Outcome of ALPPS for perihilar cholangiocarcinoma: case-control analysis including the first series from the international ALPPS registry

Revival of associating liver partition and portal vein ligation for staged hepatectomy for perihilar cholangiocarcinoma: An international multicenter study with promising outcomes

BACKGROUND

Associating liver partition and portal vein ligation for staged hepatectomy for perihilar cholangiocarcinoma has been considered to be contraindicated due to the initial poor results. Given the recent reports of improved outcomes, we aimed to collect the recent experiences of different centers performing associating liver partition and portal vein ligation for staged hepatectomy for perihilar cholangiocarcinoma to analyze factors related to improved outcomes.

METHODS

This proof-of-concept study collected contemporary cases of associating liver partition and portal vein ligation for staged hepatectomy for perihilar cholangiocarcinoma and analyzed for morbidity, short and long-term survival, and factors associated with outcomes.

RESULTS

In total, 39 patients from 8 centers underwent associating liver partition and portal vein ligation for staged hepatectomy for perihilar cholangiocarcinoma from 2010 to 2020. The median preoperative future liver remnant volume was 323 mL (155-460 mL). The median future liver remnant increase was 58.7% (8.9% -264.5%) with a median interstage interval of 13 days (6-60 days). Post-stage 1 and post-stage 2 biliary leaks occurred in 2 (7.7%) and 4 (15%) patients. Six patients (23%) after stage 1 and 6 (23%) after stage 2 experienced grade 3 or higher complications. Two patients (7.7%) died within 90 days after stage 2. The 1-, 3-, and 5-year survival was 92%, 69%, and 55%, respectively. A subgroup analysis revealed poor survival for patients undergoing additional vascular resection and lymph node positivity. Lymph node-negative patients showed excellent survival demonstrated by 1-, 3-, and 5-year survival of 86%, 86%, and 86%.

CONCLUSION

This study highlights that the critical attitude toward associating liver partition and portal vein ligation for staged hepatectomy for perihilar cholangiocarcinoma needs to be revised. In selected patients with perihilar cholangiocarcinoma, associating liver partition and portal vein ligation for staged hepatectomy can achieve favorable survival that compares to the outcome of established surgical treatment strategies reported in benchmark studies for perihilar cholangiocarcinoma including 1-stage hepatectomy and liver transplantation.

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.

Robotic liver partition and portal vein embolization for staged hepatectomy for perihilar cholangiocarcinoma

Perihilar cholangiocarcinoma (pCCA) is one of the most complex challenges for hepatobiliary surgeons. Poor results and high incidence of morbidity after Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) for pCCA discouraged this indication. It has been proposed that minimally invasive approach for ALPPS first stage, as well as combination of surgical liver partition and radiologic portal vein embolization (PVE), may improve outcomes reducing interstage morbidity. We report a case of right trisectionectomy with enbloc caudatectomy ALPPS scheduled for pCCA with robotic approach at stage-1, the full video is provided as supplementary material. Due to intraoperative presence of portal vein tumor infiltration during hilar dissection (no evidence in the pre-operative work-up), a radiologic right PVE was performed after stage-1 instead of portal vein ligation, followed by portal vein resection and biductal hepatico-jejunostomy at stage-2 with open approach. The patient was a 74-year-old female diagnosed with 3-cm mass-forming pCCA. The total clean liver volume was 1231 cc, with future liver remnant (FLR) volume of 25.1% (segments II and III). She was discharged in the interstage interval on postoperative day (POD) 4; CT scan on POD 12 showed that FLR increased up to 33% (369 cc) (Fig. 1). ALPPS was completed on POD 17, the postoperative course was uneventful, and the patient was discharged in good general condition on POD 19 after stage-2. Besides the already demonstrated advantages in terms of reduced interstage morbidity, robotic ALPPS represents a promising strategy to expand surgical indication in patients with pCCA. The combination of liver partition and PVE may increase the opportunities to perform radical resections in selected patients with pCCA and portal vein infiltration.

Application of propofol combined with sevoflurane anesthesia in staged hepatectomy liver detachment and portal vein ligation

The aim of the present study was to investigate the application of propofol combined with sevoflurane anesthesia in associating liver partition and portal vein ligation for staged hepatectomy (ALPPS). A retrospective analysis of 40 patients with liver cancer who underwent ALPPS was performed. The study included 21 (control group) and 19 (observation group) patients who were administered propofol anesthesia and propofol in combination with sevoflurane anesthesia, respectively. Changes in liver function indicators, routine blood parameters and blood coagulation function, as well as cognitive function (mini-mental state examination) were recorded. The total bilirubin and direct bilirubin levels and the alanine aminotransferase (ALT) level after the first- and second-stage operation in the two groups was also higher than that prior to the first-stage operation (P<0.05), and the ALT level was significantly lower in the two groups after the second-stage operation compared with that prior to the second-stage operation (P<0.05). The AST level after the first- and second-stage operation was lower than that prior to the first- and second-stage operation, respectively (P<0.05). The white blood cell count after the second-stage operation was significantly lower compared with that prior to the second-stage operation (P<0.05). The plasma fibrinogen (FIB) level was higher after the first-stage operation compared with that prior to the first-stage operation (P<0.05). The prothrombin time in the two groups of patients was higher after the second-stage operation compared with that prior to the second-stage operation (P<0.05), whereas the FIB level was lower (P<0.05) and the international normalized ratio was not significantly different (P>0.05). The degree of cognitive decline prior to the first/second-stage operation, according to mini-mental state examination scores, was different from that after the first/second-stage operation (P<0.05). In conclusion, propofol combined with sevoflurane has a good application value in ALPPS.

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.

The Future Liver Remnant : Definition, Evaluation, and Management

When considering patients for a major hepatectomy, one must carefully consider the volume of liver to be left behind and if additional procedures are necessary to augment its volume. This review considers the optimal volume of the future liver remnant (FLR) and analyzes the techniques of augmenting this volume, the various growth parameters to assess adequate growth of the FLR, as well as further management when there has been inadequate growth of the FLR.

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure for cholangiocarcinoma

Perihilar cholangiocarcinoma (PHCC) has been a great challenge for surgeons, requiring advanced skills and expertise and was often associated with high morbidity and mortality. Resectability rates are up to 75% even in experienced centers. In patients with PHCC, radical liver and bile duct resection aiming R0 surgical margins offers the best long-term survival. Therefore, extensive resections with low FLR are commonly needed and PVE is offered to induce remnant liver hypertrophy for a long period. Associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) is considered a promising approach inducing rapid remnant hypertrophy to prevent dropouts due to complications or tumor progression and increase resectability. Although poor results were reported initially, refinements in technique and risk adjustment of patient selection improved outcomes. The procedure is still under debate for the indication of PHCC. This article reviews the current literature on ALPPS in treatment of perihilar and intrahepatic cholangiocarcinoma.

Stage I-laparoscopy partial ALPPS procedure for perihilar cholangiocarcinoma

The treatment for perihilar cholangiocarcinoma (PHC) is a challenge for the surgeon requiring complex resections with a reported perioperative mortality rate between 15% and 48%. In PHC patients with future liver remnant (FLR) less than 30%, it is advised that hepatectomy can be safely performed after the FLR is modified. Associating Liver Partition and Portal vein ligation for Staged Hepatectomy (ALPPS) procedure is criticized heavily due to its high morbidity and mortality rate in this setting. Hereby, we are reporting a modification of ALPPS procedure for PHC. Clinical presentation, preoperative work-up as well as operation and postoperative course of two cases were described in detail. Both patients were jaundiced preoperatively, stage 1 partial-ALPPS procedures were performed laparoscopically, there was sufficient remnant hypertrophy during the interval stage and there was no posthepatectomy liver failure after the second stage (Supporting Information Video). We have followed patients with a mean follow up of 35 months without any recurrence. Here we describe the key technical aspects of this approach that are discussed in three parts: minimally invasive first stage, biliary drainage of both FLR, and deportalized liver at first stage and biliary reconstruction at the second stage. This technique, in selected patients, can extend the indication of ALPPS procedure for PHC with preoperative jaundice.

Percutaneous radiofrequency-assisted liver partition versus portal vein embolization before hepatectomy for perihilar cholangiocarcinoma

Background

Percutaneous radiofrequency‐assisted liver partition with portal vein embolization in staged liver resection (PRALPPS) represents an alternative to portal vein embolization (PVE) followed by major liver resection in patients with perihilar cholangiocarcinoma.

Methods

This was an observational case–control study. Both procedures were applied in patients with a future liver remnant (FLR) volume of less than 40 per cent. The main end points of the study were short‐term morbidity and mortality for the two procedures. The study also compared the efficacy of the preresection phases estimated by kinetic growth rate (KGR), time interval and degree of hypertrophy of the FLR.

Results

The first phase (preresection) was completed in 11 and 18 patients, and the second phase (resection) in nine and 14 patients, in the PRALPPS and PVE groups respectively. Major morbidity after the first stage did not differ between the groups. There were no differences in blood loss, severe morbidity or liver failure rate after the second stage, with no deaths. The mean KGR of the FLR after the preresection phase for PRALPPS was 3·8 (0·6–9·8) per cent/day, and that after PVE was 1·8 (0–6·7) per cent/day (P = 0·037). The mean time interval for FLR hypertrophy in the PRALPPS and PVE groups was 15 (6–29) and 20 (8–35) days respectively (P = 0·039).

Conclusion

Short‐term outcomes were similar for PRALPPS and PVE in terms of safety. Remnant hypertrophy was achieved more rapidly by PRALPPS.

Expanding the Surgical Pool for Hepatic Resection to Treat Biliary and Primary Liver Tumors

Surgical management of primary liver and biliary tract tumors has evolved over the past several decades, resulting in improved outcomes in these malignancies with historically poor prognoses. Expansion of patient selection criteria, progress in neoadjuvant and adjuvant therapies, development of techniques to increase future liver remnant, and the select utilization of liver transplantation have all contributed to increasing the patient pool for surgical intervention. Ongoing and future studies need to focus on improving multimodality treatment regimens and further refining the selection criteria for transplantation in order to optimize utilization of limited organ resources.

The HPB controversy of the decade: 2007-2017 - Ten years of ALPPS

Ten years ago the first patient underwent Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS). This report aimed to critically review literature on ALPPS in terms of methods, outcomes, and bias. In total, 237 English papers on ALPPS were identified, 75 (32%) were letters and 43 (18%) case-reports. Forty-nine single-center series reported a median 10 patients, with 0-69% morbidity and 0-50% mortality. The indications for ALPPS were reported in 35% and 47% reported on modifications. Twenty-three multicenter series included a median 45 patients. Some reports excluded up to 399 cases. 26% reported on the indications and 35% on ALPPS modifications. Across journals, variation in positive and negative conclusions on ALPPS was observed. Ten years of ALPPS have resulted in diverse publications with a high concern of bias. Although one randomized study has been published, a more critical approach towards retrospective methodology is needed to allow pragmatic conclusions for HPB-surgeons.

Modern work-up and extended resection in perihilar cholangiocarcinoma: the AMC experience

AIM

Perihilar cholangiocarcinoma (PHC) is a challenging disease and requires aggressive surgical treatment in order to achieve curation. The assessment and work-up of patients with presumed PHC is multidisciplinary, complex and requires extensive experience. The aim of this paper is to review current aspects of diagnosis, preoperative work-up and extended resection in patients with PHC from the perspective of our own institutional experience with this complex tumor.

METHODS

We provided a review of applied modalities in the diagnosis and work-up of PHC according to current literature. All patients with presumed PHC in our center between 2000 and 2016 were identified and described. The types of resection, surgical techniques and outcomes were analyzed.

RESULTS AND CONCLUSION

Upcoming diagnostic modalities such as Spyglass and combinations of serum biomarkers and molecular markers have potential to decrease the rate of misdiagnosis of benign, inflammatory disease. Assessment of liver function with hepatobiliary scintigraphy provides better information on the future remnant liver (FRL) than volume alone. The selective use of staging laparoscopy is advisable to avoid futile laparotomies. In patients requiring extended resection, selective preoperative biliary drainage is mandatory in cholangitis and when FRL is small (< 50%). Preoperative portal vein embolization (PVE) is used when FRL volume is less than 40% and optionally includes the left portal vein branches to segment 4. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) as alternative to PVE is not recommended in PHC. N2 positive lymph nodes preclude long-term survival. The benefit of unconditional en bloc resection of the portal vein bifurcation is uncertain. Along these lines, an aggressive surgical approach encompassing extended liver resection including segment 1, regional lymphadenectomy and conditional portal venous resection translates into favorable long-term survival.

Maturity of associating liver partition and portal vein ligation for staged hepatectomy-derived liver regeneration in a rat model

AIM

To establish a rat model for evaluating the maturity of liver regeneration derived from associating liver partition and portal vein ligation for staged hepatectomy (ALPPS).

METHODS

In the present study, ALPPS, partial hepatecotmy (PHx), and sham rat models were established initially, which were validated by significant increase of proliferative markers including Ki-67, proliferating cell nuclear antigen, and cyclin D1. In the setting of accelerated proliferation in volume at the second and fifth day after ALPPS, the characteristics of newborn hepatocytes, as well as specific markers of progenitor hepatic cell, were identified. Afterwards, the detection of liver function followed by cluster analysis of functional gene expression were performed to evaluate the maturity.

RESULTS

Compared with PHx and sham groups, the proliferation of FLR was significantly higher in ALPPS group (P = 0.023 and 0.001 at second day, P = 0.034 and P < 0.001 at fifth day after stage I). Meanwhile, the increased expression of proliferative markers including Ki-67, proliferating cell nuclear antigen, and cyclin D1 verified the accelerated liver regeneration derived from ALPPS procedure. However, ALPPS-induced Sox9 positive hepatocytes significantly increased beyond the portal triad, which indicated the progenitor hepatic cell was potentially involved. And the characteristics of ALPPS-induced hepatocytes indicated the lower expression of hepatocyte nuclear factor 4 and anti-tryptase in early proliferative stage. Both suggested the immaturity of ALPPS-derived liver regeneration. Additionally, the detection of liver function and functional genes expression confirmed the immaturity of renascent hepatocytes derived in early stage of ALPPS-derived liver regeneration.

CONCLUSION

Our study revealed the immaturity of ALPPS-derived proliferation in early regenerative response, which indicated that the volumetric assessment overestimated the functional proliferation. This could be convincing evidence that the stage II of ALPPS should be performed prudently in patients with marginally adequate FLR, as the ALPPS-derived proliferation in volume lags behind the functional regeneration.

ALPPS in a patient with periductal infiltrating intrahepatic cholangiocarcinoma

Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) is a novel method to prevent post-hepatectomy hepatic failure. We present a case of periductal infiltrating intrahepatic cholangiocarcinoma undergone ALPPS, that was conducted as intraoperative choice instead of conducting preoperative portal vein embolization (PVE). A 65-year-old male patient was to undergo extended right posterior sectionectomy, but the operation plan was changed to conduct right hepatectomy with/without bile duct resection due to invasion of the right hepatic duct. After deciding to conduct ALPPS, we stopped further perihilar dissection and liver was transected. The right portal vein was ligated and Surgicel was densely packed between the transected hemilivers. There was rapid regeneration of the left liver on computed tomography follow-up, thus the second-stage right hepatectomy was conducted 10 days after the first-stage operation. Bile duct resection (BDR) was not performed due to heavy perihilar adhesion and inflammation, but fortunately tumor-negative bile duct resection margin was achieved after meticulous dissection. This patient recovered uneventfully and discharged nine days after the second-stage right hepatectomy. Thereafter he underwent concurrent chemoradiation therapy. He is doing well so far without evidence of tumor recurrence for 20 months after operation. In conclusion, this case suggests that ALPPS may be applied to an unexpected situation requiring PVE, but ALPPS is not recommend for treatment of perihilar malignancy requiring BDR.

Hypertrophy and Liver Function in ALPPS: Correlation with Morbidity and Mortality

Background

ALPPS (associating liver partition and portal vein ligation for staged hepatectomy) was introduced with the promise to reduce posthepatectomy liver failure (PHLF) in extended hepatectomies but has higher morbidity and mortality rates compared to conventional methods of volume enhancement. There are few studies of the incidence of PHLF after ALPPS and little information on how to avoid PHLF by functional testing. It remains unclear what causes the compromise in liver function despite rapid volume gain and if any of the modifications proposed reduce the incidence of PHLF. This review summarizes published data on this topic.

Methods

This is a systematic review that studies literature on the incidence of liver failure and assessment of liver function following ALPPS as well as modifications of the existing technique. Articles were searched in PubMed, evaluated, selected, and tabulated.

Results

The literature search revealed 326 articles that met the selection criteria. PHLF criteria as defined by the International Study Group of Liver Surgery (ISGLS) were the most commonly used criteria, but PHLF was frequently not defined. PHLF occurred most frequently after stage 2 of ALPPS at around 30% in most larger studies. Hepatobiliary scintigraphy showed a discrepancy between volume and functional growth of the liver. Function increase was only 50% compared to volume increase. Mechanistic explanations using histologic analyses have been given to explain the immaturity of the liver after rapid hypertrophy. Modifications of ALPPS showed a comparable volumetric gain when compared to classic ALPPS, but data were lacking to assess PHLF.

Conclusion

ALPPS has relatively high rates of PHLF, morbidity, and mortality. This may be explained by data demonstrating functional growth when compared to volume growth. ALPPS should not be performed without functional assessment and with caution.

'In-Situ Split' Liver Resection/ALPPS - Historical Development and Current Practice

Background

Liver tumors that are extensive, multifocal, or critically located frequently require advanced techniques of liver resection including '!' - enabling liver resection in certain situations.

Methods

The development of the technique in the first and the subsequent 8 patients in the index center, and also the method's spread throughout Germany and the world were reviewed.

Results

In 2007, in the first patient, the new technique was developed intraoperatively by necessity. Due to the convincing outcome, it was deliberately applied again several months later in another patient, and thereafter (sparsely) used for liver resection for various indications. Following oral communication, the method spread throughout Germany, and later - mainly following the publication of the initial multicentric German series - very quickly disseminated worldwide. Currently, it is used for a very (if not overly) broad spectrum of indications by many hepatobiliary surgery centers.

Conclusion

In-situ split/ALPPS is a newly developed technique for liver resection, which was established for very specific situations. This method has created a hype, and is currently used rather generously by many centers worldwide.