Risk Adjustment in ALPPS Is Associated With a Dramatic Decrease
in Early Mortality and Morbidity

Linecker M, Björnsson B, Stavrou GA, Oldhafer KJ, Lurje G, Neumann U, Adam R, Pruvot FR, Topp SA, Li J, Capobianco I, Nadalin S, Machado MA, Voskanyan S, Balci D, Hernandez-Alejandro R, Alvarez FA, De Santibañes E, Robles-Campos R, Malagó M, de Oliveira ML, Lesurtel M, Clavien PA, Petrowsky H.

Ann Surg. 2017 Aug 11. doi: 10.1097/SLA.0000000000002446.



PDF (295 Kb)


Objective: To longitudinally assess whether risk adjustment in Associating
Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS)
occurred over time and is associated with postoperative outcome.
Background: ALPPS is a novel 2-stage hepatectomy enabling resection of
extensive hepatic tumors. ALPPS has been criticized for its high mortality,
which is reported beyond accepted standards in liver surgery. Therefore,
adjustments in patient selection and technique have been performed but have
not yet been studied over time in relation to outcome.
Methods: ALPPS centers of the International ALPPS Registry having performed
10 cases over a period of 3 years were assessed for 90-day
mortality and major interstage complications (3b) of the longitudinal study
period from 2009 to 2015. The predicted prestage 1 and 2 mortality risks were
calculated for each patient. In addition, questionnaires were sent to all centers
exploring center-specific risk adjustment strategies.
Results: Among 437 patients from 16 centers, a shift in indications toward
colorectal liver metastases from 53% to 77% and a reverse trend in biliary
tumors from 24% to 9% were observed. Over time, 90-day mortality
decreased from initially 17% to 4% in 2015 (P ¼ 0.002). Similarly, major
interstage complications decreased from 10% to 3% (P ¼ 0.011). The
reduction of 90-day mortality was independently associated with a risk
adjustment in patient selection (P < 0.001; OR: 1.62; 95% CI: 1.36–1.93)
and using less invasive techniques in stage-1 surgery (P ¼ 0.019; OR: 0.39;
95% CI: 0.18–0.86). A survey indicated risk adjustment of patient selection in
all centers and ALPPS technique in the majority (80%) of centers.
Conclusions: Risk adjustment of patient selection and technique in ALPPS
resulted in a continuous drop of early mortality and major postoperative
morbidity, which has meanwhile reached standard outcome measures
accepted for major liver surgery.