Indications and Limits for Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS). Lessons Learned from 15 Cases at a Single Centre

Abstract

Introduction: The ALPSS procedure has been recently introduced as an alternative to PVE for liver volume augmentation in cases of planned right trisectionectomy with small future RLV and high risk of PHLF. We retrospectively analysed our single centre experience with 15 ALPPS procedures in order to better assess the limits and indications of the procedure.

Patients and Methods: The following volumetric parameters were evaluated: total liver volume (TLV), remnant liver volume (RLV), remnant liver volume to total liver volume ratio (RLV/TLV), remnant liver volume to body weight ratio (RLV/BWR) and median volume gain. The ALPPS procedure was usually considered when RLV/TLV < 25 % or RLV/BWR < 0.5. The ALPPS procedure consisted of phase 1 (in situ splitting of the liver), interphase (waiting for liver regeneration) and phase 2 (completion of right trisectionectomy). Postoperative complications were reported according to the Dindo–Clavien classification. Patient survival, late complications and tumour recurrence were analysed.

Results: Between November 2010 and September 2013, we performed 15 ALPPS procedures in 10 patients with primary liver tumours (5 h-CCA, 4 i-CCA and 1 HCC) and in 5 with CRLM. The preoperative RLV/TLV ratio was 22.6 % (15.7 − 29.2) and the RLV/BWR 0.46 (0.22 − 0.66). After 10 days (range 8 − 16) the RLV/TLV ratio and RLV/BWR increased up to 36.3 % (30 − 59.2 %) and 0.67 (0.5 – 1.2) respectively, with a median volume gain of 87.2 % (23.8 − 161 %). The time interval between phases 1 and 2 was 13 days (9 − 18). An R0 status was reached in 13 patients and R1 in 2. The overall postoperative morbidity was 66.7 %. After phase 1, 8 patients experienced 19 complications and 7 none. After phase 2, 11 patients experienced 36 complications and 4 none. Four patients died postoperatively after 22 days (9 − 36 days) resulting in a postoperative mortality of 28.7 %. After a median follow-up of 17 months (1 − 33), 10 out of 15 patients are still alive (survival rate 66.6 %). Four patients (2 i-CCA, 1 CRLM, 1 HCC) developed tumour recurrences (2 intrahepatic and 2 extrahepatic). One patient with i-CCA died at POM 4 secondary to peritoneal carcinosis.

Discussion: The actual high morbidity and mortality rates related to the ALPPS procedure should lead us to a more cautious selection of the candidates for this operation and restriction of the indications through an accurate work-up based on interdisciplinary cooperation among hepatologists, oncologists, radiologists and surgeons.

Zusammenfassung

Einleitung: Das ALPSS-Verfahren wurde als Alternative zur PVE für die Augmentation des Lebervolumens bei geplanten erweiterten Hemihepatektomie rechts mit kleinem zukünftigen Restlebervolumen (RLV) und entsprechenden hohen Risiko für Post-Hepatektomie-Leberversagen (PHLF) eingeführt. Durch eine retrospektive Analyse der an unseren Zentrum durchgeführten 15 ALPPS-Verfahren, möchten wir die Grenze und Indikationen der Prozedur überprüfen.

Patienten und Methoden: Folgende volumetrische Parameter wurden ausgewertet: TLV, RLV, RLV/TLV, RLVBWR und Lebervolumengewinn. Bei RLV/TLV < 25 % oder RLVBWR < 0,5 wurde ein ALPPS-Verfahren geplant. Es bestand aus Phase 1 (In-Situ Splitten der Leber), Zwischenphase (Warten auf die Leberregeneration) und Phase 2 (Komplettieren der erweiterten Hemihepatektomie rechts). Postoperative Komplikationen wurden nach Dindo-Clavien klassifiziert. Patientenüberleben, Spätkomplikationen und Tumorrezidiv wurden untersucht.

Ergebnisse: Zwischen November 2010 und September 2013 führten wir 15 ALPPS-Verfahren in 10 Patienten mit primären Lebertumoren (5 h-CCA, 4i -CCA und 1 HCC) und in 5 mit CRLM durch. Das präoperative RLV/TLV-Verhältnis betrug 22,6 % (15,7 − 29,2 %) und das RLVBWR 0,46 (0,22 − 0,66). Zehn Tage (8 − 16) nach Phase 1 das RLV/TLV-Verhältnis und das RLVBWR anstieg jeweils bis 36,3 % (30 − 59,2 %) und 0,67 (0,5 − 1,2). Der Volumengewinn war 87,2 % (23,8 − 161 %). Der Zeitabstand zwischen den Phasen 1 und 2 betrug 13 Tage (9 − 18). Eine R0-Status wurde bei 13 Patienten erreicht und R1 in 2 (beide mit h-CCA). Die postoperative Morbidität betrug 66,7 %. Nach Phase 1 erlebten 8 Patienten 19 Komplikationen und 7 keine. Nach Phase 2 erlebten 11 Patienten 36 Komplikationen und 4 keine. Vier Patienten starben 22 Tage (9 − 36) nach Phase 2 (postoperative Mortalität 28,7 %). Nach 17 Monaten (1 − 33), sind noch 10 von 15 Patienten am Leben (Überlebensrate 66,6 %). Vier Patienten (2 i-CCA, 1 CRLM, 1 HCC) entwickelten ein Tumorrezidiv (2 intra- und 2 extrahepatisch). Ein Patient mit i-CCA starb am POM 4 mit Peritonealkarzinose.

Diskussion: Die aktuelle hohe Morbiditäts- und Mortalitätsrate des ALPPS-Verfahrens soll uns zu einer sorgfältigen Selektion der Kandidaten und Einschränkung der Indikationen durch eine enge Zusammenarbeit zwischen Hepatologen, Onkologen, Radiologen und Chirurgen führen.

Schlüsselwörter

Leber - gastro-entero-pankreatische Tumoren - kolorektales Karzinom - Leberkarzinom - Cholangiokarzinom - Leberresektion

Key words

liver - gastroenteropancreatic tumours - colorectal cancer - liver cancer - cholangiocarcinoma - liver resection

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