Objective:The objective of this study was to evaluate the long-term oncological outcomes of patients with colorectal liver metastasis (CRLM) randomized for associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) or 2-stage hepatectomy (TSH). Introduction:For advanced CRLM, TSH or ALPPS may be needed for tumor freedom. The randomized, controlled, multicenter trial LIGRO showed an increased resection rate in patients who underwent ALPPS but no difference in morbidity or mortality. The 2-year survival analysis revealed better overall survival in the ALPPS group. Here, the long-term survival analysis from the LIGRO trial is reported. Methods:In the LIGRO trial, 100 patients were randomized to TSH or ALPPS, with the option of rescue ALPPS if insufficient growth was found after the initial step of TSH. Patients were enrolled between June 2014 and August 2016. Follow-up data for this study were collected between November 2022 and February 2023. Results:In total, 16 patients were alive at the end of the follow-up period. The estimated median follow-up time was 93 months. Estimated median overall survival times were 45 months in the ALPPS group and 27 months in the TSH group (P = 0.057), with 5-year survival rates of 31% and 20%, respectively. Positive prognostic factors were liver tumor-free status at the first follow-up and rectal primary tumor. Negative prognostic factors were extrahepatic disease and increasing CLRM size. Conclusion:Liver tumor-free status is a predictor of long-term survival, along with extrahepatic disease, large CRLM size, and rectal primary tumor. Survival did not significantly differ between patients treated with ALPPS or TSH.

Abstract Background Glucocorticoids modulate the surgical stress response. Previous studies showed that high-dose preoperative glucocorticoids reduce levels of postoperative inflammatory markers and specific biomarkers of liver damage compared with placebo, and suggested a reduced complication rate and shorter hospital stay after liver surgery. However, there are no studies with a clinical primary outcome or of early recovery outcomes. The aim of this study was to investigate whether a single high dose of preoperative glucocorticoid reduces complications in the immediate postoperative phase after liver surgery. Methods This was a single-centre, double-blinded, parallel-group RCT investigating preoperative methylprednisolone 10 mg/kg (high dose) versus dexamethasone 8 mg (standard-dose postoperative nausea prophylaxis) in patients scheduled for open liver resection. The primary outcome was number of patients with a complication in the postanaesthesia care unit; secondary outcomes included duration of hospital stay, pain and nausea during admission, and 30-day morbidity. Results A total of 174 patients (88 in high-dose group, 86 in standard-dose group) were randomized and analysed (mean(s.d.) age 65(12) years, 67.2 per cent men); 31.6 per cent had no serious co-morbidities and 25.3 per cent underwent major liver resection. Complications occurred in the postanaesthesia care unit in 51 patients (58 per cent) in the high-dose group and 58 (67 per cent) in the standard-dose group (risk ratio 0.86, 95 per cent c.i. 0.68 to 1.08; P = 0.213). Median duration of hospital stay was 4 days in both groups (P = 0.160). Thirty-day morbidity and mortality rates were similar in the two groups. Conclusion A high dose of preoperative glucocorticoids did not reduce acute postoperative complications after open liver resection compared with a standard dose. Registration number: NCT03403517 (http://www.clinicaltrials.gov); EudraCT 2017–002652-81 (https://eudract.ema.europa.eu/).

Background: Since the introduction of ALPPS there has been an intense debate about the appropriateness of the procedure and some have argued that portal vein embolization (PVE) should remain the standard of care in the situation of inadequate future liver remnant (FLR). The main aim of this study was to compare successful resection rate with upfront associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) compared to PVE with rescue ALPPS on demand. Material and Methods: A retrospective analysis of all patients with standardized FLR (sFLR) =30% treated with PVE or ALPPS for colorectal liver metastases at five Scandinavian university hospitals during the years 2013-2016. Liver volumes, oncological treatment, procedures and complications were gathered. Chi-square test and Mann-Whitney U test was used to assess differences between the two groups. Successful resection rate was defined as completed liver resection without 90-day mortality. Results: A total of 165 patients (96% treated with neoadjuvant chemotherapy) was found, 64 treated with up front ALPPS (group A) and 101 treated primarily with PVE (group B), of which 20 had rescue ALPPS. There were 111 male and 54 female patients with median sFLR 21% before start of treatment. Age, sFLR, the use of chemotherapy, number and size of largest tumour was the same in both groups. In group A 88% and in group B 73% had successful resections (p=0.03). The hypertrophy of the FLR in group A was 67% compared to 90% total hypertrophy (after PVE and rescue ALPPS) in rescue ALPPS (p=0.06). Conclusion: Upfront ALPPS seems to offer higher percentage successful resections than PVE with rescue ALPPS as an addition on demand. The sequential combination of PVE and ALPPS may lead to higher degree of hypertrophy than upfront ALPPS and may therefore be the appropriate choice of treatment in very small FLR.

Background: For patients with colorectal liver metastases and low volume of the future liver remnant (FLR), two- stage hepatectomy (TSH), with addition of portal vein occlusion (PVO), is an established strategy to achieve radical resection. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS), is a relatively new technique to increase the volume of the FLR. The long term oncological Results have not previously been studied in a randomized controlled trial. Methods: 50 patients were randomized to ALPPS, 50 to TSH and PVO within the Scandinavian LIGRO trial. The first computed tomography/magnetic resonance imaging was performed 4 weeks after discharge, then after 4, 8, 12, 18 and 24 months. At follow up, recurrence/remaining tumor and treatment of recurrent disease was noted. Results: 44 patients randomized to ALPPS were resected according to per protocol, and 26 in the TSH group, p < 0.05. Resection rate according to intention to treat was 45/50 and 38/50 respectively, p=0.04. There was no statistically significant difference in postoperative complications, including mortality. At the first postoperative follow up 37 patients in the ALPPS group, compared to 28 in the TSH group were tumor free in the liver, p=0.019. Median follow up, after the first intervention, was 38 (95% CI 34-43) and 40 (95% CI 36-45) months, respectively. At the end of follow up, 27 (56%) and 16 (33%) were alive, p=0.025. Estimated median survival, according to intention to treat was 46 (95 % CI 34 -59) and 32 (95 % CI 22-42) months, respectively, p=0.107. Estimated median survival for patients resected per protocol was 46 (95% CI 39-54) months and 37 (95% CI 30-44) months, p=0.207. Conclusion: Patients randomized to ALPPS had a significantly higher resection rate. The observed survival was higher after ALPPS, than after TSH, although not statistically significant, p=0.207.

Aims: The aim of this study is to compare open (OLR) vs. laparoscopic liver resection (LLR) in patients with colorectal metastasis. Endpoints were overall survival (OS), disease free survival (DFS), Length of stay (LOS) and postoperative complications. Methods: One-hundred and twenty-four patients who underwent resection of colorectal liver metastasis from July 2009 to November 2014 at a high volume hepato-pancreato-biliary (HPB) centre were retrospectively reviewed. 62 consecutive cases of laparoscopic liver resections were compared to a matched control group of 62 open liver resections. The groups were matched by gender, age, Charlson comorbidity index, follow-up time, prior liver resection, number of liver segments involved in the procedure and number of metastasis resected. Results: The LOS was significantly shorter in the laparoscopic group median (25:75 percentile) 2 (2:4) days vs. 4 (4:5) days in the open group, P-value 0.001. Nine laparoscopic procedures (12.9 %) were converted to open surgery. Twenty (32 %) of the patients in the laparoscopic group had complications (Clavien-Dindo grade I: 8; grade II: 8; grade IIIa: 2; grade IIIb: 1) vs. 23 (37 %) patients with complications in the open resection group (grade I: 8; grade II: 9; grade IIIa: 2; grade IIIb: 3). We found no significant difference in OS (LLR Mean (95%CI) 49.2 (43.8;54.6) vs. OLR 48.4 (43.4;53.4)) or DFS (LLR Mean (95%CI) 41.8 (34.9;48.7) vs. OLR 36.6 (30.5;42.7)). Conclusions: We found laparoscopic liver resections to be safe and feasible compared to a matched control group and with a significantly shorter length of stay.

BACKGROUND:Recent developments in perioperative pathophysiology and care have documented evidence-based, multimodal rehabilitation (fast-track) to hasten recovery and to decrease morbidity and hospital stay for several major surgical procedures. The aim of this study was to investigate the effect of introducing fast-track principles for perioperative care in unselected patients undergoing open or laparoscopic liver resection.METHODS:This was a prospective study involving the first 100 consecutive patients who followed fast-track principles for liver resection. Catheters and drains were systematically removed early, and patients were mobilized and started eating and drinking from the day of surgery. An opioid-sparing multimodal pain treatment was given for the first week. Discharge criteria were: pain sufficiently controlled by oral analgesics alone, patient comfortable with discharge and no untreated complications.RESULTS:Median length of stay (LOS) for all patients was 5 days, with 2 days after laparoscopic versus 5 days following open resection (P < 0·001). Median LOS after minor open resections (fewer than 3 segments) was 5 days versus 6 days for major resections (3 or more segments) (P < 0·001). Simple right or left hemihepatectomies had a median LOS of 5 days. The readmission rate was 6·0 per cent and 30-day mortality was zero.CONCLUSION:Fast-track principles for perioperative care were introduced successfully and are safe after liver resection. Routine discharge 2 days after laparoscopic resection and 4-5 days after open liver resection may be feasible.