title: The many faces of ALPPS: surgical indications and techniques among surgeons collaborating in the international registry.
abstract: 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.
  
  
  
  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.
  
  
  
  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.
  
  
  
  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.
authors.affiliation: Dept. of Surgery, Western University, London, ON, Canada.
authors.forename: Suzana
authors.initials: S
authors.lastname: Buac
authors.affiliation: Division of Transplantation, Dept. of Surgery, Rush University Medical Center, Chicago, IL, United States; Cantonal Hospital Winterthur, Winterthur, Canton Zurich, Switzerland.
authors.forename: Erik
authors.initials: E
authors.lastname: Schadde
authors.affiliation: Dept. of General and Visceral Surgery, Frankfurt/Main, Germany.
authors.forename: Andreas A
authors.initials: AA
authors.lastname: Schnitzbauer
authors.affiliation: Dept. of Surgery, Western University, London, ON, Canada.
authors.forename: Kelly
authors.initials: K
authors.lastname: Vogt
authors.affiliation: Dept. of Surgery, Western University, London, ON, Canada. Electronic address: roberto.hernandezalejandro@lhsc.on.ca.
authors.forename: Roberto
authors.initials: R
authors.lastname: Hernandez-Alejandro
mesh_terms: D015179:Colorectal Neoplasms / Q000473:pathology*; D019538:Health Care Surveys; D054625:Healthcare Disparities; D006498:Hepatectomy / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D006801:Humans; D006984:Hypertrophy; D008026:Ligation; D008099:Liver / Q000473:pathology / Q000503:physiopathology / Q000601:surgery*; D008113:Liver Neoplasms / Q000556:secondary / Q000601:surgery*; D008115:Liver Regeneration; D009929:Organ Size; D018579:Patient Selection; D011169:Portal Vein / Q000601:surgery; D011183:Postoperative Complications / Q000209:etiology; D010818:Practice Patterns, Physicians'; D012042:Registries; D012307:Risk Factors; D066231:Surgeons; D016896:Treatment Outcome