Background

Hepatectomy 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.

Methods

A 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.

Results

A 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.

Conclusions

ALPPS 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.

中文翻译：

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从传统的两期肝切除术到 ALPPS：十五年肝胆外科经验

背景

大肿瘤负荷患者的肝切除术可能导致术后肝功能衰竭和由于过度肝实质切除引起的相关并发症。传统的两期肝切除术 (TSH) 和联合肝分割和门静脉结扎的分期肝切除术 (ALPPS) 技术是解决这一问题的可能方法。结直肠肝转移（CRLM）是最常见的适应症，有必要评估这两种技术的结果，以改善这些患者的手术和长期肿瘤学结果。

方法

一项单中心回顾性研究旨在比较 2005 年 1 月至 2020 年 1 月期间最初无法切除的双侧肝肿瘤患者的 TSH 与 ALPPS。ALPPS 从 2012 年 1 月起作为首选技术进行。长期总生存期 (OS) 和无病生存期 (DFS) 被评估为 CRLM 患者的主要结局。还评估了所有患者的术后发病率、死亡率和肝脏生长情况。

结果

总共进行了 38 次分期肝切除术：17 次 TSH 和 21 次 ALPPS。TSH 组完全切除率为 76.5%（n  = 13），ALPPS 组为 85.7%（n  = 18）（P  = 0.426）。总体主要发病率（Clavien-Dindo ≥ 3a）（第 1 阶段 + 第 2 阶段）TSH 为 41.2%（n =  7），ALPPS 患者为 33.3%（n = 7）（ P  = 0.389），围手术期 90 天死亡率 每组分别为 11.8% ( n  = 2) 和 19.0% ( n = 4) ( P  = 0.654)。CRLM 患者 1 年和 5 年 TSH（n  = 15）的意向治疗 OS 率分别为 80% 和 33%，ALPPS（n = 17) 分别为 76% 和 35%。TSH 组 1 年和 5 年的 DFS 率分别为 36% 和 27%，而 ALPPS 组分别为 33% 和 27%。

结论

ALPPS 是双侧影响肝脏肿瘤的 TSH 的有效替代方案，可实现更高的切除率，但必须仔细选择患者。在 CRLM 患者中，两种技术都可以实现相似的长期 OS 和 DFS。