title: Strategies to Increase the Resectability of Patients with Colorectal Liver Metastases: A Multi-center Case-Match Analysis of ALPPS and Conventional Two-Stage Hepatectomy.
abstract: BACKGROUND
  Two-stage hepatectomy (TSH) is well established for the treatment of patients who have colorectal cancer liver metastases (CRLM) with a small liver remnant. The technique of associating liver partitioning and portal vein occlusion for staged hepatectomy (ALPPS) has been advocated as a novel tool to increase resectability. Using a case-match design, this study aimed to compare TSH and ALPPS for patients with CRLM.
  
  
  METHODS
  All patients undergoing ALPPS for CRLM at three major hepatobiliary centers in Italy (ALPPS group) were compared in a case-match analysis with patients undergoing TSH (TSH group) at a single institution. The groups were matched with a 1:3 ratio using propensity scores based on covariates representing severity of metastatic disease. The main end points of the study were feasibility of complete resection and intra- and postoperative outcomes.
  
  
  RESULTS
  The two treatments did not differ significantly in feasibility. Two patients in the TSH group dropped out compared with no patients in the ALPPS group. A comparable volume gain in future liver remnant (FLR) was obtained in the ALPPS and TSH groups (47 vs. 41 %, nonsignificant difference) but during a shorter interval in ALPPS group. The overall and major complication rate was significantly higher after stage 2 in the ALPPS group (Clavien ≥ 3a: 41.7 vs. 17.6 % in TSH group; p = 0.025).
  
  
  CONCLUSIONS
  The feasibility of resection using ALPPS compared with TSH for CRLM was not significantly greater, but perioperative complications were increased. Therefore, ALPPS should be proposed to patients with caution and warnings. Currently, TSH remains the standard approach for performing R0 resection in patients with advanced CRLM and inadequate FLR.
authors.affiliation: Hepatopancreatobiliary Surgery Unit, IRCCS San Raffaele Hospital, Via Olgettina 60, Milan, Italy, ratti.francesca@hsr.it.
authors.forename: Francesca
authors.initials: F
authors.lastname: Ratti
authors.forename: Erik
authors.initials: E
authors.lastname: Schadde
authors.forename: Michele
authors.initials: M
authors.lastname: Masetti
authors.forename: Marco
authors.initials: M
authors.lastname: Massani
authors.forename: Matteo
authors.initials: M
authors.lastname: Zanello
authors.forename: Matteo
authors.initials: M
authors.lastname: Serenari
authors.forename: Federica
authors.initials: F
authors.lastname: Cipriani
authors.forename: Luca
authors.initials: L
authors.lastname: Bonariol
authors.forename: Nicolò
authors.initials: N
authors.lastname: Bassi
authors.forename: Luca
authors.initials: L
authors.lastname: Aldrighetti
authors.forename: Elio
authors.initials: E
authors.lastname: Jovine
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016022:Case-Control Studies; D015179:Colorectal Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D005240:Feasibility Studies; D005260:Female; D005500:Follow-Up Studies; D006498:Hepatectomy / Q000401:mortality*; D006801:Humans; D008026:Ligation; D008113:Liver Neoplasms / Q000401:mortality / Q000556:secondary / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D011169:Portal Vein / Q000601:surgery*; D011379:Prognosis; D012189:Retrospective Studies; D015996:Survival Rate