• Dimitri A Raptis, Michael Linecker, Patryk Kambakamba, Christoph Tschuor, Philip C Müller, Christopher Hadjittofi, Gregor A Stavrou, Mohammad H Fard-Aghaie, Mauro Tun-Abraham, Victoria Ardiles, Massimo Malagó, Ricardo Robles Campos, Karl J Oldhafer, Roberto Hernandez-Alejandro, Eduardo de Santibañes, Marcel Autran Machado, Henrik Petrowsky, and Pierre-Alain Clavien.
• Swiss HPB and Transplant Center Zurich, Department of Surgery and Transplantation, University Hospital Zurich, Switzerland.
• Ann. Surg. 2019 Nov 1; 270 (5): 835-841.

ObjectiveThe aim of this study was to use the concept of benchmarking to establish robust and standardized outcome references after the procedure ALPPS (Associating Liver Partition and Portal Vein Ligation for Staged hepatectomy).Background And AimsThe recently developed ALPPS procedure, aiming at removing primarily unresectable liver tumors, has been criticized for safety issues with high variations in the reported morbidity/mortality rates depending on patient, disease, technical characteristics, and center experience. No reference values for relevant outcome parameters are available.MethodsAmong 1036 patients registered in the international ALPPS registry, 120 (12%) were benchmark cases fulfilling 4 criteria: patients ≤67 years of age, with colorectal metastases, without simultaneous abdominal procedures, and centers having performed ≥30 cases. Benchmark values, defined as the 75th percentile of the median outcome parameters of the centers, were established for 10 clinically relevant domains.ResultsThe benchmark values were completion of stage 2: ≥96%, postoperative liver failure (ISGLS-criteria) after stage 2: ≤5%, ICU stay after ALPPS stages 1 and 2: ≤1 and ≤2 days, respectively, interstage interval: ≤16 days, hospital stay after ALPPS stage 2: ≤10 days, rates of overall morbidity in combining both stage 1 and 2: ≤65% and for major complications (grade ≥3a): ≤38%, 90-day comprehensive complication index was ≤22, the 30-, 90-day, and 6-month mortality was ≤4%, ≤5%, and 6%, respectively, the overall 1-year, recurrence-free, liver-tumor-free, and extrahepatic disease-free survival was ≥86%, ≥50%, ≥57%, and ≥65%, respectively.ConclusionsThis benchmark analysis sets key reference values for ALPPS, indicating similar outcome as other types of major hepatectomies. Benchmark cutoffs offer valid tools not only for comparisons with other procedures, but also to assess higher risk groups of patients or different indications than colorectal metastases.

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