Efficacy of Technical Modifications to the Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) Procedure

Abstract

Objectives: To compare the outcomes of modified-Associating Liver Partition and Portal vein Ligation for Staged hepatectomy (ALPPS) techniques with those of conventional-ALPPS. Background: ALPPS is an established technique for treating advanced liver tumors. Methods: PubMed, Web of Science, and Cochrane databases were searched. The outcomes were assessed by single-arm and 2-arm analyses. Results: Seventeen studies containing 335 modified-ALPPS patients were included in single-arm meta-analysis. The estimated blood loss was 267 ± 29 mL (95% confidence interval [CI], 210–324 mL) during the first and 662 ± 51 mL (95% CI, 562–762 mL) during the second stage. The operation time was 166 ± 18 minutes (95% CI, 131–202 minutes) during the first and 225 ± 19 minutes (95% CI, 188–263 minutes) during the second stage. The major morbidity rate was 14% (95% CI, 9%–22%) after the first stage. The future liver remnant hypertrophy rate was 65.2% ± 5% (95% CI, 55%–75%) and the interstage interval was 16 ± 1 days (95% CI, 14–17 days). The dropout rate was 9% (95% CI, 5%–15%). The overall complication rate was 46% (95% CI, 37%–56%) and the major complication rate was 20% (95% CI, 14%–26%). The postoperative mortality rate was 7% (95% CI, 4%–11%). Seven studies containing 215 patients were included in comparative analysis. The hypertrophy rate was not different between 2 methods (mean difference [MD], –5.01; 95% CI, –19.16 to 9.14; P = 0.49). The interstage interval was shorter for partial-ALPPS (MD, 9.43; 95% CI, 3.29–15.58; P = 0.003). The overall complication rate (odds ratio [OR], 10.10; 95% CI, 2.11–48.35; P = 0.004) and mortality rate (OR, 3.74; 95% CI, 1.36–10.26; P = 0.01) were higher in the conventional-ALPPS. Conclusions: The hypertrophy rate in partial-ALPPS was similar to conventional-ALPPS. This shows that minimizing the first stage of the operation does not affect hypertrophy. Moreover, the postoperative overall morbidity and mortality rates were lower following partial-ALPPS.

Promising Outcomes of Modified ALPPS for Staged Hepatectomy in Cholangiocarcinoma

“…However, externalization of biliary flow facilitates the remission of liver function and avoids the endotoxemia [53]. Recent studies have demonstrated that functional and volumetric hypertrophy were similar after the first stage of both conventional and modified ALPPS; therefore, modified ALPPS is preferred because it lowers morbidity and mortality without compromising other treatment outcomes [10,54]. Although a direct comparison between different modifications of ALPPS, such as partial ALPPS, radiofrequency-assisted ALPPS, and associating liver tourniquet and portal vein ligation for staged hepatectomy (ALTPS) was not possible due to not enough available data, a recent meta-analysis revealed similar outcomes from different techniques, using a single-arm meta-analysis [54].…”

“…Recent studies have demonstrated that functional and volumetric hypertrophy were similar after the first stage of both conventional and modified ALPPS; therefore, modified ALPPS is preferred because it lowers morbidity and mortality without compromising other treatment outcomes [10,54]. Although a direct comparison between different modifications of ALPPS, such as partial ALPPS, radiofrequency-assisted ALPPS, and associating liver tourniquet and portal vein ligation for staged hepatectomy (ALTPS) was not possible due to not enough available data, a recent meta-analysis revealed similar outcomes from different techniques, using a single-arm meta-analysis [54]. Furthermore, considering the complexity of the ALPPS procedure and the importance of the precise patients' selection, the ALPPS risk score was developed to identify patients at risk of early ALPPS-related morbidity and mortality [19,26,55].…”