ASSOCIATING LIVER PARTITION AND PORTAL VEIN LIGATION (ALPPS) FOR COLORECTAL LIVER METASTASIS: REVIEW & SINGLE-CENTER STUDY
Abstract
The associating liver partitioning and portal vein ligation for staged hepatectomy has gained interest in the treatment of unresectable colorectal liver metastases as it has allowed to expand the limits of oncological resectability. Despite the initial poor outcomes associated to this procedure, recent reports have showed reduced morbimortality in well selected patients. The current study evaluates the outcomes of ALPPS procedure in treatment of colorectal liver metastasis at our department and identify morbimortality and survival prognostic factors. A retrospective cohort study was performed, all consecutive patients submitted to ALPPS procedure between 2015 and 2020 were included. Twenty-one patients with 61,8±10,8 (37-78), 76,2% were male, with 12,05±6,34 (5-30) hepatic nodules, whose largest size was 42.3 ± 17, 5 (18-75) mm. Among these, 71.4% underwent induction chemotherapy with FOLFIRI and 61,9% with plus Cetuximab, mean of 10,9±5,6 (4-24) cycles. At ALPPS stage 1, 6±4 (1-18) nodules were resected, 19% with concomitant splenic artery occlusion and a mean Pringle Maneuver of 33±26 (0-94) minutes. All patients did adjuvant CT. We report a global mortality of 9,6% and a major morbidity (MMb) of 28,6%. The multivariable analysis identified as risk factor for MMb: more than 10 nodules, size>38mm, interstage interval> 14 days and the resection of more than 4 lesions at stage 1. The overall survival and disease-free survival rates were 25,9± 4,2 (17,6- 34,1), 17,64 ±3,95 (9,9-25,4) moths, respectively. Age >56 years and size >38mm were identified as risk factor for poor outcome. More than 10 cycles of neoadjuvant chemotherapy were identified as risk factor for poor outcome at 2 years. Our results are similar to the recently established reference values.
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References
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[3] M. C. de Jong et al., “Rates and Patterns of Recurrence Following Curative Intent Surgery for Colorectal Liver Metastasis,” Ann. Surg., vol. 250, no. 3, pp. 440–448, Sep. 2009, doi: 10.1097/SLA.0b013e3181b4539b.
[4] et al (eds) Noone AM, Howlader N, Krapcho M, “SEER Cancer Statistics Review,” Bethesda, MD: National Cancer Institute; .
[5] P. Rawla, T. Sunkara, and A. Barsouk, “Epidemiology of colorectal cancer: incidence, mortality, survival, and risk factors,” Gastroenterol. Rev., vol. 14, no. 2, pp. 89–103, 2019, doi: 10.5114/pg.2018.81072.
[6] L. Zhang, Z. Yang, S. Zhang, W. Wang, and S. Zheng, “Conventional Two-Stage Hepatectomy or Associating Liver Partitioning and Portal Vein Ligation for Staged Hepatectomy for Colorectal Liver Metastases? A Systematic Review and Meta-Analysis,” Front. Oncol., vol. 10, Aug. 2020, doi: 10.3389/fonc.2020.01391.
[7] S. Kopetz et al., “Improved Survival in Metastatic Colorectal Cancer Is Associated With Adoption of Hepatic Resection and Improved Chemotherapy,” J. Clin. Oncol., vol. 27, no. 22, pp. 3677–3683, Aug. 2009, doi: 10.1200/JCO.2008.20.5278.
[8] K. Imai, R. Adam, and H. Baba, “How to increase the resectability of initially unresectable colorectal liver metastases: A surgical perspective,” Ann. Gastroenterol. Surg., vol. 3, no. 5, pp. 476–486, Sep. 2019, doi: 10.1002/ags3.12276.
[9] A. A. Schnitzbauer et al., “Right Portal Vein Ligation Combined With In Situ Splitting Induces Rapid Left Lateral Liver Lobe Hypertrophy Enabling 2-Staged Extended Right Hepatic Resection in Small-for-Size Settings,” Ann. Surg., vol. 255, no. 3, pp. 405–414, Mar. 2012, doi: 10.1097/SLA.0b013e31824856f5.
[10] J. Belghiti, S. Dokmak, and E. Schadde, “ALPPS: Innovation for innovation’s sake,” Surgery, vol. 159, no. 5, pp. 1287–1288, May 2016, doi: 10.1016/j.surg.2015.12.027.
[11] J. Shindoh et al., “Kinetic Growth Rate after Portal Vein Embolization Predicts Posthepatectomy Outcomes: Toward Zero Liver-Related Mortality in Patients with Colorectal Liver Metastases and Small Future Liver Remnant,” J. Am. Coll. Surg., vol. 216, no. 2, pp. 201–209, Feb. 2013, doi: 10.1016/j.jamcollsurg.2012.10.018.
[12] P. Kambakamba et al., “Liver kinetic growth rate predicts postoperative liver failure after ALPPS,” HPB, vol. 18, no. 10, pp. 800–805, Oct. 2016, doi: 10.1016/j.hpb.2016.07.005.
[13] N. N. Rahbari et al., “Posthepatectomy liver failure: A definition and grading by the International Study Group of Liver Surgery (ISGLS),” Surgery, vol. 149, no. 5, pp. 713–724, May 2011, doi: 10.1016/j.surg.2010.10.001.
[14] M. Koch et al., “Bile leakage after hepatobiliary and pancreatic surgery: A definition and grading of severity by the International Study Group of Liver Surgery,” Surgery, vol. 149, no. 5, pp. 680–688, May 2011, doi: 10.1016/j.surg.2010.12.002.
[15] D. A. Raptis et al., “Defining Benchmark Outcomes for ALPPS,” Ann. Surg., vol. 270, no. 5, pp. 835–841, Nov. 2019, doi: 10.1097/SLA.0000000000003539.
[16] E. Schadde et al., “Prediction of Mortality After ALPPS Stage-1,” Ann. Surg., vol. 262, no. 5, pp. 780–786, Nov. 2015, doi: 10.1097/SLA.0000000000001450.
[17] S. Truant et al., “Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS): Impact of the inter-stages course on morbi-mortality and implications for management,” Eur. J. Surg. Oncol., vol. 41, no. 5, pp. 674–682, May 2015, doi: 10.1016/j.ejso.2015.01.004.
[18] R. Adam et al., “Outcome after associating liver partition and portal vein ligation for staged hepatectomy and conventional two-stage hepatectomy for colorectal liver metastases,” Br. J. Surg., vol. 103, no. 11, pp. 1521–1529, Sep. 2016, doi: 10.1002/bjs.10256.
[19] P. B. Olthof et al., “Survival after associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) for advanced colorectal liver metastases: A case-matched comparison with palliative systemic therapy,” Surgery, vol. 161, no. 4, pp. 909–919, Apr. 2017, doi: 10.1016/j.surg.2016.10.032.
[20] P.-J. van Dam et al., “International consensus guidelines for scoring the histopathological growth patterns of liver metastasis,” Br. J. Cancer, vol. 117, no. 10, pp. 1427–1441, Nov. 2017, doi: 10.1038/bjc.2017.334.
[21] B. Björnsson et al., “Associating liver partition and portal vein ligation for staged hepatectomy in patients with colorectal liver metastases – Intermediate oncological results,” Eur. J. Surg. Oncol., vol. 42, no. 4, pp. 531–537, Apr. 2016, doi: 10.1016/j.ejso.2015.12.013.
[22] E. Schadde et al., “Early Survival and Safety of ALPPS,” Ann. Surg., vol. 260, no. 5, pp. 829–838, Nov. 2014, doi: 10.1097/SLA.0000000000000947.
[23] W. Y. Lau, E. C. Lai, and S. H. Lau, “Associating liver partition and portal vein ligation for staged hepatectomy: the current role and development,” Hepatobiliary Pancreat. Dis. Int., vol. 16, no. 1, pp. 17–26, Feb. 2017, doi: 10.1016/S1499-3872(16)60174-1.
[24] L. Jiao et al., “Rapid Induction of Liver Regeneration for Major Hepatectomy (REBIRTH): A Randomized Controlled Trial of Portal Vein Embolisation versus ALPPS Assisted with Radiofrequency,” Cancers (Basel)., vol. 11, no. 3, p. 302, Mar. 2019, doi: 10.3390/cancers11030302.
[25] Y. Kishi et al., “Extended Preoperative Chemotherapy Does Not Improve Pathologic Response and Increases Postoperative Liver Insufficiency After Hepatic Resection for Colorectal Liver Metastases,” Ann. Surg. Oncol., vol. 17, no. 11, pp. 2870–2876, Nov. 2010, doi: 10.1245/s10434-010-1166-1.
[26] G. Torzilli et al., “Outcomes of enhanced one-stage ultrasound-guided hepatectomy for bilobar colorectal liver metastases compared to those of ALPPS: a multicenter case-match analysis,” HPB, vol. 21, no. 10, pp. 1411–1418, Oct. 2019, doi: 10.1016/j.hpb.2019.04.001.
[27] H. Lang, J. Baumgart, and J. Mittler, “Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy in the Treatment of Colorectal Liver Metastases: Current Scenario,” Dig. Surg., vol. 35, no. 4, pp. 294–302, 2018, doi: 10.1159/000488097.
[28] Y. Kawaguchi, H. A. Lillemoe, and J. Vauthey, “Dealing with an insufficient future liver remnant: Portal vein embolization and two‐stage hepatectomy,” J. Surg. Oncol., vol. 119, no. 5, pp. 594–603, Apr. 2019, doi: 10.1002/jso.25430.
[29] H. Lang, “ALPPS - Beneficial or detrimental?,” Surg. Oncol., vol. 33, pp. 249–253, Jun. 2020, doi: 10.1016/j.suronc.2019.10.013.
[30] E. Schadde et al., “ALPPS Offers a Better Chance of Complete Resection in Patients with Primarily Unresectable Liver Tumors Compared with Conventional-Staged Hepatectomies: Results of a Multicenter Analysis,” World J. Surg., vol. 38, no. 6, pp. 1510–1519, Jun. 2014, doi: 10.1007/s00268-014-2513-3.
[31] F. A. Alvarez, V. Ardiles, M. de Santibañes, J. Pekolj, and E. de Santibañes, “Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy Offers High Oncological Feasibility With Adequate Patient Safety,” Ann. Surg., vol. 261, no. 4, pp. 723–732, Apr. 2015, doi: 10.1097/SLA.0000000000001046.
[32] T. A. Aloia and J.-N. Vauthey, “Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS),” Ann. Surg., vol. 256, no. 3, p. e9, Sep. 2012, doi: 10.1097/SLA.0b013e318265fd3e.
[33] J. Figueras and J. Belghiti, “The ALPPS Approach: Should We Sacrifice Basic Therapeutic Rules in the Name of Innovation?,” World J. Surg., vol. 38, no. 6, pp. 1520–1521, Jun. 2014, doi: 10.1007/s00268-014-2540-0.
[34] E. Simoneau et al., “Portal vein embolization and its effect on tumour progression for colorectal cancer liver metastases,” Br. J. Surg., vol. 102, no. 10, pp. 1240–1249, Aug. 2015, doi: 10.1002/bjs.9872.
[35] K. Hasselgren et al., “ALPPS Improves Survival Compared With TSH in Patients Affected of CRLM,” Ann. Surg., vol. 273, no. 3, pp. 442–448, Mar. 2021, doi: 10.1097/SLA.0000000000003701.
[36] D. Moris et al., “Operative Results and Oncologic Outcomes of Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) Versus Two-Stage Hepatectomy (TSH) in Patients with Unresectable Colorectal Liver Metastases: A Systematic Review and Meta-Anal,” World J. Surg., vol. 42, no. 3, pp. 806–815, 2018, doi: 10.1007/s00268-017-4181-6.
[37] M. Donadon et al., “Parenchymal-Sparing Surgery for the Surgical Treatment of Multiple Colorectal Liver Metastases Is a Safer Approach than Major Hepatectomy Not Impairing Patients’ Prognosis: A Bi-Institutional Propensity Score-Matched Analysis,” Dig. Surg., vol. 35, no. 4, pp. 342–349, 2018, doi: 10.1159/000479336.
[38] G. Torzilli et al., “Is Enhanced One-Stage Hepatectomy a Safe and Feasible Alternative to the Two-Stage Hepatectomy in the Setting of Multiple Bilobar Colorectal Liver Metastases? A Comparative Analysis between Two Pioneering Centers,” Dig. Surg., vol. 35, no. 4, pp. 323–332, 2018, doi: 10.1159/000486210.
[39] A. Andres, G. Oldani, T. Berney, P. Compagnon, P.-D. Line, and C. Toso, “Transplantation for colorectal metastases: on the edge of a revolution,” Transl. Gastroenterol. Hepatol., vol. 3, pp. 74–74, Sep. 2018, doi: 10.21037/tgh.2018.08.04.
[40] F. Mühlbacher et al., “Is orthotopic liver transplantation a feasible treatment for secondary cancer of the liver?,” Transplant. Proc., vol. 23, no. 1 Pt 2, pp. 1567–8, Feb. 1991, [Online]. Available: http://www.ncbi.nlm.nih.gov/pubmed/1989293.
[41] I. Penn, “Hepatic transplantation for primary and metastatic cancers of the liver.,” Surgery, vol. 110, no. 4, pp. 726–34; discussion 734-5, Oct. 1991, [Online]. Available: http://www.ncbi.nlm.nih.gov/pubmed/1656538.
[42] M. Hagness et al., “Liver Transplantation for Nonresectable Liver Metastases From Colorectal Cancer,” Ann. Surg., vol. 257, no. 5, pp. 800–806, May 2013, doi: 10.1097/SLA.0b013e3182823957.
[43] Kathy Zalewska, “NHSBT. Liver Transplantation: Selection Criteria and Recipient Registratio,” 2018. .
[44] V. Mazzaferro et al., “Liver Transplantation for the Treatment of Small Hepatocellular Carcinomas in Patients with Cirrhosis,” N. Engl. J. Med., vol. 334, no. 11, pp. 693–700, Mar. 1996, doi: 10.1056/NEJM199603143341104.
[45] OPTN/SRTR, “Annual Data Report: Liver,” 2018. .
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[47] P.-D. Line, M. Hagness, A. E. Berstad, A. Foss, and S. Dueland, “A Novel Concept for Partial Liver Transplantation in Nonresectable Colorectal Liver Metastases,” Ann. Surg., vol. 262, no. 1, pp. e5–e9, Jul. 2015, doi: 10.1097/SLA.0000000000001165.
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Published
2022-12-14
How to Cite
RUIVO, Ana et al.
ASSOCIATING LIVER PARTITION AND PORTAL VEIN LIGATION (ALPPS) FOR COLORECTAL LIVER METASTASIS: REVIEW & SINGLE-CENTER STUDY.
Revista Portuguesa de Cirurgia, [S.l.], n. 53, p. 57-66, dec. 2022.
ISSN 2183-1165.
Available at: <https://revista.spcir.com/index.php/spcir/article/view/926>. Date accessed: 25 apr. 2024.
doi: https://doi.org/10.34635/rpc.926.
Section
Original Papers
