title: Importance of primary indication and liver function between stages: results of a multicenter Italian audit of ALPPS 2012-2014.
abstract: Posthepatectomy liver failure is one of the most feared complications in extended hepatic resections. In 2012, a novel two-stage liver resection was developed, able to induce rapid and extensive hypertrophy by portal vein ligation and in situ liver splitting - Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS). The technique became more widely employed but its use remained controversial due to reporting of high complication and mortality rates.
  
  
  
  A national audit was performed to gather information about the safety of the procedure and to better understand the complications. The audit was offered to all high-volume hepatobiliary centers in Italy.
  
  
  
  Of all Italian centers approached in January 2012, 12 centers with experience in ALPPS enrolled and participated in collection of data. Fifty patients underwent ALPPS between 2012 and 2014. In 48/50 patients completion of hepatectomy was performed successfully. Major morbidity occurred in 54% with a 20% 90-day mortality. Uni- and multivariate analysis showed that ALPPS for cholangiocarcinoma and a peak of bilirubin over 5 mg/dl between stages was associated with increase of 90-day mortality and worse survival.
  
  
  
  It is proposed that a moratorium be introduced for classic ALPPS in cholangiocarcinoma and to abort ALPPS in patients who develop an interstage increase in bilirubin, due to the high risk of liver failure and mortality.
authors.affiliation: Division of General Surgery, Maggiore Hospital, Bologna, Italy.
authors.forename: Matteo
authors.initials: M
authors.lastname: Serenari
authors.affiliation: Division of General Surgery, Maggiore Hospital, Bologna, Italy.
authors.forename: Matteo
authors.initials: M
authors.lastname: Zanello
authors.affiliation: Department of Surgery, Cantonal Hospital Winterthur and Institute of Physiology, University of Zurich, Zurich, Switzerland.
authors.forename: Erik
authors.initials: E
authors.lastname: Schadde
authors.affiliation: Division of General Surgery, Maggiore Hospital, Bologna, Italy.
authors.forename: Elena
authors.initials: E
authors.lastname: Toschi
authors.affiliation: Department of Surgery, Hepatobiliary Surgery Unit, Vita-Salute San Raffaele University, Milan, Italy.
authors.forename: Francesca
authors.initials: F
authors.lastname: Ratti
authors.affiliation: General Surgery and Organ Transplantation Hepatobiliary Surgery and Liver Transplant Unit, University of Padua, Padua, Italy.
authors.forename: Enrico
authors.initials: E
authors.lastname: Gringeri
authors.affiliation: Division of General Surgery, Maggiore Hospital, Bologna, Italy.
authors.forename: Michele
authors.initials: M
authors.lastname: Masetti
authors.affiliation: General Surgery and Organ Transplantation Hepatobiliary Surgery and Liver Transplant Unit, University of Padua, Padua, Italy.
authors.forename: Umberto
authors.initials: U
authors.lastname: Cillo
authors.affiliation: Department of Surgery, Hepatobiliary Surgery Unit, Vita-Salute San Raffaele University, Milan, Italy.
authors.forename: Luca
authors.initials: L
authors.lastname: Aldrighetti
authors.affiliation: Division of General Surgery, Maggiore Hospital, Bologna, Italy. Electronic address: elio.jovine@ausl.bologna.it.
authors.forename: Elio
authors.initials: E
authors.lastname: Jovine
mesh_terms: D000328:Adult; D000368:Aged; D001650:Bile Duct Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D001663:Bilirubin / Q000097:blood; D015415:Biomarkers / Q000097:blood; D018281:Cholangiocarcinoma / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D005260:Female; D006498:Hepatectomy / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D061847:Hospitals, High-Volume; D006801:Humans; D006984:Hypertrophy; D007558:Italy; D008026:Ligation; D008099:Liver / Q000378:metabolism / Q000473:pathology / Q000503:physiopathology / Q000601:surgery*; D017093:Liver Failure / Q000175:diagnosis / Q000209:etiology / Q000401:mortality / Q000503:physiopathology; D008111:Liver Function Tests; D008115:Liver Regeneration; D016015:Logistic Models; D008297:Male; D008485:Medical Audit; D008875:Middle Aged; D015999:Multivariate Analysis; D009929:Organ Size; D011169:Portal Vein / Q000601:surgery; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D012042:Registries; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D015415:Biomarkers; D001663:Bilirubin