Defining Benchmark Outcomes for ALPPS

Objective: The aim of this study was to use the concept of benchmarking to
establish robust and standardized outcome references after the procedure
ALPPS (Associating Liver Partition and Portal Vein Ligation for Staged
hepatectomy).
Background and Aims: The recently developed ALPPS procedure, aiming
at removing primarily unresectable liver tumors, has been criticized for safety
issues with high variations in the reported morbidity/mortality rates depending
on patient, disease, technical characteristics, and center experience. No
reference values for relevant outcome parameters are available.
Methods: Among 1036 patients registered in the international ALPPS registry,
120 (12%) were benchmark cases fulfilling 4 criteria: patients 67 years
of age, with colorectal metastases, without simultaneous abdominal procedures,
and centers having performed30 cases. Benchmark values, defined as
the 75th percentile of the median outcome parameters of the centers, were
established for 10 clinically relevant domains.
Results: The benchmark values were completion of stage 2: 96%, postoperative
liver failure (ISGLS-criteria) after stage 2: 5%, ICU stay after
ALPPS stages 1 and 2: 1 and 2 days, respectively, interstage interval:
16 days, hospital stay after ALPPS stage 2: 10 days, rates of overall
morbidity in combining both stage 1 and 2: 65% and for major complications
(grade 3a): 38%, 90-day comprehensive complication index was
22, the 30-, 90-day, and 6-month mortality was 4%, 5%, and 6%,
respectively, the overall 1-year, recurrence-free, liver-tumor-free, and extrahepatic
disease-free survival was 86%, 50%, 57%, and 65%, respectively.
Conclusions: This benchmark analysis sets key reference values for ALPPS,
indicating similar outcome as other types of major hepatectomies. Benchmark
cutoffs offer valid tools not only for comparisons with other procedures, but
also to assess higher risk groups of patients or different indications than
colorectal metastases.