Comparative outcome analysis of two-stage hepatectomy with PVE (TSH/PVE) versus ALPPS for patients with colorectal liver metastases (CRLM)

Question:

Surgical resection has offered the best option for prolonged survival in patients with colorectal liver metastases (CRLM). To further increase resectability in these patients, novel surgical maneuvers such as two-staged hepatectomies (TSH) combined with portal vein embolization (PVE) and associating liver partition and portal vein ligation (ALPPS) have been implemented. Even tough, both surgical procedures (TSH/PVE versus ALPPS) are technical feasible and allow complete resections (R0) in patients that were otherwise considered not resectable, little is known about the comparative clinical and oncological outcome of TSH/PVE and ALPPS.

Methods:

Between 2011 – 2016 35 patients underwent the conventional TSH/PVE approach whereas 17 patients were treated with the novel ALPPS procedure. Surgical complications were systematically assessed and associations between oncological outcome and patients” characteristics were determined by univariate and multivariate survival analysis. Differences between the groups were accessed by the log-rank and non-parametric tests.

Results:

In 20% (7/35) of all CRLM patients undergoing the conventional TSH/PVE approach, the second step was not completed due to insufficient hypertrophy of the future liver remnant (FLR) or progressive disease. From these, 5 out 7 (71%) were treated with salvage ALPPS, whereas 2 of these patients were subject to palliative care. All 17 ALPPS patients (100%) completed both steps as planned. No significant differences in mortality were observed between the groups (TSH/PVE vs. ALPPS, 6.7% vs. 5.9%, p = 0.999). However, the mean comprehensive complication index (CCI) was higher in ALPPS group (39 ± 21) than in the TSH/PVE group (24 ± 27) indicating more morbidity for patients undergoing the ALPPS procedure (p = 0.014). Preoperative risk factors, which included the number of liver metastases (p = 0.621), timing of metastases (p = 0.082), preoperative cycles of chemotherapy (p = 0.103) and the amount of chemotherapy lines (p = 0.103) were equally distributed between the groups. CRLM patients who were treated with TSH/PVE versus ALPPS did not show a significant difference in median overall survival (TSH/PVE vs. ALPPS, 29 months vs. 19 months, p = 0.819).

Conclusion:

Two-stage hepatectomies (TSH/PVE and ALPPS) are feasible and safe in experienced high-volume liver centers. Even though ALPPS was associated with increased perioperative morbidity, CRLM patients undergoing TSH/PVE versus ALPPS did not show significant differences in overall survival. As such, salvage ALPPS may be a suitable approach for TSH/PVE patients with insufficient inter-stage hypertrophy of the FLR.