Clinical Outcome and Future Liver Remnant Regenerative Response in Laparoscopic Versus Open ALPPS

Clinical Outcome and Future Liver Remnant Regenerative Response in Laparoscopic Versus Open ALPPS: A Randomized Clinical Trial

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a new surgical procedure that induces rapid liver regeneration in patients with small liver remnant planning for major liver resection. It is a two-staged operation with stage I including portal vein ligation and splitting the right liver away from the left liver. After stage I, the left liver will undergo rapid liver regeneration and the stage II operation can be performed at 7-10 days after stage I operation when the liver remnant reaches an adequate size. In stage II operation, the right liver that contains the tumor is then removed. This surgical procedure was incepted in Germany in 2013 and was later started in Queen Mary Hospital in Hong Kong for the first time in December 2015. The initial indication was mainly for colorectal liver metastasis but due to the relatively high incidence of hepatocellular carcinoma in Hong Kong, HBP surgery team of Queen Mary Hospital has transferred this procedure to be applied for hepatitis-related hepatocellular carcinoma and so far, the centre has cumulated one of the largest single-center experience in the literature. Nonetheless, the usual approach for ALPPS involved open surgery and induced substantial surgical stress to the patient, especially after stage I operation. With the advent of minimally invasive liver surgery in recent years, the team has successfully applied laparoscopic surgery to ALPPS in 2019. Despite the advancement in laparoscopic surgical skills that rendered laparoscopic ALPPS feasible, there is scarcity of data in the literature to evaluate its outcome in comparison with open ALPPS with regard to perioperative recovery and liver regeneration. Hence, the aim of this project is to evaluate the short-term clinical outcomes of laparoscopic ALPPS and the impact of laparoscopy on liver remnant regeneration after ALPPS in a prospective randomised clinical trial setting.

Study Overview

• Status: Recruiting
• Conditions: Liver Cancer
• Intervention / Treatment: Procedure: Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS)

Detailed Description

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been popularized as an alternative approach for FLR augmentation in recent years. The main indication at the early phase of development of this procedure was bilobar colorectal liver metastasis, or other non-primary liver tumors. Since 2015, HBP surgery team of Queen Mary Hospital has started to transfer this novel approach to treat patients with hepatitis-related hepatocellular carcinoma and small future liver remnant contemplating for major hepatectomy. Despite the initial global enthusiasm to embark on ALPPS, the procedure was criticized for its high postoperative morbidity and mortality rates. However, through the establishment of the international ALPPS registry and familiarization of the procedure, the outcome of ALPPS has been benchmarked and standardized with a mortality rate <4%. The initial experience of ALPPS for HCC was also reported. With cumulative experience, ALPPS has become a safe and effective treatment approach for surgical modulation of insufficient FLR when compared with the conventional approach in the form of portal vein embolization. Nonetheless, ALPPS is a two-stage procedure that commonly involved an open laparotomy. However, the postoperative pain control and speed of recovery after stage I ALPPS would be affected by the substantial surgical stress induced by laparotomy. On the other hand, the rapid development of laparoscopic surgery has rendered laparoscopic liver surgery a much more feasible and safer surgical approach in recent years. As such, minimally invasive approach becomes an attractive option for ALPPS, at least for stage I procedure. Data on the application of laparoscopic ALPPS remained scarce with only one study reported the short-term outcome in a series of 10 patients predominantly affected by colorectal liver metastasis.

Since the short-term postoperative safety profile and underlying intraoperative haemodynamic changes induced by ALPPS for hepatitis-related HCC under conventional open approach was ascertained by our recent study, it is considered that it is the right time to introduce laparoscopy for ALPPS and to compare its clinical outcome with open approach. To date, a total of 4 patients have received laparoscopic ALPPS in the centre.

Recent studies suggested that laparoscopic liver resection may be associated with reduced inflammatory and stress response as compared with open resection as indicated by a reduced expression of inflammatory cytokines such as interleukin-6, tumor necrosis factor. On the other hand, study on liver regeneration after open ALPPS showed an elevated gene expression of IL-6 and TNF as well as increased plasma levels within 24 hours after the procedure when compared with portal vein ligation. It remains uncertain if reduced level of cytokines or inflammatory markers induced by laparoscopy would affect the liver regeneration rate in ALPPS patients and its clinical outcome. Hence, there is a need to clarify this issue in the current project.

• Study Type: Interventional
• Enrollment (Estimated): 40
• Phase: Phase 3

Contacts and Locations

• Study Contact: Name: Albert Chan; Phone Number: +85222553025; Email: acchan@hku.hk
• Study Contact Backup: Name: Crystal Kwan; Phone Number: +85222556646; Email: cryskal@hku.hk

Study Locations

• Hong Kong
  • Hong Kong, Hong Kong
    • Recruiting
    • The University of Hong Kong
    • Contact: Albert Chan; Phone Number: +85222553025; Email: acchan@hku.hk
    • Principal Investigator: Albert Chan
    • Contact: Crystal Kwan; Phone Number: +85222556646; Email: cryskal@hku.hk

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

1. Patients with a diagnosis of malignant liver tumor contemplating for extended right hepatectomy or right trisectionectomy
2. Patient consent
3. Age >/= 18
4. FLR/ESLV </= 30%
5. Indocyanine green clearance rate at 15 mins : < 18%
6. Platelet count > 100x10^9/L
7. Child A cirrhosis (due to hepatitis B/C virus, or alcohol, or autoimmune disease)
8. American Society of Anaesthesiology score < 3
9. Eastern Cooperative Oncology Group (ECOG) performance status 0-2

Technical factors eligible for laparoscopic ALPPS

• single long-segment portal

Exclusion Criteria:

1. Absence of consent
2. Decompensated liver disease as indicated by the presence of ascites, varices and hepatic encephalopathy
3. ECOG performance status >/= 3
4. Main portal vein thrombosis
5. FLR/ESLV > 30%

Technical factors not eligible for laparoscopic ALPPS

• Short-segment right portal vein or early bifurcation of right anterior/posterior portal vein, or other portal vein anomalies
• Large tumor size with diameter > 5 cm
• Intolerance to CO2 pneumoperitoneum

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Factorial Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Laparoscopic ALPPS; Laparoscopic ALPPS procedure	Procedure: Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS); Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a surgical procedure that induces rapid liver regeneration in patients with small liver remnant planning for major liver resection. It is a two-staged operation with stage I including portal vein ligation and splitting the right liver away from the left liver. After stage I, the left liver will undergo rapid liver regeneration and the stage II operation can be performed at 7-10 days after stage I operation when the liver remnant reaches an adequate size. In stage II operation, the right liver that contains the tumor is then removed.; Other Names: ALPPS
Active Comparator: Open ALPPS; Open ALPPS procedure	Procedure: Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS); Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a surgical procedure that induces rapid liver regeneration in patients with small liver remnant planning for major liver resection. It is a two-staged operation with stage I including portal vein ligation and splitting the right liver away from the left liver. After stage I, the left liver will undergo rapid liver regeneration and the stage II operation can be performed at 7-10 days after stage I operation when the liver remnant reaches an adequate size. In stage II operation, the right liver that contains the tumor is then removed.; Other Names: ALPPS

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Amount of future liver remnant volume increment by percentage after stage I ALPPS	Amount of future liver remnant volume increment by percentage after stage I ALPPS	During hospital stay after stage I ALPPS, an average of 1-2 weeks

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Preoperative blood loss during stage 1 ALPPS	Preoperative blood loss during stage 1 ALPPS	During hospital stay after stage I ALPPS, an average of 1-2 weeks
Length of hospital stay after stage 1 ALPPS	Length of hospital stay after stage 1 ALPPS	During hospital stay after stage I ALPPS, an average of 1-2 weeks
Overall morbidity in number and mortality rates in percentage after stage 1 ALPPS	Overall morbidity and mortality rates after stage 1 ALPPS	During hospital stay after stage I ALPPS, an average of 1-2 weeks
Inflammatory markers associated with inflammation and regeneration after stage 1 ALPPS	Inflammatory markers e.g. IL-6 (pg/ml), IL-8 (pg/ml) and TNF-alpha (pg/ml) associated with inflammation and regeneration after stage 1 ALPPS	During hospital stay after stage I ALPPS, an average of 1-2 weeks

Collaborators and Investigators

• Sponsor: The University of Hong Kong
• Investigators: Principal Investigator: Albert Chan, The University of Hong Kong

Publications and helpful links

General Publications

• Lang H, de Santibanes E, Schlitt HJ, Malago M, van Gulik T, Machado MA, Jovine E, Heinrich S, Ettorre GM, Chan A, Hernandez-Alejandro R, Robles Campos R, Sandstrom P, Linecker M, Clavien PA. 10th Anniversary of ALPPS-Lessons Learned and quo Vadis. Ann Surg. 2019 Jan;269(1):114-119. doi: 10.1097/SLA.0000000000002797.
• Schnitzbauer AA, Lang SA, Goessmann H, Nadalin S, Baumgart J, Farkas SA, Fichtner-Feigl S, Lorf T, Goralcyk A, Horbelt R, Kroemer A, Loss M, Rummele P, Scherer MN, Padberg W, Konigsrainer A, Lang H, Obed A, Schlitt HJ. Right portal vein ligation combined with in situ splitting induces rapid left lateral liver lobe hypertrophy enabling 2-staged extended right hepatic resection in small-for-size settings. Ann Surg. 2012 Mar;255(3):405-14. doi: 10.1097/SLA.0b013e31824856f5.
• Schadde E, Ardiles V, Robles-Campos R, Malago M, Machado M, Hernandez-Alejandro R, Soubrane O, Schnitzbauer AA, Raptis D, Tschuor C, Petrowsky H, De Santibanes E, Clavien PA; ALPPS Registry Group. Early survival and safety of ALPPS: first report of the International ALPPS Registry. Ann Surg. 2014 Nov;260(5):829-36; discussion 836-8. doi: 10.1097/SLA.0000000000000947.
• Linecker M, Bjornsson B, Stavrou GA, Oldhafer KJ, Lurje G, Neumann U, Adam R, Pruvot FR, Topp SA, Li J, Capobianco I, Nadalin S, Machado MA, Voskanyan S, Balci D, Hernandez-Alejandro R, Alvarez FA, De Santibanes E, Robles-Campos R, Malago M, de Oliveira ML, Lesurtel M, Clavien PA, Petrowsky H. Risk Adjustment in ALPPS Is Associated With a Dramatic Decrease in Early Mortality and Morbidity. Ann Surg. 2017 Nov;266(5):779-786. doi: 10.1097/SLA.0000000000002446.
• Chan AC, Pang R, Poon RT. Simplifying the ALPPS procedure by the anterior approach. Ann Surg. 2014 Aug;260(2):e3. doi: 10.1097/SLA.0000000000000736. No abstract available.
• Chan AC, Poon RT, Chan C, Lo CM. Safety of ALPPS Procedure by the Anterior Approach for Hepatocellular Carcinoma. Ann Surg. 2016 Feb;263(2):e14-6. doi: 10.1097/SLA.0000000000001272. No abstract available.
• Raptis DA, Linecker M, Kambakamba P, Tschuor C, Muller PC, Hadjittofi C, Stavrou GA, Fard-Aghaie MH, Tun-Abraham M, Ardiles V, Malago M, Campos RR, Oldhafer KJ, Hernandez-Alejandro R, de Santibanes E, Machado MA, Petrowsky H, Clavien PA. Defining Benchmark Outcomes for ALPPS. Ann Surg. 2019 Nov;270(5):835-841. doi: 10.1097/SLA.0000000000003539.
• Chan A, Zhang WY, Chok K, Dai J, Ji R, Kwan C, Man N, Poon R, Lo CM. ALPPS Versus Portal Vein Embolization for Hepatitis-related Hepatocellular Carcinoma: A Changing Paradigm in Modulation of Future Liver Remnant Before Major Hepatectomy. Ann Surg. 2021 May 1;273(5):957-965. doi: 10.1097/SLA.0000000000003433.
• Machado MA, Makdissi FF, Surjan RC, Basseres T, Schadde E. Transition from open to laparoscopic ALPPS for patients with very small FLR: the initial experience. HPB (Oxford). 2017 Jan;19(1):59-66. doi: 10.1016/j.hpb.2016.10.004. Epub 2016 Nov 2.
• Burpee SE, Kurian M, Murakame Y, Benevides S, Gagner M. The metabolic and immune response to laparoscopic versus open liver resection. Surg Endosc. 2002 Jun;16(6):899-904. doi: 10.1007/s00464-001-8122-x. Epub 2002 Feb 27.
• Schlegel A, Lesurtel M, Melloul E, Limani P, Tschuor C, Graf R, Humar B, Clavien PA. ALPPS: from human to mice highlighting accelerated and novel mechanisms of liver regeneration. Ann Surg. 2014 Nov;260(5):839-46; discussion 846-7. doi: 10.1097/SLA.0000000000000949.

Study record dates

Study Major Dates

• Study Start (Actual): September 2, 2020
• Primary Completion (Actual): December 31, 2023
• Study Completion (Estimated): December 31, 2027

Study Registration Dates

• First Submitted: December 28, 2020
• First Submitted That Met QC Criteria: April 27, 2021
• First Posted (Actual): April 30, 2021

Study Record Updates

• Last Update Posted (Actual): August 15, 2024
• Last Update Submitted That Met QC Criteria: August 13, 2024
• Last Verified: August 1, 2024

More Information

Terms related to this study

• Keywords: Laparoscopic surgery; Hepatocellular carcinoma; Liver cancer; ALPPS; Minimal invasive; Small future liver remnant; Liver metastasis
• Additional Relevant MeSH Terms: Digestive System Diseases; Neoplasms; Neoplasms by Site; Digestive System Neoplasms; Liver Diseases; Liver Neoplasms
• Other Study ID Numbers: UW20-599

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No