Prediction of Mortality After ALPPS Stage-1: An Analysis of 320 Patients From the International ALPPS Registry
Erik Schadde1, Dimitri Aristotle Raptis, Andreas A Schnitzbauer
1*Kantonsspital Winterthur, Winterthur; Institute of Physiology, University of Zurich, Zurich, Switzerland †KantonsspitalOlten, Olten, Switzerland ‡Swiss HPB and Transplant Center, University Hospital Zurich, Zurich, Switzerland §Department of Visceral- and Transplantation Surgery, Johann Wolfgang von Goethe University, Frankfurt, Germany ¶Department of Surgery, Division of HPB Surgery, Liver Transplant Unit, Italian Hospital Buenos Aires, Argentina ||Lebanese American University, Beirut, Lebanon **Department of Surgery, Division of HPB Surgery, Western University Medical Center, London, Ontario, Canada ††General Surgery Unit, Maggiore Hospital, Bologna, Italy ‡‡Department of Surgery, SirioLibanes Hospital, University of São Paulo, São Paulo, Brazil §§Department of HPB and Liver Transplant Surgery, Royal Free Hospital, University College London, London, UK ¶¶Department of General Surgery, Liver Transplant Unit, Virgen De La Arrixaca University Hospital, Murcia, Spain ||||Centre Hépato-Biliaire, Hôpital Paul Brousse, Villejuif, France ***University Paris Sud, Paris, France.
Objectives:
The aim of this study was to identify predictors of 90-day mortality after Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS), available after stage-1, either to omit or delay stage-2.
Background Data:
ALPPS is a two-stage hepatectomy for patients with extensive liver tumors with predicted small liver remnants, which has been criticized for its high mortality rate. Risk factors for mortality are unknown.
Methods:
Patients in the International Registry undergoing ALPPS from April 2011 to July 2014 were analyzed. Primary outcome was 90-day mortality. Liver function after stage-1 was assessed using the criteria of the International Study Group for Liver Surgery (ISGLS) after stage-1 among others. A multivariable model was used to identify independent predictors of 90-day mortality.
Results:
Three hundred twenty patients registered by 55 centers worldwide were evaluated. Overall 90-day mortality was 8.8% (28/320). The predominant cause for 90-day mortality was postoperative liver failure in 75% of patients. Fourteen percent of patients developed liver failure according to ISGLS criteria already after stage-1 ALPPS. Those and patients with a model of end-stage liver disease (MELD) score more than 10 before stage-2 were at significantly higher risk for 90-day mortality after stage-2 with an odds ratio (OR) 3.9 [confidence interval (CI) 1.4-10.9, P = 0.01] and OR 4.9 (CI 1.9-12.7, P = 0.006), respectively. Other factors, such as size of future liver remnant (FLR) before stage-2 and time between stages, were not predictive.
Conclusions:
This analysis of the largest cohort of ALPPS patients so far identifies those patients in whom stage-2 ALPPS surgery should be delayed or even denied. These findings may help to make ALPPS safer.
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