Associating liver partition and portal vein ligation for staged hepatectomy procedure versus conventional two-stage hepatectomy for colorectal liver metastasis
27 October 2026Original research5 min read
By Shiraiwa DK, Riera R, Kleinubing DR and 2 others.
Staged surgical procedures, such as two-stage hepatectomy and associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) technique, use the liver regenerative capacity to stimulate growth of the future liver remnant. These procedures can be used in people with extensive colorectal liver metastases when the future liver remnant is too small to allow a safe postoperative recovery after major hepatectomy. Compared with conventional two-stage hepatectomy, although ALPPS results in faster and larger growth of the future liver remnant, the evidence regarding its impact on major postoperative complications, perioperative mortality, recurrence rates, and long-term survival is conflicting.
To assess the benefits and harms of liver partition and portal vein ligation for a staged hepatectomy (ALPPS) procedure versus conventional two-stage hepatectomy in people with colorectal liver metastases.
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We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, Cochrane Central Register of Controlled Trials in the Cochrane Library, MEDLINE, Embase, three other databases, online trial registries, grey literature databases, and reference lists of identified studies; we also retrieved additional information from the included trial authors. Our last study search was on 4 December 2025.
Randomised clinical trials comparing ALPPS versus conventional two-stage hepatectomy in adults with colorectal liver metastases who were unable to undergo complete resection because the future liver remnant was estimated to be < 30% of the total liver volume.
The critical outcomes were perioperative all-cause mortality at 90 days, all-cause mortality, serious adverse events, and health-related quality of life (HRQoL). Other important outcomes included overall survival, disease-free survival, and resection rate. For our primary analysis, we used data at the maximum follow-up, except for perioperative mortality, analysed at 90 days after operation.
We used the Risk of Bias 2.0 (RoB 2) tool.
We used standard Cochrane methodological procedures to develop the review. We did not perform meta-analysis because only one trial met the inclusion criteria. We expressed dichotomous outcomes as risk ratios (RR), continuous outcomes as mean differences (MD), and time-to-event outcomes as hazard ratios (HR), all with 95% confidence intervals (CIs), using RevMan. We used the GRADE approach to assess the certainty of the evidence.
The included trial was a six-centre, publicly funded, Scandinavian randomised clinical trial. The trial investigators randomised 100 participants (mean age: 65 ± 10 years; male-to-female ratio: 2.34:1.0). After randomisation, two participants in the ALPPS (1 severe comorbidity; 1 total liver volume > 30%) and one participant in the two-stage hepatectomy group (progressive disease) could not proceed to the intervention and were excluded. One other participant was lost to follow-up after emigrating. The trial was described in 15 publications. The trial provided data for all outcomes of our review. We followed the analytical approach reported by the trial authors, using a modified intention-to-treat population where applicable and available data otherwise.
The evidence suggests that ALPPS, compared with two-stage hepatectomy, results in little to no difference in perioperative all-cause mortality at 90 days (RR 1.36, 95% CI 0.32 to 5.76; I2 not applicable; 1 study; 97 participants; low-certainty evidence) and probably results in little to no difference in all-cause mortality at maximum follow-up (93 months) (RR 0.86, 95% CI 0.72 to 1.03; 1 study, 97 participants; moderate-certainty evidence). The trial reported a mean quality-adjusted survival MD of 1.25 quality-adjusted life years (QALY) (95% CI 1.08 to 1.42) for participants randomised to ALPPS, and MD 1.11 QALY (95% CI 0.94 to 1.27) for participants randomised to two-stage hepatectomy, with an estimated MD between the groups of 0.14 QALY (95% CI -0.32 to 0.60). The evidence is very uncertain about the effect of ALPPS, compared with two-stage hepatectomy, on health-related quality of life (MD 0.14, 95% CI -0.26 to 0.54; 1 study, 97 participants; very low-certainty evidence) (maximal follow-up: two years) and on the rate of serious adverse events (maximal follow-up: 30 days) (RR 1.01, 95% CI 0.58 to 1.74; 1 study, 72 participants; very low-certainty evidence). ALPPS probably results in little to no difference in the overall survival of people with colorectal liver metastases (HR 0.72, 95% CI 0.42 to 1.24; 1 study, 97 participants; moderate-certainty evidence) (median 93 months) and results in little to no difference in disease-free survival (HR 0.91, 95% CI 0.59 to 1.40; 1 study, 97 participants; low-certainty evidence) (median 93 months), but probably results in a large increase in resection rates (RR 1.60, 95% CI 1.24 to 2.07; 1 study, 97 participants; moderate-certainty evidence) (maximum follow-up: eight weeks), compared with two-stage hepatectomy. We downgraded the certainty of evidence for risk of bias, indirectness, and imprecision.
Current evidence derives from data from only one randomised clinical trial, with a low number of participants and events. We are very uncertain about the effect of ALPPS on health-related quality of life and the rate of serious adverse events (30 days of follow-up) compared with two-stage hepatectomy. We are uncertain whether there is little to no difference between ALPPS and two-stage hepatectomy in perioperative mortality at 90 days after operation and in disease-free survival. ALPPS, compared with two-stage hepatectomy, probably results in little to no difference in all-cause mortality at maximum follow-up (93 months) and in overall survival of people with colorectal liver metastases (median 93 months), but probably results in a large increase in resection rates (eight-week follow-up). The certainty of the evidence for the presented outcomes was very low, low, or moderate. We lack randomised trials comparing these two strategies to identify the best approach for routine use in surgical practice. Evidence from low- and middle-income countries is lacking. The choice of ALPPS should carefully consider clinical characteristics of the patients. More high-quality trials with large numbers of participants are needed to provide information on the risks and benefits of ALPPS for people with colorectal liver metastases.
This review does not have dedicated funding.
Protocol: published 08 March 2022, available in the Cochrane Library at https://doi.org/10.1002/14651858.CD014608.
Keywords
Humans
Hepatectomy
Portal Vein
Liver Neoplasms
Ligation
Colorectal Neoplasms
Randomized Controlled Trials as Topic
Liver Regeneration
Postoperative Complications
Authors
Shiraiwa DK
Riera R
Kleinubing DR
Linhares MM
Supported by the Cochrane Hepato-Biliary Review Group
Source
Published in The Cochrane database of systematic reviews. The abstract is shown as published and remains the work of its authors; read the full article at the source.
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