• Michael Linecker, Bergthor Björnsson, Gregor A Stavrou, Karl J Oldhafer, Georg Lurje, Ulf Neumann, René Adam, Francois-René Pruvot, Stefan A Topp, Jun Li, Ivan Capobianco, Silvio Nadalin, Marcel Autran Machado, Sergey Voskanyan, Deniz Balci, Roberto Hernandez-Alejandro, Fernando A Alvarez, Eduardo De Santibañes, Ricardo Robles-Campos, Massimo Malagó, Michelle L de Oliveira, Mickael Lesurtel, Pierre-Alain Clavien, and Henrik Petrowsky.
• *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 1; 266 (5): 779-786.

ObjectiveTo 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.BackgroundALPPS 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.MethodsALPPS 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.ResultsAmong 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.ConclusionsRisk 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.

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