The many faces of ALPPS: surgical indications and techniques among surgeons collaborating in the international registry

Abstract

Background: ALPPS was developed to induce accelerated future liver remnant (FLR) hypertrophy in order to increase hepatic tumour resectability and reduce the risk of post-operative liver failure. While early studies demonstrated concerning complication rates, others reported favourable results. This inconsistency may be due to variability in surgical indications and technique. Methods: A web-based survey was sent to surgeons participating in the International ALPPS Registry in September of 2014. Questions addressed surgeon demographics and training, surgical indications and technique, and clinical management approaches.Results: Fifty six out of 85 surgeons from 78 centers responded (66%) and half (n = 30) had training in liver transplantation. Forty seven (84%) did not reserve ALPPS solely for colorectal liver metastases (CRLM) and 30 (54%) would perform ALPPS for an FLR over 30%. Neoadjuvant chemotherapy for CRLM was recommended by 37 (66%) respondents. Surgical approaches varied considerably, with 30% not preserving outflow to the middle hepatic vein and 39% believing it necessary to skeletonize the hepatoduodenal ligament. Twenty five (45%) surgeons have observed segment 4 necrosis. Conclusion:There is considerable variability in how ALPPS is performed internationally. This heterogeneity in practice patterns may explain the current incongruity in published outcomes, and highlights the need for standardization.

Surgical Options in Synchronous Liver Metastases from Colorectal Cancer

“…This operation was performed until now almost exclusive in patients whose primary tumor has already been resected. It consists in initial resection of CLMs from the FLR, associated with PVL and in-situ splitting of the liver (102)(103)(104)(105)(106). It was observed that such a strategy was able to achieve a more rapid and robust hypertrophy of the FLR (107).…”

Asociación de Partición Hepática y Ligadura Portal para Hepatectomía por Etapas (ALPPS)

“…Disección del pedículo portal, esqueletizándolo y extirpando el tejido linfonodal (si aplica, dependiendo del origen de la enfermedad tumoral); y sección-ligadura de venas hepáticas accesorias (Ratti et al;Buac et al, 2016).…”

“…Sin embargo, existen otras indicaciones mucho menos frecuentes como metástasis de tumores de Wilms, ovario, cérvix uterino, estómago. GISTs y melanoma (Nadalin et al, 2014;Schadde et al, 2014a;Ratti et al;Rochet et al;Zhang et al, 2014;Hasselgren et al, 2015;Lang et al, 2015;Truant et al, 2015;Vivarelli et al, 2015;Buac et al;Björnsson et al, 2016a;Røsok et al, 2016); todo lo cual, debe estar en relación con la existencia de un hígado remanente menor de 25 % a 30 % (hígados sanos) y menor de 40 % (hígados colestásicos, esteatósicos, con fibrosis, o con cambios patológicos secundarios a quimioterapia (Nadalin et al; Ratti et al; Zhang et al; Buac et al).…”

GOOD TO KNOW: The ALPPS Procedure - Embracing a New Technique

“…In terms of diagnosis, the main indication for ALPPS is colorectal liver metastases (CRLM) and a small number of surgeons (16%) consider this to be the only indication for ALPPS (10). A large number of CRLM patients benefited from neoadjuvant chemotherapy, but the response was not critical for the indication of ALPPS (both CRLMs that have had a favorable or partial response to chemotherapy and tumors that have progressed under treatment can be resected).…”

“…Hilar cholangiocarcinoma and gallbladder cancer are accepted by only 27% of surgeons as an indication for ALPPS because morbidity and mortality are higher than CRLM, especially when biliary reconstruction is needed (10). The ALPPS procedure for hepatocellular carcinoma correlates with the degree of chronic liver damage, because in this context the liver regeneration is less predictable (12).…”