Conventional Two-stage Hepatectomy Research Articles

Individualized Selection Criteria Based on Tumor Burden in Future Remnant Liver for Staged Hepatectomy of Advanced CRLM: Conventional TSH or ALPPS.

Simple SummaryCurrently, two established staged hepatectomy techniques are used for curative resection of advanced colorectal liver metastasis (CRLM) as well as preventing inadequate future remnant liver (FRL). However, the selection of staged hepatectomy between the conventional two-stage hepatectomy (cTSH) and the associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) remains under debate. Therefore, the present study proposed a selection criterion based on tumor burden related to the size and number of metastases within the FRL for decision making when utilizing staged hepatectomy for advanced CRLM. Accordingly, metastatic tumors within the FRL should not exceed three nodules and none of the nodules should measure larger than 3 cm for ALPPS. By contrast, cTSH would be considered in patients whose tumor burdens within the FRL beyond the aforementioned criteria. The individualized selection criteria appear to be promising and can be used to select a more effective staged hepatectomy approach for patients with advanced CRLM.Staged hepatectomy is a promising strategy for curative resection of advanced colorectal liver metastasis (CRLM) to prevent inadequate future remnant liver (FRL). However, the selection criteria for conventional two-stage hepatectomy (cTSH) and associating liver partitioning and portal vein ligation for staged hepatectomy (ALPPS) remain unclear. This study aimed to propose a selection criterion for determining the optimal staged hepatectomy for patients with advanced CRLM. A selection criterion based on the degree of metastatic tumors within the FRL was established to determine staged hepatectomy approaches. Generally, ALPPS is recommended for patients with ≤3 metastatic nodules and whose nodules do not measure >3 cm in the FRL. cTSH is performed for patients whose tumor burden in FRL beyond the selection criteria. Data of 37 patients who underwent staged hepatectomy and curative intent of CRLM were analyzed. The clinical characteristics and outcomes of the two approaches were compared. Overall, cTSH and ALPPS were performed for 27 (73.0%) and 10 (27.0%) patients, respectively. Of those, 20 patients in the cTSH group and all patients in the ALPPS group had completed staged hepatectomy. The 1-, 3-, and 5-year survival rates were 91.6%, 62.4%, and 45.4% for all patients, respectively. The outcomes of patients who had successfully completed the staged hepatectomy were significantly better than those of other patients who failed to achieve staged hepatectomy. However, no significant difference was observed in the overall survival of patients who underwent staged hepatectomy between the two groups, but those in the ALPPS group had 100% survival at the end of this study. The individualized selection criteria based on tumor burden in the FRL that could balance the operative risk and oncologic outcome appear to be a promising strategy for achieving complete staged hepatectomy in patients with advanced CRLM.

A single center comparative retrospective study of in situ split plus portal vein ligation versus conventional two-stage hepatectomy for cholangiocellular carcinoma

Introduction Cholangiocellular carcinoma (CCA) has a poor prognosis and the goldstandard even in locally advanced cases remains radical surgical resection. This approach however is limited by the future liver remnant volume (FLRV) after extensive parenchymal dissection leading to post-operative liver failure and high mortality rates. The aim of this study was to compare the outcome of in situ liver transection with portal vein ligation (ISLT) procedure and conventional two-stage hepatectomy with portal vein embolization (PVE/TSH) in patients with CCA. Methods All patients with CCA and insufficient FLR considered for either ISLT or PVE/TSH were analyzed for outcomes including post-operative morbidity, mortality, and overall survival rates (OS). Results Sixteen patients received ISLT and eight patients underwent PVE/TSH. The completion rate of the second stage in the PVE/TSH group was 62% and 100% in the ISLT group (p = 0.027). The overall 90-day morbidity rates including severe complications (Clavien-Dindo ≥3b) were comparable (PVE/TSH 40% vs. ISLT 69%, p = 0.262). The median OS (PVE/TSH 7 months vs. ISLT 3 months) and the 90-day mortality rates (PVE/TSH 0% vs. ISLT 50%) did not significantly differ between the two groups (p > 0.05). In multivariate analysis, biliary resection and reconstruction was the only risk factor independently associated with 90-day post-operative morbidity [HR = 20.0; 95%CI (1.68–238.63); p = 0.018]. Conclusion Our results demonstrate comparable outcomes in both groups in a rather prognostically unfavorable disease. The completion rate in the ISLT group was significantly higher than in the PVE/TSH cohort. This work encourages specialized hepato-biliary-pancreatic centers in applying the ISLT procedure in selected cases with CCA.

Associating liver partition and portal vein ligation for staged hepatectomy procedure versus conventional two-stage hepatectomy for colorectal liver metastasis

Associating liver partition and portal vein ligation for staged hepatectomy procedure versus conventional two-stage hepatectomy for colorectal liver metastasis

Role of CT in Two-Stage Liver Surgery.

Complete resection is the only potentially curative treatment for primary or metastatic liver tumors. Improvements in surgical techniques such as conventional two-stage hepatectomy (TSH) with portal vein embolization and ALPPS (associating liver partition and portal vein ligation for staged hepatectomy) promote hypertrophy of the future liver remnant (FLR), expanding resection criteria to include patients with widespread hepatic disease who were formerly not considered candidates for resection. Radiologists are essential in the multidisciplinary approach required for TSH. In particular, multidetector CT has a critical role throughout the various stages of this surgical process. The aims of CT before the first stage of TSH are to define the feasibility of surgery, assess the number and location of liver tumors in relation to relevant anatomy, and provide a detailed anatomic evaluation, including vascular and biliary variants. Volume calculation with CT is also essential to determine if the FLR is sufficient to avoid posthepatectomy liver failure. The objectives of CT between the first and second stages of TSH are to recalculate liver volumes (ie, assess FLR hypertrophy) and depict expected liver changes and complications that could modify the surgical plan or preclude the second stage of definitive resection. In this review, the importance of CT throughout different stages of TSH is discussed and key observations that contribute to surgical planning are highlighted. In addition, the advantages and limitations of MRI for detection of liver metastases and assessment of complications are briefly described. ©RSNA, 2022.

A Comparative Retrospective Study of in Situ Split Plus Portal Vein Ligation (ISLT) Versus Conventional Two-Stage Hepatectomy for Cholangiocellular Carcinoma - Does the ISLT Procedure Have an Oncological Advantage?

Introduction: Cholangiocellular carcinoma (CCA) has a poor prognosis and the mainstay of therapy even in locally advanced cases remains radical surgical resection. This approach however is limited by the future liver remnant (FLR) volume after extensive parenchymal dissection leading to postoperative liver failure and high mortality rates. The aim of this study was to compare the outcome of in situ liver transection with portal vein ligation (ISLT) procedure and conventional two-stage hepatectomy with portal vein embolization (PVE/TSH) in patients with CCA. Methods: All patients with CCA and insufficient FLR considered for either ISLT or PVE/TSH were analyzed for outcomes including postoperative morbidity and mortality as well as overall survival rates (OS). Results: Of the total 24 patients included, 16 patients received ISLT. The remaining 8 patients underwent PVE/TSH. The completion rate of the second stage in the PVE/TSH group was 62% and 100% in the ISLT group (p=0.027). The overall 90-days-morbidity was comparable (PVE/TSH 40% vs. ISLT 69%, p=0.262). OS at follow-up (median: 7 months) did not significantly differ between the two groups (p>0.05). In multivariate analysis, biliary resection and reconstruction was the only risk factor independently associated with significantly higher morbidity and mortality rates (HR=23.33; 95%CI (1.99-273.29); p=0.012). Conclusion: Our results demonstrate comparable outcomes in both groups in a rather prognostically unfavourable disease. The completion rate in the ISLT group was significantly higher than in the PVE/TSH cohort. This work encourages specialized HPB centers in applying the ISLT procedure in selected cases with cholangiocellular carcinoma.

From conventional two-stage hepatectomy to ALPPS: Fifteen years of experience in a hepatobiliary surgery unit

BackgroundHepatectomy in patients with large tumor load may result in postoperative liver failure and associated complications due to excessive liver parenchyma removal. Conventional two-stage hepatectomy (TSH) and associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) technique are possible solutions to this problem. Colorectal liver metastases (CRLM) is the most frequent indication, and there is a need to assess outcomes for both techniques to improve surgical and long-term oncological outcomes in these patients. MethodsA single-center retrospective study was designed to compare TSH with ALPPS in patients with initially unresectable bilateral liver tumors between January 2005 and January 2020. ALPPS was performed from January 2012 onwards as the technique of choice. Long-term overall survival (OS) and disease-free survival (DFS) were evaluated as primary outcome in CRLM patients. Postoperative morbidity, mortality and liver growth in all patients were also evaluated. ResultsA total of 38 staged hepatectomies were performed: 17 TSH and 21 ALPPS. Complete resection rate was 76.5% (n = 13) in the TSH group and 85.7% (n = 18) in the ALPPS group (P = 0.426). Overall major morbidity (Clavien-Dindo ≥ 3a) (stage 1 + stage 2) was 41.2% (n = 7) in TSH and 33.3% (n = 7) in ALPPS patients (P = 0.389), and perioperative 90-day mortalities were 11.8% (n = 2) vs. 19.0% (n = 4) in each group, respectively (P = 0.654). Intention-to-treat OS rates at 1 and 5 years in CRLM patients for TSH (n = 15) were 80% and 33%, and for ALPPS (n = 17) 76% and 35%, respectively. DFS rates at 1 and 5 years were 36% and 27% in the TSH group vs. 33% and 27% in the ALPPS group, respectively. ConclusionsALPPS is an effective alternative to TSH in bilateral affecting liver tumors, allowing higher resection rate, but patients must be carefully selected. In CRLM patients similar long-term OS and DFS can be achieved with both techniques.

428 Hepatic Epithelioid Hemangioendothelioma: A Rare Vascular Malignancy Mimicking as Intrahepatic Cholangiocarcinoma

Abstract Hepatic epithelioid hemangio-endothelioma (EHE) is a rare, often misdiagnosed malignancy of vascular origin. We describe a case of a 36-year-old, who presented with a burning sensation in his chest on exercise and was believed to have bilobar intrahepatic cholangiocarcinoma. After receiving chemotherapy with partial response, the patient underwent staged resection modified ALPPS (associating liver partition with portal vein ligation for staged hepatectomy) procedure – laparoscopic radiofrequency assisted ALPPS (RALPPS). Histological examination of the stage 1 specimen revealed EHE deposits in the left lobe of the liver. The patient proceeded to have stage 2 open right hepatectomy with concurring histology. 90-days follow-up CT scan showed almost complete resolution of EHE lesions. Low incidence, non-specific clinical and radiological characteristics all contribute to high EHE misdiagnosis rate. Histological analysis can be used for confirmation of the diagnosis; however, specialist staining is required, which is not routinely performed. Multiple treatments are available against EHE, but only liver resection and liver transplantation are potentially curative. ALPPS and its modifications (such as RALPPS) offer an alternative for conventional two-stage hepatectomy for patients with extensive bilobar EHE, who are at risk of developing post-hepatectomy liver failure or patients with anomalous hepatic vasculature anatomy, which makes PVE challenging.

A Comparative Retrospective Study of in Situ Split Plus Portal Vein Ligation (ISLT) versus Conventional Two-stage Hepatectomy for Cholangiocellular Carcinoma

Introduction: Cholangiocellular carcinoma (CCA) has a poor prognosis and the mainstay of therapy even in locally advanced cases remains radical surgical resection. This approach however is limited by the future liver remnant (FLR) volume after extensive parenchymal dissection leading to postoperative liver failure and high mortality rates. The aim of this study was to compare the outcome of in situ liver transection with portal vein ligation (ISLT) procedure and conventional two-stage hepatectomy with portal vein embolization (PVE/TSH) in patients with CCA. Methods: All patients with CCA and insufficient FLR considered for either ISLT or PVE/TSH were analyzed for outcomes including postoperative morbidity and mortality as well as overall survival rates (OS). Results: Of the total 24 patients included, 16 patients received ISLT. The remaining 8 patients underwent PVE/TSH. The completion rate of the second stage in the PVE/TSH group was 62% and 100% in the ISLT group (p=0.027). The overall 90-days-morbidity was comparable (PVE/TSH 40% vs. ISLT 69%, p=0.262). OS at follow-up (median: 7 months) did not significantly differ between the two groups (p>0.05). In multivariate analysis, biliary resection and reconstruction was the only risk factor independently associated with significantly higher morbidity and mortality rates (HR=23.33; 95%CI (1.99-273.29); p=0.012). Conclusion: Our results demonstrate comparable outcomes in both groups in a rather prognostically unfavourable disease. The completion rate in the ISLT group was significantly higher than in the PVE/TSH cohort. This work encourages specialized HPB centers in applying the ISLT procedure in selected cases with cholangiocellular carcinoma.

Tumor Progression Molecular Pathways after ALPPS and Conventional Two-stage Hepatectomy in Patients with Colorectal Liver Metastases

Tumor Progression Molecular Pathways after ALPPS and Conventional Two-stage Hepatectomy in Patients with Colorectal Liver Metastases

Associated liver partition and portal vein ligation for staged hepatectomy: a review.

Outcomes of liver resection have improved with advances in surgical techniques, improvements in critical care and expansion of resectability criteria. However, morbidity and mortality following liver resection continue to plague surgeons. Post-hepatectomy liver failure (PHLF) due to inadequate future liver remnant (FLR) is an important cause of morbidity and mortality following liver resection. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a novel two-staged procedure described in 2012, which aims to induce rapid hypertrophy of the FLR unlike conventional two-stage hepatectomy, which require a longer time for FLR hypertrophy. Careful patient selection and modifications in surgical technique has improved morbidity and mortality rates in ALPPS. Colorectal liver metastases (CRLM) confers the best outcomes post-ALPPS. Patients <60 years old and low-grade fibrosis with underlying hepatocellular carcinoma (HCC) are also eligible for ALPPS. Evidence for other types of cancers is less promising. Current studies, though limited, demonstrate that ALPPS has comparable oncological outcomes with conventional two-stage hepatectomy. Modifications such as partial-ALPPS and mini-ALPPS have shown improved morbidity and mortality compared to classic ALPPS. ALPPS may be superior to conventional two-stage hepatectomy in carefully selected groups of patients and has a promising outlook in liver surgery.

Associated Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) Registry: What Have We Learned?

In 2007, the first associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure was performed in Regensburg, Germany. ALPPS is a variation of two-stage hepatectomy to induce rapid liver hypertrophy allowing the removal of large tumors otherwise considered irresectable due to a too small future liver remnant. In 2012, the international ALPPS registry was created, and it now contains more than 1,000 cases. During the past years, improved patient selection and refinements in operative techniques, in particular, less invasive approaches such as Partial ALPPS, Tourniquet ALPPS, Ablation-assisted ALPPS, Hybrid ALPPS or Laparoscopic or Robotic approaches, have resulted in significant improvements in safety. The most frequent indication for ALPPS is colorectal liver metastases. In the first randomized controlled study, ALPPS provided a higher resectability rate than conventional two-stage hepatectomy, with similar complication rates. Long-term outcome data are still missing. The initial results of ALPPS for hepatocellular carcinoma and for perihilar cholangiocarcinoma were devastating, but with progress in surgical technic and better patient selection, ALPPS could serve as a treatment alternative in carefully selected cases, even for these tumors. ALPPS has enlarged the armamentarium of hepato-pancreato-biliary surgeons, but there is still discussion regarding how to use this novel technique, which may allow resection of tumors that are otherwise deemed irresectable.

Surgical Treatment of a Primary Tumour and Liver Metastases in a Patient With Intracranial Haemangiopericytoma

Cancers exhibit a spectrum of behaviours ranging from aggressive malignancy to those which progress in an almost benign fashion. An appreciation of this aspect of tumour biology is crucial when planning patient management as non-curative debulking procedures for slower growing tumours often still confer a survival benefit. The present report is a case in point.&#x0D; Haemangiopericytoma is a rare cancer whilst clear indications for an ALPPS procedure are still evolving. Inherent to the patient groups in whom ALPPS is considered is the presence of advanced underlying disease. Many of these patients would previously not be considered for liver resection or have progressed beyond resectability by the time sufficient hypertrophy of their future liver remnant had been achieved using conventional two-stage hepatectomy techniques.&#x0D; ALPPS offers another treatment option for these patients, although at a cost. Early experience reported unacceptably high morbidity and mortality rates following ALPPs resection and suggested that tumour type and patient fitness were key factors in determining outcome. The patient must be fit enough to withstand two major operations 1-2 weeks apart. The slow growing nature of the tumour in the present case combined with the fit, motivated patient meant that, despite developing post-operative liver insufficiency, Mr X still recovered well.&#x0D; As is so often the case in surgery, patient selection is key

Outcomes of staged hepatectomies for liver malignancy.

Liver malignancies are the fifth most common cause of death worldwide. Surgical intervention with curative intent is the treatment of choice for liver tumors as it provides long-term survival. However, only 20% of patients with metastatic liver lesions can be managed by curative liver resection. In most of the cases, hepatectomy is not feasible because of insufficient future liver remnant (FLR). Two-stage hepatectomy is advocated to achieve liver resection in a patient who is considered to not be a candidate for resection. Procedures of staged hepatectomy include conventional two-stage hepatectomy, portal vein embolization, and associating liver partition and portal vein ligation for a staged hepatectomy. Technical success is high for each of these procedures but variable between them. All the procedures have been reported as being effective in achieving a satisfactory FLR and completing the second-stage resection. Moreover, the overall survival and disease-free survival rates have improved significantly for patients who were otherwise considered nonresectable; yet, an increase in the morbidity and mortality rates has been observed. We suggest that this type of procedure should be carried out in high-flow centers and through a multidisciplinary approach. An experienced surgeon is key to the success of those interventions.

ALPPS Versus Conventional Two-stage Hepatectomy in Patients With Advanced Colorectal Liver Metastases

ALPPS Versus Conventional Two-stage Hepatectomy in Patients With Advanced Colorectal Liver Metastases

Response To “ALPPS Versus Conventional Two-stage Hepatectomy in Patients With Advanced Colorectal Liver Metastases”

Response To “ALPPS Versus Conventional Two-stage Hepatectomy in Patients With Advanced Colorectal Liver Metastases”

ALPPS improves resectability compared to conventional two-stage hepatectomy in patients with advanced colorectal liver metastasis

The aim was to evaluate ALPPS could increase resection rates (RRs) compared with two stage hepatectomy (TSH) in a randomized controlled trial (RCT). Radical liver metastasis resection offers the only chance of a cure for patients with metastatic colorectal cancer. Patients with colorectal liver metastasis (CRLM) and an insufficient future liver remnant (FLR) volume are traditionally treated with chemotherapy with portal vein embolization or ligation followed by hepatectomy (TSH). This treatment sometimes fails. A prospective, multicenter RCT was conducted between June 2014 and August 2016. It included 97 patients with CRLM and a standardized FLR (sFLR) of < 30%. Primary outcome, resection rates (RRs) were measured as the percentages of patients completing both stages of the treatment. Secondary outcomes were complications, radicality and 90-day mortality measured from the final intervention. Baseline characteristics, besides body mass index, did not differ between the groups. The RR was 92% (C.I. 84-100%)(44/48) in the ALPPS arm compared to 57% (43-72%)(28/49) in the TSH arm (rate ratio 8.25 [95% CI 2.6-26.6]; P< 0.0001). No differences in complications (Clavien-Dindo ≥3a) (43% (19/44) vs. 43% (12/28) (1.01 [95% CI 0.4-2.6]; P=0.99), 90-day mortality (8.3% (4/48) vs. 6.1% (3/49) (1.39 [95% CI 0.3-6.6]; P=0.68) or R0 RRs (77% (34/44) vs. 57% (16/28) (2.55 [95% CI 0.9-7.1]; P=0.11)) were observed. Of the patients in the TSH arm that failed to reach a sFLR of 30%, 12 were successfully treated with ALPPS. ALPPS is superior to TSH in terms of RR, with comparable surgical margins, complications and short-term mortality.

Letter to the Editor Regarding “ALPPS Improves Resectability Compared with Conventional Two-Stage Hepatectomy in Patients with Advanced Colorectal Liver Metastasis”

Letter to the Editor Regarding “ALPPS Improves Resectability Compared with Conventional Two-Stage Hepatectomy in Patients with Advanced Colorectal Liver Metastasis”

Associating liver partition and portal vein ligation for staged hepatectomy versus conventional two-stage hepatectomy: a systematic review and meta-analysis

BackgroundIt is generally accepted that an insufficient future liver remnant is a major limitation of large-scale hepatectomy for patients with primary hepatocellular carcinoma. Conventional two-stage hepatectomy (TSH) is commonly considered to accelerate future liver regeneration despite its low regeneration rate. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS), which is characterized by a rapid regeneration, has brought new opportunities.MethodsRelevant studies were identified by searching the selected databases up to September 2017. Then, a meta-analysis of regeneration efficiency, complication rate, R0 resection ratio, and short-term outcomes was performed.ResultsTen studies, comprising 719 patients, were included. The overall analysis showed that ALPPS was associated with a larger hyperplastic volume and a shorter time interval (P < 0.00001) than TSH. ALPPS also exhibited a higher completion rate for second-stage operations (odds ratio, OR 9.50; P < 0.0001) and a slightly higher rate of R0 resection (OR 1.90; P = 0.11). Interestingly, there was no significant difference in 90-day mortality between the two treatments (OR 1.44; P = 0.35).ConclusionsThese results indicate that compared with TSH, ALPPS possesses a stronger regenerative ability and better facilitates second-stage operations. However, the safety, patient outcomes, and patient selection for ALPPS require further study.

ALPPS Improves Resectability Compared With Conventional Two-stage Hepatectomy in Patients With Advanced Colorectal Liver Metastasis: Results From a Scandinavian Multicenter Randomized Controlled Trial (LIGRO Trial).

Objective:The aim of the study was to evaluate if associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) could increase resection rates (RRs) compared with two-stage hepatectomy (TSH) in a randomized controlled trial (RCT).Background:Radical liver metastasis resection offers the only chance of a cure for patients with metastatic colorectal cancer. Patients with colorectal liver metastasis (CRLM) and an insufficient future liver remnant (FLR) volume are traditionally treated with chemotherapy with portal vein embolization or ligation followed by hepatectomy (TSH). This treatment sometimes fails due to insufficient liver growth or tumor progression.Methods:A prospective, multicenter RCT was conducted between June 2014 and August 2016. It included 97 patients with CRLM and a standardized FLR (sFLR) of less than 30%. Primary outcome—RRs were measured as the percentages of patients completing both stages of the treatment. Secondary outcomes were complications, radicality, and 90-day mortality measured from the final intervention.Results:Baseline characteristics, besides body mass index, did not differ between the groups. The RR was 92% [95% confidence interval (CI) 84%–100%] (44/48) in the ALPPS arm compared with 57% (95% CI 43%–72%) (28/49) in the TSH arm [rate ratio 8.25 (95% CI 2.6–26.6); P < 0.0001]. No differences in complications (Clavien–Dindo ≥3a) [43% (19/44) vs 43% (12/28)] [1.01 (95% CI 0.4–2.6); P = 0.99], 90-day mortality [8.3% (4/48) vs 6.1% (3/49)] [1.39 [95% CI 0.3–6.6]; P = 0.68] or R0 RRs [77% (34/44) vs 57% (16/28)] [2.55 [95% CI 0.9–7.1]; P = 0.11)] were observed. Of the patients in the TSH arm that failed to reach an sFLR of 30%, 12 were successfully treated with ALPPS.Conclusion:ALPPS is superior to TSH in terms of RR, with comparable surgical margins, complications, and short-term mortality.

Short Chemotherapy-Free Interval Improves Oncological Outcome in Patients Undergoing Two-Stage Hepatectomy for Colorectal Liver Metastases.

In patients undergoing two-stage hepatectomy (TSH) for colorectal liver metastases (CRLM), chemotherapy is discontinued before portal vein occlusion and restarted after curative resection. Long chemotherapy-free intervals (CFI) may lead to tumor progression and poor oncological outcomes. The aim of this study was to investigate the impact of the length of CFI on oncological outcome in patients undergoing TSH for CRLM. Overall, 74 patients suffering from bilobar CRLM who underwent ALPPS (associating liver partition with portal vein ligation for staged hepatectomy; n=43) or conventional TSH (n=31) at two tertiary centers were investigated. The impact of CFI on long-term outcomes was analyzed by univariable and multivariable analysis. Preoperative chemotherapy was administered in 91% (67/74) of patients, and chemotherapy was resumed postoperatively in 69% (44/64) of patients who completed TSH. The use of postoperative chemotherapy was significantly associated with improved mean overall survival (36±3 vs. 13±3months; p<0.001). Overall, the median CFI from surgery to postoperative chemotherapy was 16weeks (interquartile range 11-31) and was significantly shorter in the ALPPS group when compared with the conventional TSH group (10 vs. 21weeks; p<0.001). Multivariable analysis revealed a CFI≤10weeks as an independent factor associated with improved overall survival (p=0.006) and disease-free survival (p=0.010). A short CFI is associated with improved oncological outcome in patients undergoing TSH for CRLM. Decreased interstage intervals after ALPPS may facilitate the timely resumption of chemotherapy.