ALPPS for non-CRLM and primary hepatobiliary malignancies: Is it becoming safer?

Since the introduction of ALPPS by Schnitzbauer et al. in 2012 this novel method has been fiercely debated and over time diagnoses other than colorectal liver metastases (CRLM) as well as advanced age have become relative contraindications to the procedure. In the first analysis of the ALPPS registry by Schadde et al. the abovementioned factors were identified and following this the enthusiasm for ALPPS in the settings of primary hepatobiliary malignancies has reduced. In February 2015 the first International Expert Meeting on ALPPS concluded that CRLM remains the indication of choice for this procedure and caution should be exercised in the case of HCC, intrahepatic cholangiocarcinoma and perihilar cholangiocarcinoma (Oldhafer et al.). Similarly D´Haese et al. concluded in 2015 that the use of ALPPS in HCC patients was indicated only in highly selected cases younger than 60 years. Recent analysis of the overall Risk adjustment in ALPPS (Linecker et al. Submitted to Annals of Surgery, reference with permission from the first author) showed decreased use of ALPPS in settings other than CRLM although 23% of the procedures are still performed for indications with higher risk. These results do however only apply to centers with some experience with the procedure. Furthermore it is unknown if the adjustments made to the procedure and to the patient selection have made this type of surgery safer for patients with primary hepatobiliary malignancies and non-CRLM.