title: ALPPS offers a better chance of complete resection in patients with primarily unresectable liver tumors compared with conventional-staged hepatectomies: results of a multicenter analysis.
abstract: BACKGROUND
  Portal vein occlusion to increase the size of the future liver remnant (FLR) is well established, using portal vein ligation (PVL) or embolization (PVE) followed by resection 4-8 weeks later. Associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) combines PVL and complete parenchymal transection, followed by hepatectomy within 1-2 weeks. ALPPS has been recently introduced but remains controversial. We compare the ability of ALPPS versus PVE or PVL for complete tumor resection.
  
  
  METHODS
  A retrospective review of all patients undergoing ALPPS or conventional staged hepatectomies using PVL or PVE at four high-volume HPB centres between 2003 and 2012 was performed. Patients with primary liver tumors and liver metastases were included. Primary endpoint was complete tumor resection. Secondary endpoints include 90-day mortality, complications, FLR increase, time to resection, and tumor recurrence.
  
  
  RESULTS
  Forty-eight patients with ALPPS were compared with 83 patients with conventional-staged hepatectomies. Eighty-three percent (40/48 patients) of ALPPS patients achieved complete resection compared with 66 % (55/83 patients) in PVE/PVL (odds ratio 3.34, p = 0.027). Ninety-day mortality in ALPPS and PVE/PVL was 15 and 6 %, respectively (p = 0.2). Extrapolated growth rate was 11 times higher in ALPPS (34.8 cc/day; interquartile range (IQR) 26-49) compared with PVE/PVL (3 cc/day; IQR2-6; p = 0.001). Tumor recurrence at 1 year was 54 versus 52 % for ALPPS and PVE/PVL, respectively (p = 0.7).
  
  
  CONCLUSIONS
  This study provides evidence that ALPPS offers a better chance of complete resection in patients with primarily unresectable liver tumors at the cost of a high mortality. The technique is promising but should currently not be used outside of studies and registries.
authors.affiliation: Department of Surgery and Transplantation, Swiss HPB Center, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland.
authors.forename: Erik
authors.initials: E
authors.lastname: Schadde
authors.forename: Victoria
authors.initials: V
authors.lastname: Ardiles
authors.forename: Ksenija
authors.initials: K
authors.lastname: Slankamenac
authors.forename: Christoph
authors.initials: C
authors.lastname: Tschuor
authors.forename: Gregory
authors.initials: G
authors.lastname: Sergeant
authors.forename: Nadja
authors.initials: N
authors.lastname: Amacker
authors.forename: Janine
authors.initials: J
authors.lastname: Baumgart
authors.forename: Kris
authors.initials: K
authors.lastname: Croome
authors.forename: Roberto
authors.initials: R
authors.lastname: Hernandez-Alejandro
authors.forename: Hauke
authors.initials: H
authors.lastname: Lang
authors.forename: Eduardo
authors.initials: E
authors.lastname: de Santibaňes
authors.forename: Pierre-Alain
authors.initials: PA
authors.lastname: Clavien
mesh_terms: D000368:Aged; D002423:Cause of Death; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D006498:Hepatectomy / Q000379:methods* / Q000401:mortality; D017052:Hospital Mortality; D006801:Humans; D008026:Ligation / Q000379:methods; D008113:Liver Neoplasms / Q000401:mortality* / Q000473:pathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009361:Neoplasm Invasiveness / Q000473:pathology; D009367:Neoplasm Staging; D011169:Portal Vein / Q000601:surgery*; D012189:Retrospective Studies; D018570:Risk Assessment; D016019:Survival Analysis; D013997:Time Factors; D016896:Treatment Outcome
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