Schadde Erik, Schnitzbauer Andreas A, Tschuor Christoph, Raptis Dimitri A, Bechstein Wolf O, Clavien Pierre-Alain
Department of Surgery, Swiss HPB and Transplant Center, University Hospital Zurich, Zurich, Switzerland.
Ann Surg Oncol. 2015 Sep;22(9):3109-20. doi: 10.1245/s10434-014-4213-5. Epub 2014 Dec 2.
Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a novel strategy to resect liver tumors despite the small size of the liver remnant. It is an hepatectomy in two stages, with PVL and parenchymal transection during the first stage, which induces rapid growth of the remnant liver exceeding any other technique. Despite high postoperative morbidity and mortality in most reports, the technique was adopted by a number of surgeons.
This systematic review explores current data regarding the feasibility, safety, and oncologic efficacy of ALPPS; the search strategy has been published online. A meta-analysis of hypertrophy, feasibility (ALPPS stage 2 performed), mortality, complications, and R0 (complete) resection was performed.
A literature search revealed a total of 13 publications that met the search criteria, reporting data from 295 patients. Evidence levels were low, with the highest Oxford evidence level being 2c. The most common indication was colorectal liver metastasis in 203 patients. Hypertrophy in the meta-analysis was 84 %, feasibility (ALPPS stage 2 performed) 97 % (CI 94-99 %), 90-day mortality 11 % (CI 8-16 %), and complications grade IIIa or higher occured in 44 % (CI 38-50 %) of patients. A standardized reporting format for complications is lacking despite the widespread use of the Clavien-Dindo classification. Oncological outcome is not well-documented. The most common topics in the selected studies published were technical feasibility and indications for the procedures. Publication bias due to case-series and single-center reports is common.
A systematic exploration of this novel operation with a rigid methodology, such as registry analyses and a randomized controlled trial, is highly advised.
联合肝脏分隔和门静脉结扎的分期肝切除术（ALPPS）是一种用于切除肝肿瘤的新策略，尽管剩余肝脏体积较小。这是一种分两阶段进行的肝切除术，第一阶段进行门静脉结扎和实质离断，可促使剩余肝脏快速生长，超过其他任何技术。尽管大多数报告显示术后发病率和死亡率较高，但该技术仍被许多外科医生采用。
本系统评价探讨了关于ALPPS可行性、安全性和肿瘤学疗效的现有数据；检索策略已在线发表。对肝脏肥大、可行性（完成ALPPS第二阶段手术）、死亡率、并发症和R0（根治性）切除进行了荟萃分析。
文献检索共发现13篇符合检索标准的出版物，报告了295例患者的数据。证据级别较低，最高牛津证据级别为2c。最常见的适应证是203例患者的结直肠癌肝转移。荟萃分析中肝脏肥大率为84%，可行性（完成ALPPS第二阶段手术）为97%（94%-99%可信区间），90天死亡率为11%（8%-16%可信区间），44%（38%-50%可信区间）的患者出现Ⅲa级或更高等级的并发症。尽管Clavien-Dindo分类法被广泛使用，但仍缺乏并发症的标准化报告格式。肿瘤学结局记录不完善。所选已发表研究中最常见的主题是手术的技术可行性和适应证。病例系列和单中心报告导致的发表偏倚很常见。
强烈建议采用严格的方法对这种新手术进行系统探索，如注册分析和随机对照试验。
