Indicating ALPPS for Colorectal Liver Metastases: A Critical Analysis of Patients in the International ALPPS Registry

Abstract

ObjectivesIn the international associating liver partition and portal vein ligation for staged hepatectomy registry, more than 50% of patients underwent associating liver partition and portal vein ligation for staged hepatectomy with a right hepatectomy. This study evaluated the necessity of two-stage hepatectomies being performed as right hepatectomy associating liver partition and portal vein ligation for staged hepatectomy in patients with colorectal liver metastases versus right trisectionectomy associating liver partition and portal vein ligation for staged hepatectomy. Patients and MethodsAll patients registered between 2012 and 2017 undergoing associating liver partition and portal vein ligation for staged hepatectomy for colorectal liver metastases were included. A liver to body weight index of 0.5 or less prior to stage I in the presence of liver damage was used as an internationally accepted standard to justify a two-stage hepatectomy. ResultsFour-hundred and three patients with colorectal liver metastases with right hepatectomy associating liver partition and portal vein ligation for staged hepatectomy (n = 183) or right trisectionectomy associating liver partition and portal vein ligation for staged hepatectomy (n = 220) were analyzed. Presence of metastases in segments II/III, liver damage, number of patients on chemotherapy, and cycles were comparable, and there was a comparable response to chemotherapy. Liver to body weight index was different prior to stage 1 (right trisectionectomy associating liver partition and portal vein ligation for staged hepatectomy: 0.33 ± 0.12 versus right hepatectomy associating liver partition and portal vein ligation for staged hepatectomy: 0.40 ± 0,14; P < .001) and prior to stage 2 (right trisectionectomy associating liver partition and portal vein ligation for staged hepatectomy: 0.58 ± 0.17 versus right hepatectomy associating liver partition and portal vein ligation for staged hepatectomy: 0.66 ± 0,18; P < .001). Hypertrophy rates were similar between groups. As much as 16.9% and 7.2% of patients in right hepatectomy associating liver partition and portal vein ligation for staged hepatectomy and right trisectionectomy associating liver partition and portal vein ligation for staged hepatectomy had no apparent justification for a two-stage hepatectomy based on LBWI prior to stage 1 and absence of chemotherapy (<12 cycles). ConclusionMore than 15% of associating liver partition and portal vein ligation for staged hepatectomy procedures were performed in patients who may have had no indication for a two-stage hepatectomy, especially in the group of patients with right hepatectomy. Thus, it appears that there is a risk of the overuse of associating liver partition and portal vein ligation for staged hepatectomy because of its great potential to induce volume growth. Due to the high perioperative risk of associating liver partition and portal vein ligation for staged hepatectomy, indications should be carefully reconsidered.