Comparison of feasibility, safety and oncological efficacy of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) with conventional two-stage hepatectomy (TSH): a systemic review and meta-analysis

The clinical application of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is controversial. Thus, we conducted a systemic review and meta-analysis of studies comparing ALPPS to conventional two-stage hepatectomy (TSH). This review aims at summarizing and assessing studies on this topic, and using meta-analysis to provide data support regarding the feasibility, safety and oncological efficacy of ALPPS by comparing with conventional TSH. Articles comparing ALPPS with TSH were identified by searching Medline, Embase and Cochrane library, using pre-specified criteria. Newcastle-Ottawa scale was used for quality evaluation. Chi's test was used for heterogeneity exploration among eligible studies. Random and fixed effect models were used to synthesize the outcomes regarding feasibility, safety and oncological efficacy. A total of 6 studies were eligible for systemic review and meta-analysis, involving 502 patients (118 in ALPPS group, 384 in TSH group). Patients underwent ALPPS experienced more overall morbidities and major morbidities (Clavien-Dindo >= IIIa) than patients received TSH did (58% vs. 42.8%, P = 0.04; and 23.4% vs. 15.3%, P = 0.002). R0/R1 resection rates were 86.4% and 71.5% in ALPPS and TSH groups, respectively (P = 0.014). One study reported similar 1-year recurrence free survival (RFS) in both groups. While another study including only patients with colorectal liver metastases observed similar 1-year overall survival in both groups, but higher 1-year RFS in TSH group. Our systemic review suggests that ALPPS induces faster future liver remnant (FLR) hypertrophy, larger FLR increase, and achieves higher completion rate of major hepatectomy than TSH does. Even though mortality rate is similar in these two surgical techniques, overall and major complication rates are higher in ALPPS group. The initial oncological efficacy of ALPPS seems to be encouraging. Yet, R0 status should be paid more attention to in future studies. Controlled trials with extreme caution and carefully selected patients are needed to further assess the advantages and disadvantages of ALPPS.