Rescue associating liver partition and portal vein ligation for staged hepatectomy after portal embolization: Our experience and literature review

Table 1 Preoperative characteristics of patients

Variable	Rescue ALPPS (n = 7)
Male/female gender	4/3
Age, yr (range)	61 (53-70)
Body mass index (range)	23 (21-27)
ASA 1-2	6
ASA 3	1
Colorectal liver metastases	4
Number of liver metastases (range)	5 (2-7)
Size of the largest metastases, mm (range)	45 (20-65)
Tumor location
Right lobe ± segment IV	3
Right lobe + segment IV + left lateral segment	1
Previous colorectal resection	3
Previous hepatic resection or thermoablation	3
Preoperative chemotherapy	4
Oxaliplatin based	4
Irinotecan based	3
Angiogenesis inhibitor	1
Intra-arterial chemotherapy	1
Number of preoperative chemotherapy cycles (range)	16 (8-25)
Cholangiocarcinoma	3
Perihilar/intrahepatic	2/1
Preoperative chemotherapy	1
Gemcitabine and oxaliplatin	1
No. of preoperative chemotherapy cycles	3
Portal vein embolization	7
Right lobe	5
Right lobe + segment IV	2
Comorbidity
Cardiovascular	2
Pulmonary	0
Diabetes	0
Prior history of cancer	2

ALPPS: Associating Liver Partition and Portal vein ligation for Staged hepatectomy.

Table 2 Clinical outcomes and complications

Variable	Rescue ALPPS (n = 7)
Surgery
Right trisegmentectomy extended to segment I	4/7
Right lobectomy	1/7
Right lobectomy combined with thermoablation	2/7
Days between ALPPS-1 and ALPPS-2 (range)	7 (7-9)
ALPPS-1
Surgery duration ALPPS-1, min (range)	240 (180-300)
Blood loss during ALPPS-1, mL (range)	750 (300-1000)
Prothrombin ratio day 5, % (range)	76 (70-85)
Bilirubin day 5, µmol/L (range)	24 (15-70)
MELD score day 5 (range)	10 (8-15)
ALPPS-2
Surgery duration ALPPS-2, min (range)	90 (60-120)
Blood loss during ALPPS-2, mL (range)	300 (0-800)
Prothrombin ratio day 5, % (range)	60 (41-73)
Bilirubin day 5, µmol/L (range)	43 (10-182)
MELD score day 5 (range)	14 (9-21)
Complications
Liver failure after ALPPS-1	0/7
Liver failure after ALPPS-2	2/7
Complications after ALPPS-1 and before ALPPS-2	0/7
Complications after ALPPS-2	7/7
Clavien I-II	4/7
Clavien III	1/7
Clavien IV	1/7
Clavien V	1/7
30 d mortality	1/7
90 d mortality	1/7
R0 resection	6/7

ALPPS: Associating liver partition and portal vein ligation for staged hepatectomy; ALPPS-1: First stage ALPPS; ALPPS-2: Second stage ALPPS.

Table 3 Patient characteristics

Patient number	Gender	Age	Tumor	Underlying liver function	FLR/BWR before PVE, %	FLR/BWR before ALPPS-1, %	FLR/BWR before ALPPS-2, %	ALPPS-2 day 5 Bilirubin, µmol/L	ALPPS-2 day 5 PT, %	Dindo-Clavien classification	Complications(by order of appearance)
1	M	68	pCCA	Cholestasis	0.35	0.59	1.05	182	45	V	Intraoperative blood transfusion, intra-abdominal abscess, pleural effusion, death due to peritonitis caused by bowel perforation
2	M	70	iCCA	-	0.33	0.58	0.82	43	60	II	Intraoperative blood transfusion, transitory ascites
3	M	55	CRLM	FNH	0.45	0.55	0.76	43	41	II	Intraoperative blood transfusion
4	F	66	pCCA	Cholestasis	0.43	0.66	1.21	44	73	III	Transitory ascites and intra-abdominal abscess
5	F	59	CRLM	SOS and steatosis	0.42	0.80	1.23	10	69	II	Intraoperative blood transfusion, urinary infection
6	F	53	CRLM	Dystrophy	0.52	0.62	0.89	87	50	IV	Intraoperative blood transfusion, internal hemorrhage, transitory hepatic insufficiency, infected ascites, septic choc, and intra-abdominal abscess
7	M	61	CRLM	-	0.46	0.83	1.14	13	67	II	Intraoperative blood transfusion, transitory chylous ascites

pCCA: Perihilar cholangiocarcinoma; iCCA: Intrahepatic cholangiocarcinoma; CRLM: Colorectal liver metastases; FNH: Focal nodular hyperplasia; SOS: Sinusoidal obstruction syndrome; M: Male; F: Female; ALPPS: Associating Liver Partition and Portal vein ligation for Staged hepatectomy; ALPPS: Associating liver partition and portal vein ligation for staged hepatectomy.

Table 4 Literature review of rescue Associating Liver Partition and Portal vein ligation for Staged hepatectomy

	Rescue ALPPS after PVO (PVE/PVL/PVE + PVL)	Tumor	Days between ALPPS-1 and ALPPS-2	FLR/BWR before PV0, %	FLR/BWR before ALPPS-1, %	FLR/BWR before ALPPS-2, %	Growth of FLR between PVO and ALPPS-1, % (range)	Growth of FLR between ALPPS-1 and ALPPS-2, % (range)	Clavien Dindo > III	30-d mortality
Conrad et al[37], 2012	1 (1/0/0)	CRLM	9	NC	NC	NC	-1	47	0/1	0/1
Gauzolino et al[15], 2013	1 (1/0/0)	CRLM	7	NC	NC	0.4	NC	26	0/1	0/1
Knoefel et al[21], 2013	3 (3/0/0)	NC	6	NC	NC	NC	462	652	1/2	1/2
Björnsson et al[20], 2013	2 (2/0/0)	CRLM (n = 1) HCC (n = 1)	9	NC	NC	NC	NC	NC	0/2	NC
Tschuor et al[22], 2013	3 (1/1/1)	CRLM	8	NC	NC	NC	612	792	2/3	0/3
Vyas et al[38], 2014	1 (1/0/0)	Neuroendocrine metastases	8	0.4	0.5	0.9	24	70	0/1	0/1
Nadalin et al[39], 2014	2 (2/0/0)	CRLM (n = 1)	13	NC	0.52	NC	NC	NC	1/2	1/2
		Pancreatic metastases (n = 1)
Fard-Aghaie et al[40], 2015	1 (1/0/0)	CRLM	26	NC	NC	NC	69	50	1/1	1/1
Alavrez et al[41], 2015	1 (0/0/1)	CRLM	7	NC	NC	NC	38	65	1/1	0/1
Croome et al[42], 2015	2 (2/0/0)	CRLM	8	NC	NC	NC	NC	NC	NC	NC
Truant et al[23], 2015	9 (9/0/0)	NC	8	NC	NC	NC	NC	NC	NC	NC
Björnsson et al[43], 2016	10 (NC)	CRLM	8	NC	NC	NC	NC	NC	NC	0/10
Sparrelid et al[24], 2016	11 (7/4/2)	CRLM	7	0.31	0.41	0.71	271 (7-67)	621 (19-120)	4/11	0/11
Ulmer et al[44], 2017	9 (9/0/0)	CRLM (n = 6), CCA (n = 2), others liver metastases (n = 1)	9	NC	NC	NC	302	782	6/9	1/9
Maulat, 2017	7 (7/0/0)	CRLM (n = 4), CCA (n = 3)	71	0.41	0.61	11	691	451	3/7	1/7

¹Median;

²Mean. PVE: Portal vein embolization; PVL: Portal vein ligation; PVE + PVL: Portal vein embolization associated with portal vein ligation; CRLM: Colorectal liver metastases; HCC: Hepatocellular carcinoma; CCA: Cholangiocarcinoma; NC: Not communicated.