The therapeutic benefit of ALPPS technique for classically described marginal irresectable intrahepatic cholangiocarcinoma tumors: a propensity score analysis

Introduction: Despite of its encouraging primary results, “Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy” ALPPS procedure remains highly controversial. At present, the mid and long-term outcome of ALPPS procedures performed for Intrahepatic Cholangiocarcinoma (IC) patients remain unverified. Aim of Work To evaluate the long-term therapeutic benefit of ALPPS procedure for Intrahepatic cholangiocarcinoma in terms of oncological outcome and overall survival, in comparison to palliative chemotherapy with special emphasis on morbidity and early mortality. Patients and Methods: This is a longitudinal cohort multicenter study with prospective evaluation of long-term outcome of ALPPS procedure for IC patients in comparison to a propensity scored matched patients received palliative chemotherapy (CTH). Results: For ALPPS group (n=79), the median overall survival (OS) was 27.6 months. The 1,2,3-year survival rates were 68,1%, 60.1% and 40.8%. For propensity score matched group of CTH patients (n=79), the median OS was 12 months. The 1,2,3-year survival rates were 49,7%, 18.4% and 9.2%. (p value < 0.004). By multivariate COX regression analysis poor prognosis has been reported for cases developing infection post 2nd stage hepatectomy (p=0.03, HR=2.1, CI= 95%) and/or positive lymph node metastasis(p=0.007, HR=2.7, CI95%). During the study period, 90-day mortality rate was reported in 19% of the cases. According Dindo-Clavien classification of postoperative complications; 34.5% had score ≥ 3b (n=28/81). Sever infection classified as Dindo-Clavien grade IIIb was reported in 9% (n=7/77). According to ISLGS; biliary leakage reported in 9 % of the patients which is classified as grade C and 13.4 % of the patients (n=9/67) have developed PHLF classified as grade C. Conclusion: Despite of its relatively high morbidity and early mortality; ALPPS approach shows remarkable superior results in overall survival analysis compared to palliative chemotherapy for Intrahepatic cholangiocarcinoma patients. More strict risk adjustments are mandatory to avoid post-operative morbidity and mortality. Further studies are needed to identify the subgroup of IC patients who would potentially benefit from the procedure with acceptable morbidities and negligible early postoperative mortality