Annals of Surgical Oncology

, Volume 22, Issue 9, pp 3109–3120 | Cite as

Systematic Review and Meta-Analysis of Feasibility, Safety, and Efficacy of a Novel Procedure: Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy

  • Erik Schadde
  • Andreas A. Schnitzbauer
  • Christoph Tschuor
  • Dimitri A. Raptis
  • Wolf O. Bechstein
  • Pierre-Alain Clavien
Hepatobiliary Tumors



Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a novel strategy to resect liver tumors despite the small size of the liver remnant. It is an hepatectomy in two stages, with PVL and parenchymal transection during the first stage, which induces rapid growth of the remnant liver exceeding any other technique. Despite high postoperative morbidity and mortality in most reports, the technique was adopted by a number of surgeons.

Materials and Methods

This systematic review explores current data regarding the feasibility, safety, and oncologic efficacy of ALPPS; the search strategy has been published online. A meta-analysis of hypertrophy, feasibility (ALPPS stage 2 performed), mortality, complications, and R0 (complete) resection was performed.


A literature search revealed a total of 13 publications that met the search criteria, reporting data from 295 patients. Evidence levels were low, with the highest Oxford evidence level being 2c. The most common indication was colorectal liver metastasis in 203 patients. Hypertrophy in the meta-analysis was 84 %, feasibility (ALPPS stage 2 performed) 97 % (CI 94–99 %), 90-day mortality 11 % (CI 8–16 %), and complications grade IIIa or higher occured in 44 % (CI 38–50 %) of patients. A standardized reporting format for complications is lacking despite the widespread use of the Clavien–Dindo classification. Oncological outcome is not well-documented. The most common topics in the selected studies published were technical feasibility and indications for the procedures. Publication bias due to case-series and single-center reports is common.


A systematic exploration of this novel operation with a rigid methodology, such as registry analyses and a randomized controlled trial, is highly advised.


Colorectal Liver Metastasis Portal Vein Embolization Future Liver Remnant Evidence Level Parenchymal Transection 
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.



The authors thank Martina Gosteli, PhD, from the University of Zurich Library, for her help with the literature search strategies for this systematic review.

Financial Support

This study was supported in part by a grant to Erik Schadde for Protected Research Time from the Medical Faculty of the University of Zurich, Switzerland. The literature search was supported by a grant to Pierre A. Clavien from the University of Zurich, Switzerland (Klinischer Forschungsschwerpunkt: “Non-Resectable Liver Tumors: From Palliation to Cure”).


Erik Schadde, Andreas A. Schnitzbauer, Christoph Tschuor, Dimitri Raptis, Wolf O. Bechstein, and Pierre A. Clavien have no conflicts of interest to disclose, and further disclose any commercial interest that they may have in the subject of study and the source of any financial or material support.


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Copyright information

© Society of Surgical Oncology 2014

Authors and Affiliations

  • Erik Schadde
    • 1
  • Andreas A. Schnitzbauer
    • 2
  • Christoph Tschuor
    • 1
  • Dimitri A. Raptis
    • 1
  • Wolf O. Bechstein
    • 2
  • Pierre-Alain Clavien
    • 1
  1. 1.Department of SurgerySwiss HPB and Transplant Center, University Hospital ZurichZurichSwitzerland
  2. 2.Department of General and Visceral Surgery, Frankfurt University HospitalsGoethe-University Frankfurt/MainFrankfurt/MainGermany

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