ALPPS: Safety, Feasibility and Efficacy at a Single Center
Condition: Locally Advanced Malignant Liver Disease
MeSH terms: Liver Diseases
Study type: Observational

Summary: 
      The possibility to achieve a curative resection in patients with liver malignancies is
      limited by the future liver remnant (FLR). The Associating Liver Partition and Portal vein
      ligation for Staged hepatectomy (ALPPS) approach has recently been introduced as a
      revolutionary strategy to achieve resectability by inducing a rapid and large FLR
      hypertrophy. However, the possibility of achieving a short-term hypertrophy and high
      resectability rates has been counteracted in most published series by an increased risk of
      morbidity and mortality.The aim of this study was to evaluate the results with the ALPPS
      procedure in a single high-volume HPB center, with special emphasis in the safety and
      feasibility of this new 2-stage strategy. The aim of the present study was to assess the
      safety, feasibility and efficacy of ALPPS in a single high-volume hepatobiliary center.
    

Detailed description: 
      Complete resection of liver malignancies remains as the best treatment to offer the
      possibility of long-term survival or cure. At diagnosis, many patients have locally advanced
      disease that often precludes a curative resection. During the past two decades, a better
      assessment of resectability through modern imaging techniques along with new multimodal
      therapies and the introduction of modern chemotherapy regimens have allowed to increase the
      pool of candidates for surgical treatment in patients with locally advanced disease. The
      current principles for safe liver resections focus mainly on the liver parenchyma that
      remains after resection rather than the liver resected. In fact, one of the main conditioning
      factors of posthepatectomy liver failure (PHLF) is the amount and quality of future liver
      remnant (FLR). The induction of hypertrophy of healthy parenchyma using either portal vein
      embolization (PVE) or ligation (PVL), in the setting of 1-stage or 2-stage liver resections,
      is nowadays considered the standard of care for patients with locally advanced liver tumors
      and small FLR.2,5-8 However, the need for long intervals between interventions (6-12 weeks),
      results in resectability rates that rarely exceed 60-80%.

      In 2012, Schnitbauer et al introduced a novel 2-stage technique that allowed tumor resection
      in 25 patients from 5 German centers with marginally resectable or primarily nonresectable
      disease by means of a rapid and large FLR hypertrophy. This technique was later popularized
      with the acronym ALPPS for "Associating Liver Partition and Portal Vein Ligation for Staged
      Hepatectomy". The promising preliminary results obtained with this new surgical proposal in
      terms of hypertrophy and the possibility of challenging the previous methods generated a
      pronounced reaction in the surgical community world-wide that has rarely been seen in the
      history of hepato-pancreato-biliary (HPB) surgery. However, the possibility of achieving a
      short-term hypertrophy and high resectability rates has been counteracted in most published
      series by an increased risk of morbidity and mortality. The aim of this study was to evaluate
      the results with the ALPPS procedure in a single high-volume HPB center, with special
      emphasis in the safety and feasibility of this new 2-stage strategy.

      Data for all patients undergoing 2-stage hepatectomies with the ALPPS approach at the HPB
      Surgery Section of the Hospital Italiano de Buenos Aires between June 2011 and April 2014 was
      analyzed on an intention to treat basis. Patient demographics, clinical characteristics (body
      mass index, anesthesiological risk score, Charlson comorbidity index, preoperative
      chemotherapy), tumor type, surgical details, FLR hypertrophy, postoperative liver function,
      postoperative complications, length of hospital stay and survival were analyzed.

      Regarding the surgical procedure, during the first stage a complete tumor resection
      (clean-up) of the FLR is performed if bilateral disease was present, either trough anatomical
      or atypical resections. Subsequently, the portal vein of the diseased hemi-liver (DH) is
      divided and either total (up to the inferior vena cava) or partial (up to the middle hepatic
      vein) parenchymal transection using the Cavitron Ultrasonic Surgical Aspirator (CUSA; Valley
      Lab, Boulder, CO, USA) is carried out. At the end of the first stage, the DH is either
      wrapped in a plastic bag or a plastic sheath placed between the cut surfaces. Once volumetric
      CT analysis demonstrated enough FLR hypertrophy and provided the patient is in good
      condition, the second stage is carried out the next available operative day resecting the DH.
      The type of liver resections performed were defined using the Brisbane 2000 nomenclature.
    

Intervention name(s): ALPPS
Intervention type(s): Procedure
Intervention description(s): Associating Liver Partition and Portal vein ligation for Staged hepatectomy
Observational model: Cohort
Time perspective: Prospective
Sampling method: Non-Probability Sample
Study population: 
        High-Volume University Hospital population
      
Keywords: Liver tumor; ALPPS; Two-stage hepatectomy; Morbidity; Hypertrophy