Optimization of ALPPS stage II timing with the APRI/ALBI score-an international, multicenter cohort study

Primarily unresectable liver tumors may be approached by the Associating Liver Partition and Portal vein Ligation for Staged Hepatectomy (ALPPS) procedure. Post-hepatectomy liver failure (PHLF) poses the most significant risk factor for poor outcomes. The AST-to-platelets ratio index (APRI)/albumin-to-bilirubin index (ALBI) score has been proposed as an easy and routinely available score to monitor liver function. Here, we explored the predictive capability of the APRI/ALBI score to determine PHLF and perioperative morbidity to help determine the optimal timing of the 2nd stage of ALPPS.

Based on the international multicenter ALPPS registry, patients from 2012 to 2020 with an available APRI/ALBI score were included. Postoperative outcomes (clinically relevant PHLF B + C, 90-day mortality, and severe morbidity (≥ Clavien-Dindo 3b) after ALPPS stage II were assessed. The APRI/ALBI score was monitored perioperatively, and the predictive value was evaluated using logistic regression and receiver operating characteristics. Performance of APRI/ALBI score was compared to the ALPPS futility risk score in this cohort study.

Overall, 464 patients from 16 participating centers were included. Clinically relevant PHLF (B + C) was observed in 7.5% of patients, of which 63% ultimately died. After stage I, the APRI/ALBI score gradually recovered. The pre-stage II APRI/ALBI score significantly predicted clinically relevant PHLF [area under the curve (AUC) =0.78; P<0.001], 90-day mortality (AUC =0.67; P=0.002), and severe morbidity (AUC =0.65; P<0.001). Three clinically relevant APRI/ALBI score risk groups were defined: clinically relevant PHLF occurred in 3.1% in the low-, 8.7% in the intermediate-, and 28.0% in the high-risk groups. 90-day mortality was 6.8% in the low-, 15.9% in the intermediate-, and 19.4% in the high-risk groups. Integrated assessment of the established futility risk score in combination with the APRI/ALBI score documented further increased predictive potential for clinically relevant PHLF (AUC 0.81; P<0.001).

The APRI/ALBI score allows for simple and dynamic liver function recovery monitoring after the first ALPPS stage. Inadequate recovery of the APRI/ALBI score until ALPPS stage II was associated with PHLF B + C, 90-day mortality, and severe morbidity. With the proposed risk model, optimized timing of the second stage of ALPPS may further increase the safety of this procedure.