The study compares two-stage hepatectomy (TSH) and associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in patients with unresectable colorectal liver metastases. Although ALPPS showed a higher rate of complete resection feasibility (100% vs 63%) and lower 90-day mortality, its overall survival rate was lower than that of TSH, with a higher recurrence of liver metastases. Consequently, despite its advantages, ALPPS did not demonstrate superior oncological outcomes compared to two-stage hepatectomy.

1. Two-Stage Hepatectomy
vs ALPPS for
Unresectable Metastases
R Adam,
K Imai, C Castro, MA Allard,
E Vibert, A Sa Cunha, D
Cherqui, H Baba, D Castaing
Hôpital Paul Brousse, Villejuif, France
Université Paris-Sud, France

2. Multi Unilobar Multi Bilobar Multi Bilobar
Remnant Liver <30% ≤3 nod. ≤30 mm >3 nod. >30 mm
Hepatectomy +
Local Ablation
2-Stage
Hepatectomy
Portal Vein
Embolization
Two-Stage Hepatectomy: Patient Selection
Standard 2-Stage ALPPS

3. Portal vein
ligation
Tumorectomy
of liver remnant
Hypertrophy of
liver remnant
Stage 1 Stage 2
>30% of
total liver
4-8 weeks
Removal of the
deportalized lobe
Portal vein
embolization
Clavien et al. Strategies for safer liver surgery. NEJM, 2017
The Selective Staged method…
Two-stage Hepatectomy
Exclusion Pts
in progression

5. Portal vein
ligation
Tumorectomy
of liver remnant
Hypertrophy of
liver remnant
Stage 1 Stage 2
>30% of
total liver
9 days
Removal of the
deportalized lobe
Portal vein
embolization
Clavien et al. Strategies for safer liver surgery. NEJM, 2017
The fast-surgery method…: ALPPS

6. Present status
• Higher feasibility of complete resection with ALPPS
• Faster hypertrophy rate of liver remnant
Are the oncological results better than conventional
2-stage ?
Pending question

7. Results: flow chart
January 2000 – June 2014
248 Pts Resected of CLM at Paul Brousse Hospital
56 Two stage hepatectomy (23%)
TSH (N = 41)
15 Failure
(36%)
26 Complete
(64%)
ALPPS (N = 17)

8. Patient Selection
• Two-stage hepatectomy and ALPPS : indicated in
patients with bilobar colorectal liver metastases not
resectable by a single-stage hepatectomy with or without
portal vein embolization or local ablation therapy.
• ALPPS was favoured in patients with an estimated
smaller liver remnant volume irrespective of other tumour
or patient characteristics

9. Male 65 yrs
Synchronous Bilateral Irresectable LMCCR
FOLFOX AVASTIN 6 Courses
ACE 228 --- 83
FLR: 313cc ( < 0.5% ratio to Body weight)

10. Methods
• Between January 2010 and June 2014,
• 58 consecutive patients who underwent either
ALPPS (n=17) or two-stage hepatectomy (n=41)
for colorectal liver metastases were enrolled in
the study.
• Short-term and oncological outcomes were
compared.

11. Methods: ALPPS or TSH?
Bilobar multiple CLM
Unresectable with a single hepatectomy
even with portal vein embolization
Estimated small remnant liver
(requiring right hepatetomy
extended to segment IV)
ALPPS or Two stage hepatectomy?
Possibility to spare
segment IV

12. Methods: Techniques for ALPPS
• Clairance of future remnant liver
• Portal vein embolization
• Parenchymal transection
12 days later….
Right hepatectomy extended to segment IV
1st stage

13. Methods: End points
Oncological outcomes on intention to treat
• Overall survival
• Disease-free survival

14. Two stage vs ALPPS: baseline characteristics
Study group (n=58)
ALPPS
(n=17)
TSH
(n=41)
P value
Sex (M/F) 12/5 23/18 0.30
Age 58 (23-75) 58 (32-75) 0.90
T-stage CR tumour (1-2/3-4) 15 (88) 30 (73) 0.53
Site of primary tumour (colon/rectum) 13 (76) 27 (66) 0.42
Liver metastases: synchronous 15 (88) 38 (93) 0.59
No of liver lesions at diagnosis 10 (3-20) 10 (2-35) 0.37
Largest size at diagnosis (mm) 40 (13-145) 50 (10-150) 0.39
No of liver lesions at hepatectomy 8 (3-32) 10 (3-30) 0.39
Largest size at hepatectomy (mm) 38 (8-140) 43 (10-140) 0.26
CEA at hepatectomy (ng/mL) 8 (1-1195) 7.9 (0.5-940) 0.90
Preoperative chemotherapy 17 (100) 41 (100) 1
Progression at last line 0 0 1
Concomitant extra-hepatic disease 6 (35.3%) 12 (29.3%) 0.65

15. Two stage vs ALPPS: operative data
Study group (n=58)
ALPPS
(n=17)
TSH (n=41) P value
Percentage of estimated FLR before first-stage (%) 24 (11-38) 30 (19-53) 0.056
Percentage of estimated FLR before 2nd-stage (%) 36 (26-49) 40 (25-55) 0.12
Portal vein embolization 17 38 0.14
First-stage
Radiofrequency ablation 1 6 0.32
Red blood cell transfusion 4 2 0.044
No. of treated tumours* 2 (0-7) 4 (1-18) 0.04
Interval chemotherapy (days) 0 35 <0.0001
Time interval between the stages (day) 12 (9-39) 103 (19-450) <0.0001
Second-stage
Radiofrequency ablation 0 1 0.31
Red blood cell transfusion 4 8 0.60
No. of treated nodules* 8 (1-25) 6 (2-15) 0.53

16. Two stage vs ALPPS: operative data
Study group (n=58)
ALPPS
(n=17)
TSH (n=41) P value
Percentage of estimated FLR before first-stage (%) 24 (11-38) 30 (19-53) 0.056
Portal vein embolization 17 38 0.14
First-stage
Radiofrequency ablation 1 6 0.32
Red blood cell transfusion 4 2 0.044
No. of treated tumours* 2 (0-7) 4 (1-18) 0.04
Interval chemotherapy (days) 0 35 <0.0001
Time interval between the stages (day) 12 (9-39) 103 (19-450) <0.0001
Second-stage
Radiofrequency ablation 0 1 0.31
Red blood cell transfusion 4 8 0.60
No. of treated nodules* 8 (1-25) 6 (2-15) 0.53
Total (completed)
No. of treated nodules* 9 (2-32) 8 (1-30) 0.36

17. ALPPS vs Two stage Hep: early outcome
ALPPS (N = 17) TSH (N = 41) P value
90-day mortality 0 (0) 1 (2.4) 0.91
Dindo-Clavien ≥ III 7 (41) 16 (39) 0.88

18. Overall Survival after ALPPS vs TSH
in ITT after hepatectomy

19. Overall Survival after ALPPS vs TSH
in ITT after the diagnosis of liver metastases

20. Overall Survival after Matching for ALPPS vs TSH
in ITT after the diagnosis of liver metastases

21. Patient Outcome after ALPPS procedure

22. Cohort updated to 24 pts:
Months
OSprobability
0 12 24 36 48
0.00.20.40.60.81.0
41 35 18 9 3 Two stage
24 13 3 ALPPS
P = 0.005
MS : 28.9 mo
MS : Not reached
Two stage
ALPPS

23. Conclusions
• Despite a higher feasibility (100% vs 63%)
• …the absence of 90 day-mortality and a
comparable morbidity
• Survival of ALPPS group was lower than TSH,
in intention to treat (42 vs 77 % at 2 years)
• DFS was similar with however a higher
proportion of liver recurrences (100 vs 53%) and
a lower use of repeat surgery .

24. Summary
The higher feasibility rate of ALPPS did not seem
to translate into a better oncological outcome
compared to two-stage hepatectomy.