Associated Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) for Cholangiocarcinoma: a single center experience

Abstract

Extended liver surgery is the only option to achieve long-term survival in patients with cholangiocarcinoma (CCA) in advanced stage, at the cost of Post-Hepatectomy Liver Failure (PHLF) and mortality. Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) is a new two-stage augmentation technique that induces unprecedented hypertrophy of the Future Liver Remnant in the shortest possible time, promising to reduce PHLF and interstage dropout in one fell swoop. We retrospectively reviewed our single center experience in patients with phCCA and iCCA undergoing ALPPS for right trisectionectomy. This study includes 21 patients with CCA (10 perihilar CCA (phCCA) and 11 intrahepatic CCA (iCCA)) at University Hospital Tübingen between November 2010 and November 2019. No dropout was observed between the two Stages, however the rate of PHLF after completion of the procedure was 40% in phCCA and 36% in iCCA. The overall mortality was 20% for phCCA and 18% for iCCA, but no deceases were recorded in the last 5 years. The median overall survival for phCCA and iCCA was 36.8 and 36.4 months, respectively. We have shown how impaired liver quality, particularly fibrosis, can slow down hypertrophy and the functional recovery of the liver, increasing the risk of PHLF. Proper perioperative management can address morbidity and consequently reduce the mortality even in extended resection. The long-term oncological results obtained are very promising and game-changing for a type of patient who is currently condemned to a very short life expectancy. As a conclusion ALPPS in CCA is an important card to play in selected patients with advanced cancer stages and no other treatment options.