Enlarged and uncommon indications for ALPPS—where do we stand?

HepatoBiliary Surg Nutr 2022;11(5):743-745 | https://dx.doi.org/10.21037/hbsn-22-371 Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been introduced in 2012 as an innovative surgical option that offers patients curative resection in otherwise nonresectable tumors. Considering the high morbi-mortality rates and poor oncologic outcome in the early experience, indications of ALPPS have been restricted to young patients with colorectal liver metastases (CRLM) following the first report on the international ALPPS registry (1). ALPPS further gained in safety after the first International ALPPS Meeting held in 2015 (2) in Hamburg, which prompted surgeons to better patient selection by chemotherapy (3), technical refinements toward less invasive ALPPS procedures (4), and better inter-stage decision making (5). In a recent comparative study (6), ALPPS showed higher resection rates than liver venous deprivation [LVD; i.e., radiological simultaneous portal vein embolization (PVE) and hepatic vein embolization] as an alternative. Regarding long-term outcomes, the randomized controlled trial LIGRO compared ALPPS vs. two-stage hepatectomy showing a significantly longer median overall survival (46 vs. 26 months) for ALPPS on intent-to-treat analysis (7). Thus, the oncological outcomes after ALPPS appear promising. This process has enabled validating ALPPS as a safe and beneficial surgical option when appropriately used. Following the opening of the International ALPPS registry, the number of patients receiving ALPPS has been increasing over time, with more than 1,200 cases reported in the registry so far (8). These studies published in 159 journals were written by 2,157 authors from 694 organizations in 43 regions. To date most of ALPPS studies have been published for the treatment of CRLM, hepatocellular carcinoma, and intrahepatic cholangiocarcinoma (ICC). Regarding locally advanced ICC, the largest series published by Li et al. (9,10) came from the ALPPS registry. Among 102 patients, 99 completed the second stage, with R0 resection obtained in 87 (85%). The 90-day mortality rate of 20.8% reported in that study was high in comparison with that observed for conventional major hepatectomy or ALPPS performed for non-primary liver cancer. One possible explanation for this observation was the high complexity of surgery in ICC patients undergoing ALPPS (i.e., trisectionectomy in 78.7% of cases, biliary reconstruction in 35.6% and complex vascular reconstruction in 12.1%). Once again, better patient selection and improvement in inter-stage management contributed to a significant decrease in mortality over time (7% in the last 2 years). Despite the 90-day mortality, the comparative survival analysis demonstrated superior longterm outcomes of the ALPPS procedure over chemotherapy alone. In a recent systematic literature review, Lai et al. (11) Editorial