Associating liver partition and portal vein ligation for staged hepatectomy in patients with primary liver malignancies: A systematic review of the literature.

Purpose: Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) represents a revolutionary new surgical technique and one of the most promising advances in liver surgery over the last decade, which provides rapid and effective growth of liver remnant volume, allowing surgical resection of hepatic lesions initially considered unresectable. The aim of this review was to address from a critical point of view, the impact of this novel procedure conducted for primary liver malignancies, on tumor biology itself and thus on short and long-term outcomes, as disease free survival and overall survival.

Methods: The present study was designed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Identification of eligible studies was performed through a systematic search of the literature using Medline/PubMed, Scopus, Cochrane, Google Scholar, and clinicaltrials.gov databases. The end date of the literature search was set to 30th November 2018. The following keywords were used for the search: "Associating Liver Partition and Portal Vein Ligation for Staged hepatectomy", "ALPPS", "Portal Vein Embolization (PVE) And In Situ Split", "Portal Vein Ligation (PVL) And In Situ Split".

Results: The 28 studies enrolled in the present analysis incorporated 136 patients who were subjected to ALPPS due to primary liver malignancy. R0 resection status has been documented in 20 studies estimated to be 97.24%. 30-day mortality was 9.55%. Concerning 30-day morbidity graded according to Clavien-Dindo classification, interestingly 7 studies stated no postoperative complications, neither minor (I-II) nor major (III-V). As for the oncological outcomes, median follow up was 10 months (range 0-36), recurrence rate was 36%, disease free survival ranged from 1 to 36 months with a median of 6 months and overall survival ranged from 1 to 36 months with a median of 11 months.

Conclusions: ALPPS offers a reasonable chance of complete resection in patients with unresectable primary liver tumors. Optimal selection of patients, gaining the surgical experience of carrying out this technique and its impact on short and long-term results are issues that still remain under debate while waiting for the final outcomes of the multicenter registries with larger number of cases.