Journal of Gastrointestinal Surgery

, Volume 23, Issue 12, pp 2391–2400 | Cite as

Two-Stage Hepatectomy and ALPPS for Advanced Bilateral Liver Metastases: a Tailored Approach Balancing Risk and Outcome

  • Janine Baumgart
  • Florian Jungmann
  • Fabian Bartsch
  • Michael Kloth
  • Jens Mittler
  • Stefan HeinrichEmail author
  • Hauke Lang
Original Article


Background and Aim

Two-stage hepatectomy (TSH) with or without portal vein ligation (PVL) or portal vein embolization (PVE) and associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) are surgical strategies in the treatment of advanced colorectal liver metastases (CRLM). The role of each strategy is yet ill defined. The aim of this analysis is to share our center experience with conventional TSH with or without PVL/PVE and ALPPS in patients with advanced bilateral CRLM.

Patients and Methods

Data were extracted from a prospectively collected institutional database. Complication rates according to the Dindo-Clavien classification, overall and recurrence-free survival data were analyzed.


Between 2008 and 2017, 790 liver resections were performed in 611 patients with CRLM. Out of 320 patients with bilateral disease, TSH (as right or extended right hepatectomy) with or without PVL/PVE was performed in 50 patients and ALPPS in 8. Stage 2 was completed in 36 (72%) out of 50 TSH/PVL/PVE and in all ALPPS patients (100%). Median follow-up was 15.8 months (0.9 to 111.9 months). On an intention-to-treat basis, the median overall survival was 26.7 (21.8–35.1 range) months after TSH/PVL/PVE and 36.2 months (11.3–61.2 range) after ALPPS (p = 0.809). In the TSH/PVL/PVE cohort, the median overall survival was 29.9 (19.0–40.3) months in patients who completed stage 2 compared to 13.8 months in patients who did not (p < 0.001). Disease recurred in 60% in the TSH/PVL/PVE cohort and in 87.5% in the ALPPS cohort (p = 0.777). The median recurrence-free survival was 5.9 (1.7–18.6) months after TSH/PVL/PVE and 3 (1.6–14.8) months after ALPPS (p = 0.680).


The treatment of advanced bilateral CRLM remains a surgical and oncological challenge. A tailored approach to bilateral CRLM uses TSH/PVL/PVE as first and ALPPS as second rescue treatment in order to achieve resectability in patients with extensive tumor burden not amenable to one-stage resection. ALPPS should be reserved for patients with no other surgical options.


Liver surgery Surgical management of bilateral colorectal liver metastases Two-stage hepatectomy Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) 



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Copyright information

© The Society for Surgery of the Alimentary Tract 2019

Authors and Affiliations

  1. 1.Department of General, Visceral and Transplantation Surgery, University Medical Center MainzJohannes Gutenberg UniversityMainzGermany
  2. 2.Department of Diagnostic and Interventional Radiology, University Medical Center MainzJohannes Gutenberg UniversityMainzGermany
  3. 3.Department of Pathology, University Medical Center MainzJohannes Gutenberg UniversityMainzGermany

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