant Surgery, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
Tel: +49-6131-172730, Fax: +49-6131-173660, E-mail: hauke.lang@unimedizin-mainz.de
In 2007, the first associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure was performed in Regensburg, Germany. ALPPS is a variation of twostage hepatectomy to induce rapid liver hypertrophy allowing the removal of large tumors otherwise considered irresectable due to a too small future liver remnant. In 2012, the international ALPPS registry was created, and it now contains more than 1,000 cases. During the past years, improved patient selection and refinements in operative techniques, in particular, less invasive approaches such as Partial ALPPS, Tourniquet ALPPS, Ablation-assisted ALPPS, Hybrid ALPPS or Laparoscopic or Robotic approaches, have resulted in significant improvements in safety. The most frequent indication for ALPPS is colorectal liver metastases. In the first randomized controlled study, ALPPS provided a higher resectability rate than conventional two-stage hepatectomy, with similar complication rates. Long-term outcome data are still missing. The initial results of ALPPS for hepatocellular carcinoma and for perihilar cholangiocarcinoma were devastating, but with progress in surgical technic and better patient selection, ALPPS could serve as a treatment alternative in carefully selected cases, even for these tumors. ALPPS has enlarged the armamentarium of hepato-pancreato-biliary surgeons, but there is still discussion regarding how to use this novel technique, which may allow resection of tumors that are otherwise deemed irresectable.
Keywords: ALPPS, ALPPS registry, Two-stage hepatectomy, Carcinoma, hepatocellular, Perihilar cholangiocarcinoma
In 2007 Schlitt from Regensburg, Germany, performed somewhat by chance the first “associating liver partition and portal vein ligation for staged hepatectomy” (ALPPS) procedure. The original procedure consisted of a right portal vein ligation combined with simultaneous parenchymal transection during stage 1, followed by resection of the tumor-bearing extended right lobe 9 days later.1 A novel surgical concept–named “
With the introduction of ALPPS a milestone in liver surgery seemed to be reached offering patients with an even extensive hepatic tumor burden the chance of resection. However, the early enthusiasm was hampered as the procedure was associated with a high morbidity and mortality rate which was 68% and 12% in the initial series.3 It was assumed that the high early complication rates would lower with increasing experience. This was confirmed by the first major report of 202 ALPPS procedures from the registry, showing a decrease of Clavien-Dindo grade ≥3 morbidity and mortality to 27% and 9%, respectively.9 It became clear that patient age and tumor type were independent risk factors for a poor outcome.9,11 Morbidity and mortality rates for CRLM were lower than for primary hepatobiliary malignancies. Nevertheless, complication rates after ALPPS for CRLM still were higher than after conventional liver resection, but this was attributed to a selection bias in the ALPPS group. It was obvious that patients undergoing ALPPS, although there was no matched pair analysis, had more advanced disease and a higher tumor burden than those patients usually treated by extended hepatectomy after PVE and PVL (portal vein ligation).
At the same time reports from Belgium, France and Italy demonstrated that post stage 1 complications grade ≥3b were significant predictors of post stage 2 mortality.12,13 Potential risk factors for an unfavorable outcome were in particular post stage 1 biliary fistula or ascites, and infected and/or bilious peritoneal fluid at stage 2.
Due to these data and a better know how and based on a growing experience with the procedure´s pitfalls, continuous efforts were made aiming at a reduction of the surgical morbidity and mortality. Modifications addressed anatomical and diagnostic aspects as well as the surgical technique itself. Anatomically, special attention was paid to the vascularization and biliary drainage of segment 4 in order to avoid ischemia/necrosis or bile leakage. At the end of stage 1 and stage 2 procedure, a bile leak test in order to prevent bile leaks was strongly recommended, and bile duct ligation of the future specimen was considered absolutely contraindicated as it might cause cholestasis, cholangitis or bile leaks.5,6,13 In order to prevent or minimize adhesions and to reduce bleeding and trauma during stage 2, either placement of a silastic bag between the two liver parts or other surface sealing materials not necessarily requiring removal was suggested.13
Further on, the importance of the venous drainage of segment 4 became evident. The concept of preserving the middle hepatic vein during stage 1 operation finally led to the development of “partial ALPPS.” It could be shown that the transection of only 50% to 80% of liver parenchyma resulted in similar effects on the velocity and extent of hepatic hypertrophy but with a significant reduction in perioperative morbidity.14,15 Complete transection of the liver parenchyma during stage 1 seemed to be mandatory only in those cases with a risk of invasion of the tumor into the FLR in between both stages due to close proximity of the tumor to the FLR.
Parallel to anatomical considerations special emphasis was laid on preoperative diagnostics. The two main diagnostic issues in ALPPS are the evaluation of the FLR and the timing of the stage 2 operation. It became clear that there was no good correlation of the CT-scan volumetry with the liver function even when based on three-dimensional reconstruction.16,17 Hepatobiliary scintigraphy (HBS) using 99mTc-labeled iminodiacetic acid derivates could show that volumetry overestimated the liver function in ALPPS while in PVE it was the other way around.18 Although the mechanisms are not fully understood the discrepancy between volume increase and the high rate of liver failure in ALPPS may be attributed to initial edema and enlarged but still at least partially immature and not completely functioning hepatocytes within the first 2 weeks of regeneration.19 This warranted an assessment of both function and volume of the FLR during the interstage course of ALPPS. Combining HBS with SPECT-CT (single photon emission computed tomography-computed tomography) offers quantitative information regarding segmental liver function and therefore provides an accurate measure of the function of the FLR.20 In a preliminary report Kambakamba
Over the ensuing years manifold other technical variations have been introduced, for example the replacement of parenchymal transection by just applying a tourniquet around the liver in the future transection line or by using radiofrequency or microwave ablation to create a virtual liver partition through a “necrotic groove” (Fig. 2).22-24 Another technical modification aiming to reduce the trauma during stage 1 was to avoid surgical manipulation of the hepatic hilum by replacing the portal vein transection by portal vein embolization (Hybrid ALPPS), either in a simultaneous or a subsequent fashion.25 The combination of only partial parenchymal transection and simultaneous intraoperative portal vein embolization (instead of portal vein ligation) was named Mini ALPPS.26 With the introduction of Mini ALPPS not only a modification of the ALPPS procedure but an entire change of paradigm was accomplished. In contrast to classic ALPPS, the surgical extent and the associated trauma of the stage 1 operation were dramatically reduced while the main surgical steps were performed at stage 2.
Only shortly after the introduction of ALPPS the first reports on laparoscopic approaches appeared–initially mainly regarding the stage 1 procedure but to a lesser extent also stage 2.7,27 The first larger series on laparoscopic ALPPS from Brazil showed a stage 2 completion rate similar to the open approach with no mortality and no complication Clavien-Dindo grade ≥3a, and a significant shorter hospital stay compared to an open ALPPS group (11 days vs 14 days; p=0.011).27 These encouraging results could be confirmed in further series, and the above mentioned technical variations for the open procedure such as partial or Mini ALPPS were also applicable and successful in the laparoscopic setting.28,29 In the meantime first case reports on robotic ALPPS have appeared.30 Technically, the robotic approach is feasible but needs further evaluation. In order to allow comparability of data, a “consensus” terminology was suggested to harmonize reports.31 All these technical refinements and a better patient selection led to a stepwise reduction in the perioperative complication rate of ALPPS.32 In a subsequent paper from the ALPPS registry in 2017 a continuous drop in early mortality and morbidity was reported.33 These data clearly demonstrated a significant improvement of results of ALPPS. Although a recent meta-analysis by Moris
The second major concern in ALPPS was about its oncological benefit. The initial enthusiasm about increased resectability in patients with even extensive tumor load had cooled down with first reports on early and aggressive tumor recurrence in many cases.36 The assumed pathological mechanism was a simultaneous massive stimulation of hepatocellular hypertrophy as well as growth of tumor cells in the systemic circulation and in the liver. However, experimental and also clinical data were contradictory.37 While some authors described an earlier tumor recurrence in admittedly very small series the meta-analysis by Moris
In the initial report indications for ALPPS were CRLM (n=14), hepatocellular carcinoma (HCC; n=3), ICC (n=2), perihilar cholangiocarcinoma (PHC; n=2), gallbladder carcinoma (n=1), malignant epithelioid hemangioendothelioma (n=1), non-colorectal liver metastases (n=2). Looking at the ALPPS registry CRLM are by far the most frequent indication for ALPPS (Fig. 3). Although ALPPS has been performed for almost any primary and secondary liver tumor, there are some larger series only about ALPPS for HCC and, to a much lesser extent, for PHC.
ALPPS has expanded the treatment options for patients with CLRM which are currently by far the main indication for this procedure (about 2/3 of patients in the ALPPS registry).38 However, there seems to be a lack of hard criteria when ALPPS is necessary. In a recent analysis by Schnitzbauer
A recent case-match study from the ALPPS registry compared otherwise irresectable “ALPPS patients” to historic controls receiving palliative chemotherapy and concluded a non-superiority in early oncological outcome in the ALPPS group.42 It has to be pointed out that with a median of seven liver segments affected and a median of four lesions in the FLR the disease in the surgical group was very far advanced. Thus, the poor outcome (data) has to be regarded rather as a failure of patient selection than a failure of the concept of ALPPS.
So far, only a few series were published comparing ALPPS to TSH, showing all in all no survival difference. While Adam
Surgery for HCC is often challenging due to an underlying liver cirrhosis with concomitant portal hypertension and/or impaired hepatic function. As such, ALPPS seemed to be an attractive approach to increase resectability. However, a first report from the ALPPS registry with 35 ALPPS for intermediate-stage HCC revealed a 90-day mortality of 31%.50 Such a devastating result certainly called for abandoning the ALPPS procedure for this indication but careful analysis elucidated that ALPPS had been used with wide inclusion criteria and in a somewhat undifferentiated manner. Much better results came from the Hong Kong University and, with smaller numbers, from San Camillo Forlanini in Rome.51,52 In particular the Hong Kong group could outline strict criteria which patients with HCC were good candidates for ALPPS (FLR volume <30% estimated standard liver volume, Child A cirrhosis, indocyanine green clearance rate <20% at 15 minutes, platelet count >100/nL, and no total right portal vein thrombosis). Although the degree of FLR hypertrophy in fibrotic/cirrhotic livers appeared somewhat less than in non-cirrhotic livers–in the initial report there was a volume gain of the FLR of a little less than 50%–the 90-day mortality rate of 7.1% was encouraging.51-53 Of note, in chronic liver disease complete parenchymal transection seems to be associated with a more rapid hypertrophy of the FLR than partial ALPPS.54
A recent single-center study from Fudan University, China, analyzed their outcome of standard ALPPS in 45 HCC patients. The in-detail analysis revealed that the severity of liver disease was inversely correlated with the degree and velocity of hypertrophy. With overall 1- and 3-year survival rates of 64% and 60% the survival of patients undergoing ALPPS was significantly better than of those receiving TACE.55
The experiences from Hong Kong, Rome and Fudan show that in selected patients ALPPS seems to be an attractive approach to increase resectability in HCC patients otherwise left with palliative treatment options.54-56
The first study of the international ALPPS registry reported 11 patients with PHC with a 90-day mortality rate of 27%.9 In 2017, Olthof
Now, more than 10 years ago Schlitt from Regensburg, Germany, performed the first ALPPS procedure. In 2012, the first report on 25 so called “
The most frequent indication for ALPPS is CRLM. In a first randomized controlled study ALPPS could be shown to provide a higher resectability rate than conventional TSH but with similar complication rates. Long-term outcome data are still missing. First results of ALPPS for HCC and PHC were devastating but with technical refinements and better patient selection even in these tumors ALPPS could be a treatment alternative allowing resection of otherwise irresectable tumors.
As with every surgery in particular for ALPPS is true that the most essential decision is the indication when to use it. ALPPS certainly does not replace other techniques such as PVE or standard TSH, but may allow tumor resection in selected patients without any other surgical option left. As such, ALPPS is a welcome novel asset in the armamentarium in the hands of experienced hepatobiliary surgeons.
No potential conflict of interest relevant to this article was reported.
Table 1 Survival after ALPPS for Colorectal Liver Metastases-Literature Review
Author | Year | No. of patients | Year, % | Median survival, mo | |||
---|---|---|---|---|---|---|---|
1 | 2 | 3 | 5 | ||||
Schadde | 2014 | 141 | 76 | 63 | - | - | - |
Oldhafer | 2014 | 7 | 57 | - | - | - | - |
Lang | 2015 | 7 | - | - | 64 | - | - |
Ratti | 2015 | 12 | 92 | - | - | - | - |
Adam | 2016 | 17 | - | 42 | - | - | - |
Björnsson | 2016 | 23 | 83 | 59 | - | - | - |
Kambakamba | 2016 | 41 | - | - | - | - | 24.7±2.3 |
Olthof | 2017 | 70 | - | 62 | - | - | - |
Wanis | 2018 | 58 | 93 | 66 | 50 | - | - |
Robles-Campos | 2019 | 21 | 76 | - | 57 | 23 | 36 |
Baumgart | 2019 | 8 | 75 | - | 40 | - | 36.2 |
ALPPS, associating liver partition and portal vein ligation for staged hepatectomy.