title: Should ALPPS be Used for Liver Resection in Intermediate-Stage HCC?
abstract: BACKGROUND
  Extended liver resections in patients with hepatocellular carcinoma (HCC) are problematic due to hepatitis, fibrosis, and cirrhosis. Associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) has been promoted as a novel method to induce hypertrophy for patients with extensive colorectal liver metastases, but outcomes in HCC have not been well investigated.
  
  
  METHODS
  All patients registered in the international ALPPS Registry ( www.alpps.org ) from 2010 to 2015 were studied. Hypertrophy of the future liver remnant, perioperative morbidity and mortality, age, overall survival, and other parameters were compared between patients with HCC and patients with colorectal liver metastases (CRLM).
  
  
  RESULTS
  The study compared 35 patients with HCC and 225 patients with CRLM. The majority of patients undergoing ALPPS for HCC fall into the intermediate-stage category of the Barcelona clinic algorithm. In this study, hypertrophy was rapid and extensive for the HCC patients, albeit lower than for the CRLM patients (47 vs. 76 %; p < 0.002). Hypertrophy showed a linear negative correlation with the degrees of fibrosis. The 90-day mortality for ALPPS used to treat HCC was almost fivefold higher than for CRLM (31 vs. 7 %; p < 0.001). Multivariate analysis showed that patients older than 61 years had a significantly reduced overall survival (p < 0.004).
  
  
  CONCLUSIONS
  The ALPPS approach induces a considerable hypertrophic response in HCC patients and allows resection of intermediate-stage HCC, albeit at the cost of a 31 % perioperative mortality rate. The use of ALPPS for HCC remains prohibitive for most patients and should be performed only for a highly selected patient population younger than 60 years with low-grade fibrosis.
authors.affiliation: Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, Hospital of the University of Munich, Munich, Germany.
authors.forename: J G
authors.initials: JG
authors.lastname: D'Haese
authors.affiliation: Department of Pathology, Ludwig-Maximilians-Universität München, Munich, Germany.
authors.forename: J
authors.initials: J
authors.lastname: Neumann
authors.affiliation: Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, Hospital of the University of Munich, Munich, Germany.
authors.forename: M
authors.initials: M
authors.lastname: Weniger
authors.affiliation: Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, Hospital of the University of Munich, Munich, Germany.
authors.forename: S
authors.initials: S
authors.lastname: Pratschke
authors.affiliation: Department of Surgery, County Council of Östergötland, Linköping University, Linköping, Sweden.
authors.forename: B
authors.initials: B
authors.lastname: Björnsson
authors.affiliation: HPB Surgery and Liver Transplant Unit, Italian Hospital Buenos Aires, Buenos Aires, Argentina.
authors.forename: V
authors.initials: V
authors.lastname: Ardiles
authors.affiliation: Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA.
authors.forename: W
authors.initials: W
authors.lastname: Chapman
authors.affiliation: Medical Center London, Western University, Ontario, Canada.
authors.forename: R
authors.initials: R
authors.lastname: Hernandez-Alejandro
authors.affiliation: Department of HPB Surgery and Liver Transplant, Beaujon Hospital, Clichy, France.
authors.forename: O
authors.initials: O
authors.lastname: Soubrane
authors.affiliation: Virgen de la Arrixaca University Hospital, Murcia, Spain.
authors.forename: R
authors.initials: R
authors.lastname: Robles-Campos
authors.affiliation: Department of Surgery, University Clinical Center, Nis, Serbia.
authors.forename: M
authors.initials: M
authors.lastname: Stojanovic
authors.affiliation: Department of Surgery, Parma University Hospital, Parma, Italy.
authors.forename: R
authors.initials: R
authors.lastname: Dalla Valle
authors.affiliation: Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong, People's Republic of China.
authors.forename: A C Y
authors.initials: AC
authors.lastname: Chan
authors.affiliation: Department of Medical Informatics, Biometry, and Epidemiology-IBE, Chair for Public Health and Health Services Research, Research Unit for Biopsychosocial Health, Ludwig-Maximilians-Universität München, Munich, Germany.
authors.forename: M
authors.initials: M
authors.lastname: Coenen
authors.affiliation: Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, Hospital of the University of Munich, Munich, Germany.
authors.forename: M
authors.initials: M
authors.lastname: Guba
authors.affiliation: Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, Hospital of the University of Munich, Munich, Germany.
authors.forename: J
authors.initials: J
authors.lastname: Werner
authors.affiliation: Department of Surgery, Cantonal Hospital Winterthur, Institute of Physiology, University of Zürich, Zurich, Switzerland.
authors.forename: E
authors.initials: E
authors.lastname: Schadde
authors.affiliation: Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, Hospital of the University of Munich, Munich, Germany. martin.angele@med.uni-muenchen.de.|Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, Campus Grosshadern, Ludwig Maximilians-University, Munich, Germany. martin.angele@med.uni-muenchen.de.
authors.forename: M K
authors.initials: MK
authors.lastname: Angele
mesh_terms: D000368:Aged; D006528:Carcinoma, Hepatocellular / Q000473:pathology / Q000601:surgery*; D015179:Colorectal Neoplasms / Q000473:pathology / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006498:Hepatectomy; D006801:Humans; D008026:Ligation; D008113:Liver Neoplasms / Q000556:secondary / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D060787:Neoplasm Grading; D009367:Neoplasm Staging; D011169:Portal Vein / Q000473:pathology / Q000601:surgery*; D011379:Prognosis; D012189:Retrospective Studies; D015996:Survival Rate; D014656:Vascular Surgical Procedures / Q000379:methods*