Risk Adjustment in ALPPS Is Associated With a Dramatic Decrease in Early Mortality and Morbidity

被引：130

作者：

Linecker, Michael ^{[1
]}

Bjoernsson, Bergthor ^{[2
,3
]}

Stavrou, Gregor A. ^{[4
,5
]}

Oldhafer, Karl J. ^{[4
,5
]}

Lurje, Georg ^{[6
]}

Neumann, Ulf ^{[6
]}

Adam, Rene ^{[7
]}

Pruvot, Francois-Rene ^{[8
]}

Topp, Stefan A. ^{[9
]}

Li, Jun ^{[10
]}

Capobianco, Ivan ^{[11
]}

Nadalin, Silvio ^{[11
]}

Machado, Marcel Autran ^{[12
]}

Voskanyan, Sergey ^{[13
]}

Balci, Deniz ^{[14
]}

Hernandez-Alejandro, Roberto ^{[15
,20
]}

Alvarez, Fernando A. ^{[16
]}

De Santibanes, Eduardo ^{[16
]}

Robles-Campos, Ricardo ^{[17
,18
]}

Malago, Massimo ^{[19
]}

de Oliveira, Michelle L. ^{[1
]}

Lesurtel, Mickael ^{[1
]}

Clavien, Pierre-Alain ^{[1
]}

Petrowsky, Henrik ^{[1
]}

机构：

[1] Univ Hosp Zurich, Dept Surg, Swiss HPB & Transplantat Ctr, Zurich, Switzerland

[2] Linkoping Univ, Dept Surg, Linkoping, Sweden

[3] Linkoping Univ, Dept Clin & Expt Med, Linkoping, Sweden

[4] Asklepios Hosp Barmbek, Dept Gen & Abdominal Surg, Hamburg, Germany

[5] Semmelweis Univ Budapest, Campus Hamburg, Hamburg, Germany

[6] Univ Hosp Aachen, Dept Gen Visceral & Transplantat Surg, RWTH Aachen, Aachen, Germany

[7] Hop Paul Brousse, Ctr Hepato Biliaire, Villejuif, France

[8] Univ Hosp, Dept Digest Surg & Transplantat, Lille, France

[9] Univ Hosp Dusseldorf, Dept Surg, Dusseldorf, Germany

[10] Univ Med Ctr Hamburg Eppendorf, Dept Hepatobiliary Surg & Transplantat, Hamburg, Germany

[11] Univ Tubingen Hosp, Dept Gen Visceral & Transplant Surg, Tubingen, Germany

[12] Univ Sao Paulo, Dept Surg, Sao Paulo, Brazil

[13] FMBA, Dept Surg, AI Burnazyan FMBC Russian State Sci Ctr, Moscow, Russia

[14] Ankara Univ, Dept Surg, Ankara, Turkey

[15] London Hlth Sci Ctr, Dept Surg, Div HPB Surg & Liver Transplantat, London, ON, Canada

[16] Italian Hosp Buenos Aires, Div HPB Surg, Dept Surg, Liver Transplant Unit, Buenos Aires, DF, Argentina

[17] Virgen Arrixaca Clin, Dept Surg & Liver & Pancreas Transplantat, Murcia, Spain

[18] Univ Hosp, Murcia, Spain

[19] UCL, Royal Free Hosp, Dept HPB & Liver Transplantat Surg, London, England

[20] Univ Rochester, Div Transplantat Hepatobiliary Surg, Rochester, NY 14627 USA

来源：

ANNALS OF SURGERY | 2017年 / 266卷 / 05期

关键词：

ALPPS; colorectal liver metastases; less invasive ALPPS variants; outcome; risk adjustment; two-stage hepatectomy; PORTAL-VEIN LIGATION; STAGED HEPATECTOMY ALPPS; LIVER PARTITION; 2-STAGE HEPATECTOMY; COMPLETE RESECTION; IMPACT; SAFETY; EMBOLIZATION; HYPERTROPHY; MULTIPLE;

D O I：

10.1097/SLA.0000000000002446

中图分类号：

R61 [外科手术学];

学科分类号：

摘要：

Objective: 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. Background: 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. Methods: 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. Results: 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. Conclusions: 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.

引用

页码：779 / 786

页数：8

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