Annals of Surgical Oncology

, Volume 22, Issue 6, pp 1933–1942 | Cite as

Strategies to Increase the Resectability of Patients with Colorectal Liver Metastases: A Multi-center Case-Match Analysis of ALPPS and Conventional Two-Stage Hepatectomy

  • Francesca Ratti
  • Erik Schadde
  • Michele Masetti
  • Marco Massani
  • Matteo Zanello
  • Matteo Serenari
  • Federica Cipriani
  • Luca Bonariol
  • Nicolò Bassi
  • Luca Aldrighetti
  • Elio Jovine
Hepatobiliary Tumors



Two-stage hepatectomy (TSH) is well established for the treatment of patients who have colorectal cancer liver metastases (CRLM) with a small liver remnant. The technique of associating liver partitioning and portal vein occlusion for staged hepatectomy (ALPPS) has been advocated as a novel tool to increase resectability. Using a case-match design, this study aimed to compare TSH and ALPPS for patients with CRLM.


All patients undergoing ALPPS for CRLM at three major hepatobiliary centers in Italy (ALPPS group) were compared in a case-match analysis with patients undergoing TSH (TSH group) at a single institution. The groups were matched with a 1:3 ratio using propensity scores based on covariates representing severity of metastatic disease. The main end points of the study were feasibility of complete resection and intra- and postoperative outcomes.


The two treatments did not differ significantly in feasibility. Two patients in the TSH group dropped out compared with no patients in the ALPPS group. A comparable volume gain in future liver remnant (FLR) was obtained in the ALPPS and TSH groups (47 vs. 41 %, nonsignificant difference) but during a shorter interval in ALPPS group. The overall and major complication rate was significantly higher after stage 2 in the ALPPS group (Clavien ≥ 3a: 41.7 vs. 17.6 % in TSH group; p = 0.025).


The feasibility of resection using ALPPS compared with TSH for CRLM was not significantly greater, but perioperative complications were increased. Therefore, ALPPS should be proposed to patients with caution and warnings. Currently, TSH remains the standard approach for performing R0 resection in patients with advanced CRLM and inadequate FLR.


Propensity Score Colorectal Liver Metastasis Portal Vein Embolization Future Liver Remnant Middle Hepatic Vein 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



There are no conflicts of interest to disclose.


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Copyright information

© Society of Surgical Oncology 2014

Authors and Affiliations

  • Francesca Ratti
    • 1
  • Erik Schadde
    • 2
  • Michele Masetti
    • 3
  • Marco Massani
    • 4
  • Matteo Zanello
    • 3
  • Matteo Serenari
    • 3
  • Federica Cipriani
    • 1
  • Luca Bonariol
    • 4
  • Nicolò Bassi
    • 4
  • Luca Aldrighetti
    • 1
  • Elio Jovine
    • 3
  1. 1.Hepatopancreatobiliary Surgery UnitIRCCS San Raffaele HospitalMilanItaly
  2. 2.Department of Surgery, Kantonspital Winterthur and Institute of PhysiologyUniversity of ZurichZurichSwitzerland
  3. 3.General Surgery UnitMaggiore HospitalBolognaItaly
  4. 4.Hepatopancreatobiliary Surgery UnitOspedale S. Maria di Cà FoncelloTrevisoItaly

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