*Swiss HPB and Transplantation Center, Department of Surgery, University Hospital Zurich, Zurich, Switzerland †Department of Surgery, Linköping University, Linköping, Sweden ‡Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden §Department of General and Abdominal Surgery, Asklepios Hospital Barmbek, Hamburg, Germany ¶Semmelweis University Budapest, Campus Hamburg, Germany ||Department of General, Visceral and Transplantation Surgery, University Hospital Aachen, RWTH Aachen, Aachen, Germany **Centre Hépato-Biliaire, Hôpital Paul Brousse, Villejuif, France ††Department of Digestive Surgery and Transplantation, University Hospital, Lille, France ‡‡Department of Surgery, University Hospital Düsseldorf, Düsseldorf, Germany §§Department of Hepatobiliary Surgery and Transplantation University Medical Center Hamburg-Eppendorf Hamburg, Hamburg, Germany ¶¶Department of General, Visceral, and Transplant Surgery, University Hospital Tübingen, Tübingen, Germany ||||Department of Surgery, University of São Paulo, São Paulo, Brazil ***Department of Surgery, A.I. Burnazyan FMBC Russian State Scientific Center of FMBA, Moscow, Russia †††Department of Surgery, Ankara University, Ankara, Turkey ‡‡‡Division of HPB Surgery and Liver Transplantation, Department of Surgery, London Health Sciences Centre, London, Ontario, Canada §§§Liver Transplant Unit, Division of HPB Surgery, Department of Surgery, Italian Hospital Buenos Aires, Buenos Aires, Argentina ¶¶¶Department of Surgery and Liver and Pancreas Transplantation, Virgen de la Arrixaca Clinic and University Hospital, Murcia, Spain ||||||Department of HPB- and Liver Transplantation Surgery, University College London, Royal Free Hospitals, London, UK ****Division of Transplantation, Hepatobiliary Surgery, University of Rochester, Rochester, USA.
Ann Surg. 2017 Nov;266(5):779-786. doi: 10.1097/SLA.0000000000002446.
To longitudinally assess whether risk adjustment in Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) occurred over time and is associated with postoperative outcome.
ALPPS is a novel 2-stage hepatectomy enabling resection of extensive hepatic tumors. ALPPS has been criticized for its high mortality, which is reported beyond accepted standards in liver surgery. Therefore, adjustments in patient selection and technique have been performed but have not yet been studied over time in relation to outcome.
ALPPS centers of the International ALPPS Registry having performed ≥10 cases over a period of ≥3 years were assessed for 90-day mortality and major interstage complications (≥3b) of the longitudinal study period from 2009 to 2015. The predicted prestage 1 and 2 mortality risks were calculated for each patient. In addition, questionnaires were sent to all centers exploring center-specific risk adjustment strategies.
Among 437 patients from 16 centers, a shift in indications toward colorectal liver metastases from 53% to 77% and a reverse trend in biliary tumors from 24% to 9% were observed. Over time, 90-day mortality decreased from initially 17% to 4% in 2015 (P = 0.002). Similarly, major interstage complications decreased from 10% to 3% (P = 0.011). The reduction of 90-day mortality was independently associated with a risk adjustment in patient selection (P < 0.001; OR: 1.62; 95% CI: 1.36-1.93) and using less invasive techniques in stage-1 surgery (P = 0.019; OR: 0.39; 95% CI: 0.18-0.86). A survey indicated risk adjustment of patient selection in all centers and ALPPS technique in the majority (80%) of centers.
Risk adjustment of patient selection and technique in ALPPS resulted in a continuous drop of early mortality and major postoperative morbidity, which has meanwhile reached standard outcome measures accepted for major liver surgery.
纵向评估在联合肝脏离断和门静脉结扎的逐步肝切除术（ALPPS）中，风险调整是否随着时间的推移而发生变化，以及与术后结果是否相关。
ALPPS 是一种新的两阶段肝切除术，可切除广泛的肝肿瘤。ALPPS 的死亡率很高，据报道超出了肝脏手术的可接受标准，因此对患者选择和技术进行了调整，但尚未在时间上针对结果进行研究。
对在 2009 年至 2015 年的纵向研究期间，国际 ALPPS 注册中心中至少进行了 10 例手术且持续时间至少为 3 年的 ALPPS 中心进行了 90 天死亡率和主要中间期并发症（≥3b）评估。为每个患者计算了术前 1 期和 2 期的预测死亡率风险。此外，还向所有中心发送了调查问卷，以探讨中心特定的风险调整策略。
在来自 16 个中心的 437 名患者中，观察到结直肠肝转移的适应证从 53%转变为 77%，胆道肿瘤的适应证从 24%转变为 9%。随着时间的推移，90 天死亡率从最初的 17%下降到 2015 年的 4%（P = 0.002）。同样，主要中间期并发症从 10%下降到 3%（P = 0.011）。90 天死亡率的降低与患者选择的风险调整（P < 0.001；OR：1.62；95%CI：1.36-1.93）和第一阶段手术中使用微创技术（P = 0.019；OR：0.39；95%CI：0.18-0.86）独立相关。一项调查显示，所有中心都进行了患者选择的风险调整，大多数（80%）中心都进行了 ALPPS 技术的风险调整。
在 ALPPS 中，患者选择和技术的风险调整导致早期死亡率和主要术后发病率持续下降，同时达到了接受的主要肝脏手术的标准结果测量。
