Virtual Journal Club - ALPPS

By Alison Shamwana | Started 1st Apr 2017

Since ALPPS was first described in 2012 there has been considerable interest from the HPB surgical community. There remains many unanswered questions, principle of which is the acceptability of the associated morbidity and mortality. Therefore it seems timely to present a journal club summarising the articles available in HPB.

The aim of the journal club is to:

  1. Understand the 50% mortality associated with its use in hilar cholangiocarcinoma.
  2. Understand that a laparoscopic approach to ALPPS is possible by technically skilled surgeons and early data suggests it may be associated with reduced morbidity
  3. Understand that a minimum future liver volume and kinetic growth rate are required if post-operative liver failure is to be avoided after stage 2 of the ALPPS procedure.
  4. Understand that the rapid adoption has led to considerable variability in indications, preoperative work up and surgical technique. Reflect on the apparent lack of understanding by some surgeons of the techniques available to optimise outcomes from portal vein embolisation and to understand if such factors may be contributing to the variable outcomes observed in the published literature.
  5. Understand a reliable animal model exists and should be increasingly used to answer both physiological and technical questions in an effort to improve patient outcomes.
  6. Understand the kinetic growth rate of the future liver remnant is proportional to the initial size of the future liver remnant.

 References:

  1. Pim B. Olthof, Robert J.S. Coelen, Jimme K. Wiggers, Bas Groot Koerkamp, Massimo Malago, Roberto Hernandez-Alejandro, Stefan A. Topp, Marco Vivarelli, Luca A. Aldrighetti, Ricardo Robles Campos, Karl J. Oldhafer, William R. Jarnagin & Thomas M. van Gulik.High mortality after ALPPS for perihilar cholangiocarcinoma: case-control analysis including the first series from the international ALPPS registry. HPB 2017 April. In press http://www.hpbonline.org/article/S1365-182X(16)31926-8/fulltext.
  2. Machado MA, Makdissi FF, Surjan RC, Basseres T, Schadde E. Transition from open to laparoscopic ALPPS for patients with very small FLR: the initial experience. HPB 2017;19(1):59-66.
  3. Kambakamba P, Stocker D, Reiner CS, Nguyen-Kim TD, Linecker M, Eshmuminov D, Petrowsky H, Clavien PA, Lesurtel M. Liver kinetic growth rate predicts postoperative liver failure after ALPPS. HPB 2016;18(10):800-805.
  4. Buac S, Schadde E, Schnitzbauer AA, Vogt K, Hernandez-Alejandro R. The many faces of ALPPS: surgical indications and techniques among surgeons collaborating in the international registry. HPB 2016;18(5):442-8.
  5. Day RW, Conrad C, Vauthey JN, Aloia TA. Evaluating surgeon attitudes towards the safety and efficacy of portal vein occlusion and associating liver partition and portal vein ligation: a report of the MALINSA survey. HPB 2015;17(10):936-41.
  6. Croome KP, Mao SA, Glorioso JM, Krishna M, Nyberg SL, Nagorney DM. Characterization of a porcine model for associating liver partition and portal vein ligation for a staged hepatectomy. HPB 2015;17(12):1130-6.
  7. Croome KP, Hernandez-Alejandro R, Parker M, Heimbach J, Rosen C, Nagorney DM. Is the liver kinetic growth rate in ALPPS unprecedented when compared with PVE and living donor liver transplant? A multicentre analysis. HPB 2015;17(6):477-84

Videos:

  1. Animated technical description of ALPPS:
    https://www.youtube.com/watch?v=VQuegI_wGhk
  2. Animated description using ablation to achieve the liver partition: https://www.youtube.com/watch?v=A9DPM09xVcw
  3. Laparoscopic ALPPS. Marcel A. Machado, MD, FACS:
    https://youtu.be/IueMk9nZA3Y
Comments (2)
  • saxon connor 5th Apr 2017

    Moderator

    (0)

    I think the authors of these recent publications be congratulated. They are highlighting that in patients where the "boundaries need to be pushed" very careful consdieration needs to be given to determine the optimal treatment plan.

    I would be interested in peoples comments on how they might institue safely an ALLPS programme into their institution with particular thought  to data monitoring.

  • O James Garden 5th Apr 2017

    (0)

    Good point, Saxon. It is good that there is a regiostry to inform us on outcomes for procedures such as this but I guess many would have a concern that adverse outcomes might not always reported to a voluntary register? 

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