Hypertrophy Of Future Liver Remnant Research Articles

Abstract No. 524 Future liver remnant hypertrophy after portal vein embolization is inversely correlated to intrahepatic tumor burden

Abstract No. 524 Future liver remnant hypertrophy after portal vein embolization is inversely correlated to intrahepatic tumor burden

Feasibility of Percutaneous Intrahepatic Split by Microwave Ablation (PISA) After Portal Vein Embolization for Hypertrophy of Future Liver Remnant: The Radiological Stage-1 ALPPS.

To assess the feasibility of radiological stage-1 ALPPS, associating liver partition and portal vein ligation for staged hepatectomy, by combining portal vein embolization (PVE) with percutaneous intrahepatic split by ablation (PISA). Three patients (mean age 65.0±7.3years) underwent PVE and PISA. PISA was performed 21days after PVE by microwave ablation to create a continuous intrahepatic cutting plane. Abdominal CT examinations were performed before and after PVE and PISA. The future liver remnant (FLR) volume was calculated by semiautomatic segmentation, and increase was reported as a percentage of the pre-procedural volume. The FLR/body weight (FLR/BW) ratio was calculated; a ratio greater than 0.8% was considered sufficient for guaranteeing adequate liver function after surgery. The liver function before and after PISA was also evaluated by 99mTc-mebrofenin hepatobiliary scintigraphy. Patients' laboratory tests, performance status, ability to walk were assessed before and after PVE and PISA procedures. No procedure-related complications were recorded. The FLR volume increase in each patient was 42.0, 33.1 and 30.4% within 21days of PVE and 109.3, 68.1 and 71.7% within 10days after PISA. The FLR/BW ratios were 0.76, 0.66, 0.63% and 1.13, 0.83, 0.83% after PVE and PISA procedures, respectively. Two patients underwent successful right hepatectomy; in one patient, despite 1.13% FLR/BW, surgery was not performed because of the absolute rejection of blood transfusion due to the patient's religious convictions. Radiological stage-1 ALPPS is a feasible, minimally invasive option to be further investigated to become an effective alternative to surgical stage-1 ALPPS.

Efficacy of ALPPS procedure versus portal vein embolization for hypertrophy of future liver remnant in right trisectionectomy: quality and outcome

Efficacy of ALPPS procedure versus portal vein embolization for hypertrophy of future liver remnant in right trisectionectomy: quality and outcome

ALPPS as a salvage procedure after insufficient future liver remnant hypertrophy following portal vein occlusion

BackgroundA minimum future liver remnant (FLR) of 30% is required to avoid post hepatectomy liver failure (PHLF). Portal vein occlusion (PVO) is the main strategy to induce hypertrophy of the FLR, but some patients will not reach sufficient FLR hypertrophy to enable resection. Recently ALPPS has emerged as a “Salvage Procedure” for PVO failure. The aim of this study was to report the short term outcomes of ALPPS following PVO failure. MethodsA retrospective analysis of patients enrolled within the international ALPPS Registry between October 2012 and November 2015 (NCT01924741) was performed. Patients with documented PVO failure were included. The outcomes reported included feasibility, FLR growth rate and safety of ALPPS. Complications were recorded as per Clavien-Dindo classification. ResultsFrom 510 patients enrolled in the Registry there were 22 patients with previous PVO failure. Two patients were excluded due to missing data and twenty patients were analysed. All of them completed the proposed ALPPS with a medium FLR increase of 88% (23–115%) between two stages and no 90-day mortality. ConclusionIn experienced centers, ALPPS following PVO failure is feasible and safe. The FLR hypertrophy was similar to other ALPPS series. ALPPS is a potential rescue strategy after PVO failure.

Remnant Liver Tumor Growth Activity During Treatment Associating Liver Partition and Portal Vein Occlusion for Staged Hepatectomy (ALPPS)

BackgroundWe compared tumor growth activity during treatment associating liver partition and portal vein occlusion for staged hepatectomy (ALPPS) with that in classical 2-stage hepatectomy. MethodsShort-term outcomes, serial changes in volume of the future liver remnant (FLR), and tumor growth activity during the treatment period were compared between 12 patients treated with ALPPS and 20 patients treated with 2-stage hepatectomy for colorectal liver metastases. This study was registered in UMIN Clinical Trials Registry (registration number, UMIN000018622). ResultsThe FLR hypertrophy ratio at 1 week after the first operation was greater in the ALPPS group (1.43 ± 0.24) than the 2-stage group (1.21 ± 0.28, P = 0.043). The mean kinetic growth rate (mKGR) of tumors in the ALPPS group (0.548±7.29 mL/day) did not differ significantly from that in the 2-stage group (−3.53±7.02 mL/day) in the first week after the initial procedure (P = 0.210). However, mKGR between 1 and 3 weeks after the first procedure (1.29±2.34 mL/day) was significantly greater than that in first week after the procedure in the 2-stage group (P = 0.034). ConclusionsALPPS induces a rapid FLR volume increase while avoiding remnant tumor progression.

Associating Liver Partition and Portal Vein Occlusion, Including Venous Congestion, Induction in Rats.

Associating liver partition with portal vein occlusion for staged hepatectomy (ALPPS) is a recently developed strategy for inducing rapid hypertrophy of the future liver remnant (FLR). To explore possible mechanisms, we designed the first model of ALPPS with venous congestion (ALPPS+C) in rats. Rats were assigned randomly to 3 experimental groups: ALPPS, ALPPS+C and sham. Hepatic regeneration rate, Ki-67 and histopathology were assessed at 24 h, 48 h, and 7 days postoperatively. Hepatic regeneration rate was much higher for ALPPS+C than for ALPPS at 48 h and 7 days postoperatively (p<0.01). Microscopically, the regenerating liver showed greater hepatocyte density and smaller hepatocyte size in ALPPS+C than in ALPPS (p<0.01 for each). Greater hepatic regeneration in ALPPS+C than in ALPPS confirmed that we established a rat model of ALPPS with benefit from venous congestion. Producing a congested area may contribute importantly to rapid FLR hypertrophy during ALPPS.

Update on Embolization Therapies for Hepatocellular Carcinoma.

The purpose of the review is to summarize the latest applications for embolotherapy in the management of patients with HCC according to BCLC stage. While traditionally reserved for patients with unresectable HCC and stage B disease, there is an important role for embolization therapies in earlier stage patients as an adjunct to ablation, bridging, or downstaging therapy, as a means to improve safety of resection, and potentially as an arterial ablative option in the case of radioembolization. Newer applications of radioembolization such as radiation segmentectomy have the potential to provide cure in localized unifocal disease, and transarterial chemoembolization-portal vein embolization and radiation lobectomy may provide a combination of treatment and future liver remnant hypertrophy for planned hepatic resection. There is also an increasing role for embolization in the treatment of stage C disease, and recent data suggest it can be used in combination with sorafenib with the potential for survival benefit over sorafenib alone, even in the case of portal vein tumor thrombus. Embolization therapies play an increasingly important role in patients with BCLC stage A-C hepatocellular carcinoma. While different therapies may be offered on a patient-specific basis, there are limited prospective RCT data to support superiority of one technique over another.

The ALPPS in the Treatment of Hepatitis B-Related Hepatocellular Carcinoma With Cirrhosis: A Single-Center Study and Literature Review.

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been reported to be a new treatment strategy for patients with predicted small volumes of future liver remnant (FLR). ALPPS is associated with rapid hypertrophy of FLR but it has a high postoperative mortality and morbidity. Up to now, it is controversial to apply ALPPS in hepatocellular carcinoma, especially for patients with liver cirrhosis. Between May 2014 and June 2015, consecutive patients who underwent ALPPS with hepatitis B-related hepatocellular carcinoma with cirrhosis carried out in our center were included into the study. Demographic characteristics, surgical outcomes, and pathological results were evaluated. Subsequently, follow-up was still in progress. The median operating time of the first (n = 12) and the second procedures (n = 10) were 285.0 and 212.5 minutes, respectively. The median blood loss were 200 and 800 mL for 2 stages of operations. The severe complication (≥IIIB) rates for the first and the second operations were 25.0% versus 40.0%, respectively. Six patients with too small future live remnant died of postoperative hepatic failure. On a median follow-up of 16 months of the 6 patients discharged, 4 patients were still alive and of 2 were disease-free. In terms of the feasibility and safety, this study showed that ALPPS in the treatment of hepatocellular carcinoma with insufficient future liver remnant might be a double-edged sword, and careful patients selected was proposed. Too small of FLR/SLV, less than 30%, is not recommended for ALPPS in liver with cirrhosis.

Neoadjuvant chemotherapy does not affect future liver remnant growth and outcomes of associating liver partition and portal vein ligation for staged hepatectomy

The only potentially curative treatment for patients with colorectal liver metastases is hepatectomy. Associating liver partition and portal vein ligation for staged hepatectomy has emerged as a method of treatment for patients with inadequate future liver remnant. One concern about associating liver partition and portal vein ligation for staged hepatectomy is that preoperative chemotherapy may negatively affect the volume increase of the future liver remnant and outcomes. This study from the International Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy Registry (NCT01924741) includes 442 patients with colorectal liver metastases registered from 2012-2016. Future liver remnant hypertrophy (absolute increase, percent increase, and kinetic growth rate) and clinical outcome were analyzed retrospectively in relation to type and amount of chemotherapy. The analyzed groups included patients with no chemotherapy, 1 regimen of chemotherapy, >1 regimen, and a group that received monoclonal antibodies in addition to chemotherapy. Ninety percent of the patients received neoadjuvant oncologic therapy including 42% with 1 regimen of chemotherapy, 44% with monoclonal antibodies, and 4% with >1 regimen. Future liver remnant increased between 74-92% with the largest increase in the group with 1 regimen of chemotherapy. The increase in milliliters was between 241mL (>1 regimen) and 306mL (1 regimen). Kinetic growth rate was between 14-18% per week and was greatest for the group with 1 regimen of chemotherapy. No statistical significance was found between the groups with any of the measurements of future liver remnant hypertrophy. Neoadjuvant chemotherapy, including monoclonal antibodies, does not negatively affect future liver remnant growth. Patients with colorectal liver metastases who might be potential candidates for associating liver partition and portal vein ligation for staged hepatectomy should be considered for neoadjuvant chemotherapy.

Identification of cofactors influencing hypertrophy of the future liver remnant after portal vein embolization—the effect of collaterals on embolized liver volume

The purpose of this retrospective study was to monitor hypertrophy of future liver remnant following portal vein embolization (PVE) before planned extended right hepatectomy. However, because individual responses to PVE are highly variable, our focus was to identify cofactors of successful hypertrophy. 28 patients with primary or secondary liver tumours, mean age 64.1 ± 12.9 years, underwent PVE. Volumetric analysis of hypertrophy before and after PVE (median 39.0 ± 15.7 days) was performed. The embolized liver segments were investigated for occurrence of reperfusion of their portal branches. Blood parameters before PVE were additionally investigated. Patients were divided into responders (21/28) and non-responders (7/28) by post-PVE standardized future liver remnant being above or below 25%, respectively. No significant differences between the groups were found regarding biometric and volumetric parameters before PVE. In the entire group after PVE, the mean absolute increase of Segments 2 and 3 was 196.0 ± 84.7 cm3 and the median relative increase was 46.6 ± 98.8%. The formation of left to right hepatic portoportal collaterals exhibited a negative correlation to successful hypertrophy (p = 0.004) as well as low plasma total protein (p = 0.019). Successful embolization of Segment IV showed only a trend to significance (p = 0.098). Cofactors associated with a favourable outcome regarding hypertrophy were the absence of collaterals in the control CT scans and high plasma total protein. Advances in knowledge: Portoportal collaterals negatively influence hypertrophy after PVE. On the other hand, plasma total protein is a positive prognostic indicator on hypertrophy of the liver in our cohort.

Meta-analysis of associating liver partition with portal vein ligation and portal vein occlusion for two-stage hepatectomy.

Discussion is ongoing regarding whether associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) or portal vein occlusion is better in staged hepatectomy. The aim of this study was to compare available strategies using a two-stage approach in extended hepatectomy. A literature search was performed in MEDLINE, Scopus, the Cochrane Library and Embase, and additional articles were identified by hand searching. Data from the international ALPPS registry were extracted. Clinical studies reporting volumetric changes, mortality, morbidity, feasibility of the second stage and tumour-free resection margins (R0) in two-stage hepatectomy were included. Ninety studies involving 4352 patients, including 320 from the ALPPS registry, met the inclusion criteria. Among these, nine studies (357 patients) reported on comparisons with other strategies. In the comparison of ALPPS versus portal vein embolization (PVE), ALPPS was associated with a greater increase in the future liver remnant (76 versus 37 per cent; P < 0·001) and more frequent completion of stage 2 (100 versus 77 per cent; P < 0·001). Compared with PVE, ALPPS had a trend towards higher morbidity (73 versus 59 per cent; P = 0·16) and mortality (14 versus 7 per cent; P = 0·19) after stage 2. In the non-comparative studies, complication rates were 39 per cent in the PVE group, 47 per cent in the portal vein ligation (PVL) group and 70 per cent in the ALPPS group. After stage 2, mortality rates were 5, 7 and 12 per cent respectively. ALPPS is associated with greater future liver remnant hypertrophy and a higher rate of completion of stage 2, but this may be at the price of greater morbidity and mortality.

Parenchymal Congestion Is Important for Rapid Regeneration of the Future Liver Remnant Following the ALPPS Procedure.

To evaluate whether the congested area that develops in associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) contributes to rapid future liver remnant (FLR) hypertrophy. Eight patients undergoing liver partition and right portal vein (RPV) ligation within the FLR in the first operation of ALPPS were compared with eight patients undergoing RPV embolization in the FLR as the first operation of classical two-stage (CTS) hepatectomy. Extrapolated kinetic growth of the FLR in ALPPS was 32.7±18.7 ml/day, 7.8-times that in CTS (4.2±2.0 ml/day, p=0.001). Extrapolated kinetic reduction in volume of the ventral aspect of the right paramedian sector, which became congested after the first procedure in ALPPS, was 19.8±11.6 ml/day, 11-times that in CTS (1.8±1.3 ml/day, p=0.001). Production of a congested area within the deportalized liver may contribute importantly to rapid FLR hypertrophy during ALPPS.

Impact of split completeness on future liver remnant hypertrophy in associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in hepatocellular carcinoma: Complete-ALPPS versus partial-ALPPS

Recent evidence suggested that associating liver partition and portal vein ligation for staged hepatectomy with a partial split could effectively induce the same degree of future liver remnant hypertrophy as a complete split in non-cirrhotic and non-cholestatic livers with better postoperative safety profiles. Our aim was to evaluate if the same phenomenon could be applied to hepatitis-related chronic liver diseases. In the study, 25 patients who underwent associating liver partition and portal vein ligation for staged hepatectomy from October 2013 to January 2016 for hepatocellular carcinoma were analyzed. Partial-associating liver partition and portal vein ligation for staged hepatectomy (n=12) was defined as 50-80% of the transection surface split and complete-associating liver partition and portal vein ligation for staged hepatectomy (n=13) was split down to inferior vena cava. Perioperative outcomes stratified by split completeness were evaluated. There was no significant difference in operating times and blood loss for stage I and II operations between complete-associating liver partition and portal vein ligation for staged hepatectomy and partial-associating liver partition and portal vein ligation for staged hepatectomy. All patients underwent stage II operation without any inter-stage complications. Complete split induced greater future liver remnant hypertrophy than partial split (hypertrophy rate: 31.2 vs 17.5mL/day, P=.022) with more pronounced effect in chronic hepatitis (P=.007) than cirrhosis (P=.283). Complete-associating liver partition and portal vein ligation for staged hepatectomy was more likely to attain a future liver remnant/estimated standard liver volume ratio >35% within 10days (76.9% vs 33.3%, P=.024) and proceed to stage II within 14days after stage I (100% vs 58.4%, P=.009). The overall postoperative morbidity (≥grade 3a) after stage II was 16% (complete versus partial split: 7.7% vs 25%, P=.238) and hospital mortality after stage II was 8% (complete versus partial split: 0% vs 16.7%, P=.125). Complete-associating liver partition and portal vein ligation for staged hepatectomy induced more rapid future liver remnant hypertrophy than partial-associating liver partition and portal vein ligation for staged hepatectomy without increased perioperative risk in chronic liver diseases.

ALPPS Procedure in Insufficient Hypertrophy After Portal Vein Embolization (PVE).

The main limiting factor for major liver resections is the volume and function of the future remnant liver (FLR). Portal vein embolization (PVE) is now standard in most centers for preoperative hypertrophy of FLR. However, it has a failure rate of about 20-30%. In these cases, the "Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy" (ALPPS) may represent a suitable and possibly the only alternative. We performed a retrospective analysis of nine patients who had ALPPS following an insufficient hypertrophy after PVE. Computed tomography volumetry were performed before and after PVE as well as the first step of ALPPS. Furthermore, complications, 30-day mortality and outcome were analyzed. The FLR volume rose significantly by 77.7±40.7% (FLR/TLV: 34.9±9.7%) as early as 9days after the first stage despite insufficient hypertrophy after preoperative portal vein embolization. Major complications (Grade>IIIb) occurred in 33% of the patients, and 30-day mortality was 11.1%. The OS at 1 and 2years was 78 and 44%. Four patients are presently still alive at a median of 33.4 (range 15-48)months (survival rate 44.4%). The ALPPS procedure could be a suitable alternative for patients following insufficient PVE or indeed the last chance of a potentially curative treatment in this situation. Nevertheless, the high morbidity and mortality rates and the lack of data on the long-term oncological outcome must also be taken into account.

Factors Affecting Left Lobe Hypertrophy after Right Portal Vein Embolization in Patients with Chronic Liver Disease

Background: Right portal vein embolization (PVE), performed either surgically or radiologically, is the main method used to induce growth of the future liver remnant (FLR) before right hemihepatectomy in patients with an insufficient future liver remnant volume (FLRV) due to chronic liver disease. The purpose of this study was to evaluate whether clinical and laboratory variables, as well as METAVIR fibrosis score, are predictive of PVE-induced growth of the FLR in patients with chronic liver disease. Methods: During the period from January 2007 to September 2014, a total of 813 patients underwent hemihepatectomy for hepatocellular carcinoma (HCC) or cholangiocarcinoma. Of those patients, 20 had an inadequate FLR and required right PVE before hemihepatectomy. None of the 20 patients had received preoperative chemotherapy or transarterial chemoembolization. Results: Of the parameters evaluated (serum levels of AST, ALT, ALP, GGT, albumin, total bilirubin, AFP, prothrombin time, Child- Pugh score, METAVIR fibrosis score and history of hepatitis B or hepatitis C infection), only the fibrosis score was associated with a significant change in the estimated rate of functional future liver remnant (%FFLR) volume (p = 0.042). Further analysis revealed that only mild (F1) and moderate (F2) degrees of fibrosis were associated with a significant increase in the FLRV (p = 0.043 and p = 0.028, respectively). Conclusion: The severity of liver fibrosis was found to be negatively correlated with the degree of FLR hypertrophy prior to portal vein embolization.

“Liver-first” approach with ALPPS: The natural combination of two new concepts in liver surgery

Modern colorectal liver metastasis (CRLM) surgery has undergone a very impressive development over the last ten years due to the evolution of methods, techniques and extension of surgical indications. The main limits of surgical CRLM treatment were extension of liver disease, volume and quality of future liver remnant and foreseeable hypertrophy induced by portal vein embolisation or ligation (PVE/PVL) for a possible two-staged hepatectomy. In 2007 Dr. Schlitt, performing the first associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) [1], unconsciously opened Pandora’s box; leading to intense surgical research into two-staged hepatectomies and allowing a further expansion of the resectable pool of liver tumour patients affected by bilobar tumour load. Now, 9 years after the first ALPPS, and after the recently proposed technical evolution named “monosegment ALPPS” [2], we can affirm that we are about to abandon a dogma of liver surgery: for extended liver resection at least 2 liver segments as future liver remnant are necessary; in fact, now this seems to no longer be true. This recent advancement further enhances the concept of liver hypertrophy and the application of ALPPS after agreements of the first consensus meeting [1]. As

(90) Y radiation lobectomy: Outcomes following surgical resection in patients with hepatic tumors and small future liver remnant volumes.

The purpose of this study is to assess operative, post-operative, and long-term outcomes in patients who underwent radiation lobectomy (RL) for tumor control and/or hypertrophy of small future liver remnant (FLR) prior to resection. Right lobar +/- segment 4 radioembolization was performed prior to lobectomy/tri-segmentectomy in patients with hepatic tumor but inadequate FLR. Parenchymal/tumor volumes were calculated from pre/post-RL imaging; FLR/%FLR hypertrophy were determined. Complications were graded by the Clavien-Dindo classification. Thirteen patients (HCC n = 10, cholangiocarcinoma n = 2, mCRC n = 1) underwent RL prior to resection. The median time between RL and post-RL imaging was 40 days (23-190 days); the median time to resection was 86 days (30-210 days). Median FLR increased significantly [pre: 33% (22-43%); post: 43% (29-69%), P < 0.01] to yield a median %FLR hypertrophy of 30% (4-105%). The median hospital stay after resection was 4 days (3-11 days). Transient hepatobiliary toxicities normalized post-operatively. Ninety-two percent of resected tumors had >50% pathologic necrosis. Median follow up time after surgery was 604 days (144-1,416 days); one death occurred. In this preliminary study, radiation lobectomy was a safe and effective method to achieve remnant liver hypertrophy while providing tumor control. This approach may facilitate safe resection and favorable post-operative outcomes.J. Surg. Oncol. 2016;114:99-105. © 2016 Wiley Periodicals, Inc.

Inverting the ALPPS paradigm by minimizing first stage impact: the Mini-ALPPS technique.

The current associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) approach is represented by an aggressive first surgical procedure followed by a shorter and less aggressive second procedure. This paradigm has been associated with high morbidity and mortality. Inverting the aggressiveness of the surgical stages might be beneficial in order to facilitate patient recovery during interval period. We propose a new technical paradigm for the ALPPS approach. During the first stage, partial parenchymal transection combined with intraoperative portal vein embolization (PVE) was performed. Liver mobilization was kept at minimum while hilar plate or hilum dissection was strictly avoided. The completion surgery by means of the anterior approach was carried out once sufficient future liver remnant (FLR) hypertrophy and function were certified. We applied this technique in four patients (hepatocellular carcinoma in a cirrhotic liver = 1 and colorectal liver metastases = 3). The mean FLR hypertrophy was 62.6% (range 49-79). All the four patients underwent the completion surgery with R0 margins, and neither one developed liver failure nor major complications. The technique proposed inverts the current ALPPS strategy, minimizing the first stage impact to promote rapid patient recovery and leaving the main surgical procedure for the second stage. The combination of evidence-based facts such as partial parenchymal transection, intraoperative PVE, and "non-touch" oncological rules was feasible and safe, allowing complete tumor resection in highly selected candidates with extensive liver disease.

Salvage hepatectomy in failed portal vein embolisation

Background: The traditional approach to induce liver hypertrophy of future liver remnant (FLR) is portal vein embolization (PVE). We analyse the cases which failed to achieve sufficient hypertrophy following PVE and has been salvaged by two staged hepatectomy. Methods: Of 72 cases of PVE over 8 years, 4 cases didn't achieve sufficient hypertrophy and subsequently underwent two stage hepatectomy. Patient characteristics, volume increase, postoperative complications and outcomes were analyzed. Results: All 4 patients had extended right hepatectomy. One patient had colorectal liver metastasis and the other three had hilar cholangiocarcinoma. Three patients with hilar cholangiocarcinoma or gall bladder carcinoma had resection of extrahepatic bile ducts and PV resection. The staged resections were carried out at an average of 11 (7–20) days apart. Patient 1 had an FLR of 18%after PVE that increased to 28% after parenchymal transection (stage 1). Patient 2 had an FLR of 20% after PVE which increased to 29% after stage 1 resection. Patient 3 had FLR of 21% after PVE which increased to 34% after stage 1 resection. Patient 4 had FLR volume of 30% with background chronic liver fibrosis that increased to 38% after stage 1. A further 10% (8–13) increase in FLR was achieved following stage 1 resection. Two patients had postoperative bile leak. There was no operative mortality and all patients are alive with a median disease free survival of 20 months. Conclusion: Salvage resection of liver is an effective approach to patients who do not achieve sufficient FLR volume following PVE.

ALPPS in patients with colorectal liver metastases

Background: The Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) approach allows achieving resectability of liver malignancies by a rapid and large future liver remnant (FLR) hypertrophy. However, the long-term oncological outcomes of this approach in patients with colorectal liver metastases (CLM) remain unclear. Methods: A single-prospective-cohort study between June 2011 and august 2015 including patients with CLM who underwent ALPPS. Results: Twenty-four patients were treated. Mean age was 55.8 y (range = 35-81) and 17 were males (71%). Twenty-two patients received a mean of 7.5 cycles of preoperative chemotherapy, all of them having either a good morphological response (n = 18) or stable disease (n = 4) before surgery. In a median of 6 days (range = 4-67) the median FLR hypertrophy was 106% (range = 286–21.5). All patients completed the second stage (100% feasibility). Seven patients underwent a simultaneous resection of the primary tumor. Morbidity according to the Dindo-Clavien classification was 58.3% and grade ≥IIIb 20.8%. The mortality was nil. Median hospital stay was 17.5 days (r = 9–49). Within a mean follow-up of 20.4 months, seventeen patients experienced recurrence. Mean time to progresion was 8.7 months. The overall and disease-free survival at one year was 77% and 44%, at two years was 60% and 20%, and at three years was 53% and 17% respectively. Conclusions: The present study shows that ALPPS has a high safety profile in patients with CLM. The oncological outcomes provided by ALPPS so far seem similar to that of other surgical strategies in patients with initially unresectable disease and dismal prognosis.