How much liver needs to be transected in ALPPS? A translational study investigating the concept of less invasiveness.
ALPPS induces rapid liver hypertrophy after stage-1 operation, enabling safe, extended resections (stage-2) after a short period. Recent studies have suggested that partial transection at stage-1 might be associated with a better safety profile. The aim of this study was to assess the amount of liver parenchyma that needs to be divided to achieve sufficient liver hypertrophy in ALPPS.



In a bi-institutional, prospective cohort study, nonfibrotic patients who underwent ALPPS with complete (n = 22) or partial (n = 23) transection for colorectal liver metastases were analyzed and compared with an external ALPPS cohort (n = 23). A radiologic tool was developed to quantify the amount of parenchymal transection. Liver hypertrophy and clinical outcome were compared between both techniques. The relationship of partial transection and hypertrophy was investigated further in an experimental murine model of partial ALPPS.



The median amount of parenchymal transection in partial ALPPS was 61% (range, 34-86%). The radiologic method correlated poorly with the intraoperative surgeon's estimation (rS= 0.258). Liver hypertrophy was equivalent for the partial ALPPS, ALPPS, and external ALPPS cohort (64% vs 60% vs. 64%). Experimental data demonstrated that partial transection of at least 50% induced comparable hypertrophy (137% vs 156%) and hepatocyte proliferation compared to complete transection.



The study provides clinical and experimental evidence that partial liver partition of at least 50% seems to be equally effective in triggering volume hypertrophy as observed with complete transection and can be re recommended as less invasive alternative to ALPPS.
Swiss HPB and Transplantation Center, University Hospital Zurich, Zurich, Switzerland.
Michael
M
Linecker
Swiss HPB and Transplantation Center, University Hospital Zurich, Zurich, Switzerland.
Patryk
P
Kambakamba
Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland.
Cäcilia S
CS
Reiner
Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland.
Thi Dan
TD
Linh Nguyen-Kim
Department of General and Abdominal Surgery, Asklepios Hospital Barmbek, Hamburg, Germany; Semmelweis University Budapest, Campus Hamburg, Hamburg, Germany.
Gregor A
GA
Stavrou
Department of General and Abdominal Surgery, Asklepios Hospital Barmbek, Hamburg, Germany.
Robert M
RM
Jenner
Department of General and Abdominal Surgery, Asklepios Hospital Barmbek, Hamburg, Germany; Semmelweis University Budapest, Campus Hamburg, Hamburg, Germany.
Karl J
KJ
Oldhafer
Department of Surgery and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.
Bergthor
B
Björnsson
Swiss HPB and Transplantation Center, University Hospital Zurich, Zurich, Switzerland.
Andrea
A
Schlegel
Swiss HPB and Transplantation Center, University Hospital Zurich, Zurich, Switzerland.
Georg
G
Györi
Swiss HPB and Transplantation Center, University Hospital Zurich, Zurich, Switzerland.
Marcel André
MA
Schneider
Swiss HPB and Transplantation Center, University Hospital Zurich, Zurich, Switzerland; Department of General Surgery and Liver, Croix-Rousse University Hospital, Hospices Civils de Lyon, University of Lyon, Lyon, France.
Mickael
M
Lesurtel
Swiss HPB and Transplantation Center, University Hospital Zurich, Zurich, Switzerland.
Pierre-Alain
PA
Clavien
Swiss HPB and Transplantation Center, University Hospital Zurich, Zurich, Switzerland. Electronic address: Henrik.Petrowsky@usz.ch.
Henrik
H
Petrowsky
D000328:Adult; D000368:Aged; D000818:Animals; D015331:Cohort Studies; D004195:Disease Models, Animal; D018572:Disease-Free Survival; D005260:Female; D006498:Hepatectomy / Q000379:methods* / Q000401:mortality; D006801:Humans; D021621:Imaging, Three-Dimensional; D008026:Ligation / Q000379:methods; D008099:Liver / Q000601:surgery*; D008113:Liver Neoplasms / Q000000981:diagnostic imaging* / Q000401:mortality / Q000601:surgery*; D008279:Magnetic Resonance Imaging / Q000379:methods; D008297:Male; D051379:Mice; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000379:methods / Q000401:mortality; D009361:Neoplasm Invasiveness / Q000473:pathology; D009367:Neoplasm Staging; D009929:Organ Size; D018579:Patient Selection; D011169:Portal Vein / Q000601:surgery*; D011379:Prognosis; D011446:Prospective Studies; D018570:Risk Assessment; D015996:Survival Rate; D014057:Tomography, X-Ray Computed / Q000379:methods; D057170:Translational Research, Biomedical; D016896:Treatment Outcome