title: Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS): impact of the inter-stages course on morbi-mortality and implications for management.
abstract: BACKGROUND
  Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) was recently developed to induce rapid hypertrophy and reduce post-hepatectomy liver failure in patients with insufficient remnant liver volume (RLV). However, mortality rates >12% have been reported. This study aimed to analyze the perioperative course of ALPPS and to identify factors associated with morbi-mortality.
  
  
  METHODS
  Between April 2011 and September 2013, 62 patients operated in 9 Franco-Belgian hepatobiliary centres underwent ALPPS for colorectal metastases (N = 50) or primary tumors, following chemotherapy (N = 50) and/or portal vein embolization (PVE; N = 9).
  
  
  RESULTS
  Most patients had right (N = 31) or right extended hepatectomy (N = 25) (median RLV/body weight ratio of 0.54% [0.21-0.77%]). RLV increased by 48.6% [-15.3 to 192%] 7.8 ± 4.5 days after stage1, but the hypertrophy decelerated beyond 7 days. Stage2 was cancelled in 3 patients (4.8%) for insufficient hypertrophy, portal vein thrombosis or death and delayed to ≥9 days in 32 (54.2%). Overall, 25 patients (40.3%) had major complication(s) and 8 (12.9%) died. Fourteen patients (22.6%) had post-stage1 complication of whom 5 (35.7%) died after stage2. Factors associated with major morbi-mortality were obesity, post-stage1 biliary fistula or ascites, and infected and/or bilious peritoneal fluid at stage2. The latter was the only predictor of Clavien ≥3 by multivariate analysis (OR: 4.9; 95% CI: 1.227-19.97; p = 0.025). PVE did not impact the morbi-mortality rates but prevented major cytolysis that was associated with poor outcome.
  
  
  CONCLUSIONS
  The inter-stages course was crucial in determining ALPPS outcome. The factors of high morbi-mortality rates associated with ALPPS are linked to the technique complexity.
authors: Department of Digestive Surgery and Transplantation, CHU, Univ Nord de France, Lille, France. Electronic address: stephanie.truant@chru-lille.fr.
authors: S
authors: S
authors: Truant
authors: Department of Hepatobiliary Surgery and Liver Transplant, St Antoine Hospital, France.
authors: O
authors: O
authors: Scatton
authors: Department of Hepatopancreatobiliary Surgery and Liver Transplantation, Beaujon Hospital, Clichy, France.
authors: S
authors: S
authors: Dokmak
authors: Department of Digestive Surgery, Amiens University Medical Centre, Amiens, France.
authors: J-M
authors: JM
authors: Regimbeau
authors: Department of Abdominal Surgery and Transplantation, Hospital Erasme, Brussels University, Belgium.
authors: V
authors: V
authors: Lucidi
authors: Department of Digestive and Hepatobiliary Surgery, AP-HP, Henri Mondor University Hospital, Créteil, France.
authors: A
authors: A
authors: Laurent
authors: Department of General and Visceral Surgery, University Hospital of Poitiers, France.
authors: R
authors: R
authors: Gauzolino
authors: Hepatobiliary Centre, Paul Brousse Hospital, AP-HP, Univ Paris-Sud, Villejuif, France.
authors: C
authors: C
authors: Castro Benitez
authors: Department of Digestive Surgery, Amiens University Medical Centre, Amiens, France.
authors: A
authors: A
authors: Pequignot
authors: Department of Abdominal Surgery and Transplantation, Hospital Erasme, Brussels University, Belgium.
authors: V
authors: V
authors: Donckier
authors: Department of Digestive and Hepatobiliary Surgery, AP-HP, Henri Mondor University Hospital, Créteil, France.
authors: C
authors: C
authors: Lim
authors: Department of General and Visceral Surgery, University Hospital of Poitiers, France.
authors: M-L
authors: ML
authors: Blanleuil
authors: Department of Hepatobiliary Surgery and Liver Transplant, St Antoine Hospital, France.
authors: R
authors: R
authors: Brustia
authors: Department of Digestive Surgery and Liver Transplantation, AP-HM, La Conception Hospital, Aix-Marseille University, France.
authors: Y-P
authors: YP
authors: Le Treut
authors: Department of Hepatobiliary Surgery and Liver Transplant, St Antoine Hospital, France.
authors: O
authors: O
authors: Soubrane
authors: Department of Digestive and Hepatobiliary Surgery, AP-HP, Henri Mondor University Hospital, Créteil, France.
authors: D
authors: D
authors: Azoulay
authors: Department of Hepatopancreatobiliary Surgery and Liver Transplantation, Beaujon Hospital, Clichy, France.
authors: O
authors: O
authors: Farges
authors: Hepatobiliary Centre, Paul Brousse Hospital, AP-HP, Univ Paris-Sud, Villejuif, France.
authors: R
authors: R
authors: Adam
authors: Department of Digestive Surgery and Transplantation, CHU, Univ Nord de France, Lille, France.
authors: F-R
authors: FR
authors: Pruvot
mesh_terms: D000368:Aged; D001650:Bile Duct Neoplasms / Q000601:surgery*; D001653:Bile Ducts, Intrahepatic; D002277:Carcinoma / Q000556:secondary / Q000601:surgery*; D006528:Carcinoma, Hepatocellular / Q000601:surgery; D018281:Cholangiocarcinoma / Q000601:surgery; D015179:Colorectal Neoplasms / Q000473:pathology*; D018450:Disease Progression; D004621:Embolization, Therapeutic; D005240:Feasibility Studies; D005260:Female; D005706:Gallbladder Neoplasms / Q000601:surgery*; D006498:Hepatectomy / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D006801:Humans; D008026:Ligation; D008099:Liver / Q000000981:diagnostic imaging / Q000601:surgery*; D017093:Liver Failure / Q000517:prevention & control*; D008113:Liver Neoplasms / Q000556:secondary / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D011169:Portal Vein / Q000601:surgery*; D011859:Radiography; D012189:Retrospective Studies; D016896:Treatment Outcome
keywords: ALPPS; Liver regeneration; Morbi-mortality; Remnant liver; Two-stage hepatectomy