title: The ALPPS Risk Score: Avoiding Futile Use of ALPPS.
abstract: OBJECTIVE
  To create a prediction model identifying futile outcome in ALPPS (Associating Liver Partition and Portal vein ligation for Staged hepatectomy) before stage 1 and stage 2 surgery.
  
  
  BACKGROUND
  ALPPS is a 2-stage hepatectomy, which incorporates parenchymal transection at stage 1 enabling resection of extensive liver tumors. One of the major criticisms of ALPPS is the associated high mortality rate up to 20%.
  
  
  METHODS
  Using the International ALPPS Registry, a risk analysis for futile outcome (defined as 90-day or in-hospital mortality) was performed. Futility was modeled using multivariate regression analysis and a futility risk score formula was computed on the basis of the relative size of logistic model regression coefficients.
  
  
  RESULTS
  Among 528 ALPPS patients from 38 centers, a futile outcome was observed in 47 patients (9%). The pre-stage 1 model included age 67 years or older [odds ratio (OR) = 5.7], and tumor entity (OR = 3.8 for biliary tumors) as independent predictors of futility from multivariate analysis. For the pre-stage 1 model scores of 0, 1, 2, 3, 4 and 5 were associated with futile risk of 2.7%, 4.9%, 8.6%, 15%, 24%, and 37%. The pre-stage 2 model included major complications (grade ≥ 3b) after stage 1 (OR = 3.4), serum bilirubin (OR = 4.4), serum creatinine (OR = 5.4), and cumulative pre-stage 1 risk score (OR = 1.9). The model predicted futility risk of 5%, 10%, 20%, and 50% for patients with scores of 3.9, 4.7, 5.5, and 6.9, respectively.
  
  
  CONCLUSIONS
  Both models have an excellent prediction to assess the individual risk of futile outcome after ALPPS surgery and can be used to avoid futile use of ALPPS.
authors.affiliation: *Department of Surgery and Transplantation, Swiss HPB and Transplant Center, University Hospital Zurich, Zurich, Switzerland†Department of General and Abdominal Surgery, Asklepios Hospital Barmbek, Hamburg, Germany‡Semmelweis University, Budapest, Campus Hamburg, Germany§Institute for Epidemiology, Biostatistics and Prevention, University of Zurich, Zurich, Switzerland¶Department of General, Visceral and Transplantation Surgery, University Hospital Aachen, RWTH Aachen, Germany||General, Visceral and Transplant Surgery, University Hospital Tübingen, Tübingen, Germany**Department of Surgery and Liver and Pancreas transplantation, Virgen de la Arrixaca Clinic and University Hospital, Murcia, Spain††Department of Surgery, Division of HPB Surgery, Liver Transplant Unit, Italian Hospital Buenos Aires, Buenos Aires, Argentina‡‡Department of HPB and Liver Transplant Surgery, University College London, Royal Free Hospital, London, UK.
authors.forename: Michael
authors.initials: M
authors.lastname: Linecker
authors.forename: Gregor A
authors.initials: GA
authors.lastname: Stavrou
authors.forename: Karl J
authors.initials: KJ
authors.lastname: Oldhafer
authors.forename: Robert M
authors.initials: RM
authors.lastname: Jenner
authors.forename: Burkhardt
authors.initials: B
authors.lastname: Seifert
authors.forename: Georg
authors.initials: G
authors.lastname: Lurje
authors.forename: Jan
authors.initials: J
authors.lastname: Bednarsch
authors.forename: Ulf
authors.initials: U
authors.lastname: Neumann
authors.forename: Ivan
authors.initials: I
authors.lastname: Capobianco
authors.forename: Silvio
authors.initials: S
authors.lastname: Nadalin
authors.forename: Ricardo
authors.initials: R
authors.lastname: Robles-Campos
authors.forename: Eduardo
authors.initials: E
authors.lastname: de Santibañes
authors.forename: Massimo
authors.initials: M
authors.lastname: Malagó
authors.forename: Mickael
authors.initials: M
authors.lastname: Lesurtel
authors.forename: Pierre-Alain
authors.initials: PA
authors.lastname: Clavien
authors.forename: Henrik
authors.initials: H
authors.lastname: Petrowsky
mesh_terms: D000368:Aged; D005260:Female; D006498:Hepatectomy / Q000009:adverse effects* / Q000401:mortality; D017052:Hospital Mortality; D006801:Humans; D008026:Ligation; D008113:Liver Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D016015:Logistic Models; D008297:Male; D018447:Medical Futility; D008875:Middle Aged; D061646:Operative Time; D011169:Portal Vein / Q000601:surgery; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome