Home›Gastroenterology› ALPPS yields fastest liver growth but worse 1-year DFS than PVE in meta-analysis
ALPPS yields fastest liver growth but worse 1-year DFS than PVE in meta-analysisALPPS surgery shows faster liver growth for tumor removal
HPB : the official journal of the International Hepato Pancreato Biliary AssociationPublished August 7, 2026Study authors: Fotiadou Afroditi, Evangelou Kyriacos, Arkadopoulos Nikolaos, Hatzaras IoannisPubMed ↗DOI ↗Editorial oversight: Dr. Amelia Tan, PhD · Internal Medicine & Chronic Disease
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Key Takeaway
Consider ALPPS for rapid hypertrophy but weigh the associated worse 1-year DFS against PVE.
This meta-analysis pooled 24 retrospective cohort studies involving 1263 patients with primary or metastatic liver tumors undergoing major hepatectomy. The authors compared three strategies for inducing future liver remnant (FLR) hypertrophy: ALPPS, portal vein embolization (PVE), and liver venous deprivation (LVD). The primary outcome was kinetic growth rate (KGR), with secondary outcomes including hepatectomy completion rates and 1-year disease-free survival (DFS).
ALPPS induced a significantly higher mean KGR than PVE (SMD = 1.61, 95% CI 1.23 to 1.99, p < 0.01) and than LVD (ROM = 3.15, 95% CI 2.66 to 3.71, p < 0.01). LVD also outperformed PVE (ROM = 1.96, 95% CI 1.75 to 2.22, p < 0.01). ALPPS was associated with superior hepatectomy completion rates compared to PVE (OR = 13.75, 95% CI 3.24 to 58.57, p < 0.01).
However, ALPPS was associated with worse 1-year DFS compared to PVE (OR = 0.45, 95% CI 0.21 to 0.93, p = 0.03). The authors note that no substantial differences in postoperative outcomes were observed overall, despite the faster hypertrophy with ALPPS.
Limitations include the retrospective design of all included studies, with one-third judged at moderate risk of bias and the remainder at severe overall risk of bias. The authors emphasize the lack of randomized studies needed to draw clear and clinically relevant conclusions.
Clinicians should interpret these findings cautiously, recognizing that while ALPPS may accelerate liver growth, the potential trade-off in 1-year DFS warrants careful patient selection and shared decision-making.
How this fits prior evidence
This meta-analysis extends prior coverage of surgical approaches for liver tumors by comparing three hypertrophy techniques. It confirms that ALPPS provides faster liver growth than PVE, consistent with earlier findings favoring minimally invasive approaches for short-term outcomes. However, it contrasts with the prior meta-analysis on minimally invasive hepatectomy, which reported shorter operative time and reduced blood loss without addressing oncologic outcomes. Here, ALPPS's worse 1-year DFS introduces a cautionary note, addressing a gap in prior coverage that focused on perioperative benefits. The findings are based on retrospective cohorts, so they should be weighed against the higher-quality evidence from the minimally invasive comparison.
When a patient has a tumor in their liver, surgeons must ensure there is enough healthy liver tissue left to sustain life after removing the cancer. This study looked at 1,263 patients undergoing large-scale surgery to see which preparation method worked best. They compared three methods: ALPPS, PVE, and LVD.
The results showed that the ALPPS technique led to a significantly faster growth rate of healthy liver tissue compared to both PVE and LVD. Additionally, surgeons were much more likely to successfully complete the surgery when using ALPPS instead of PVE.
However, the data also showed a complication in long-term outcomes. While ALPPS helped the liver grow faster for the immediate surgery, it was associated with worse disease-free survival at the one-year mark compared to PVE. Because these findings come from retrospective studies rather than perfectly controlled trials, doctors should weigh these specific trade-offs carefully when choosing a treatment plan.
What this means for you:
ALPPS helps liver tissue grow faster for surgery but may show lower disease-free survival at one year compared to PVE.
Common questions
What is the main benefit of using the ALPPS method?
The ALPPS method is associated with a significantly higher mean Kinetic Growth Rate (KGR) of liver tissue compared to both PVE and LVD. It also showed much higher completion rates for the surgery when compared specifically to the PVE method.
How does ALPPS compare to PVE for long-term survival?
While ALPPS helps the liver grow faster, it was associated with worse 1-year disease-free survival (DFS) compared to the PVE method. You should discuss these specific outcomes with your doctor to understand what they mean for your specific case.
How much evidence is there for these findings?
These results come from a meta-analysis of 24 retrospective cohort studies involving 1,263 patients. Because these were not perfectly randomized trials, the data provides an important look at how different methods perform in real-world clinical settings.
BACKGROUND: Large scale hepatectomy for primary or metastatic liver tumors may be limited by insufficient Future Liver Remnant (FLR). Strategies to enhance FLR hypertrophy include associating liver partition and portal vein ligation for staged hepatectomy (ALPPS), portal vein embolization (PVE), and Liver Venous Deprivation (LVD). Their comparative efficacy in the context of open hepatectomy remains unclear.
METHODS: A systematic review and meta-analysis of pairwise comparative studies was conducted (PubMed, Embase, Scopus, Cochrane). Risk of bias was assessed using ROBINS-I. Random-effects models were applied, with p < 0.05 considered significant.
RESULTS: 24 retrospective cohort studies with a total of 1263 patients were included, with 1/3 judged as moderate and the rest as severe overall risk of bias. ALPPS induced higher mean Kinetic Growth Rate (KGR) than PVE (SMD = 1.61; 95%CI = 1.23,1.99; p < 0.01) and LVD (ROM = 3.15; 95%CI = 2.66,3.71, p < 0.01), and LVD than PVE (ROM = 1.96; 95%CI = 1.75,2.22; p < 0.01). ALPPS was associated with superior hepatectomy completion rates compared to PVE (OR = 13.75; 95%CI = 3.24,58.57; p < 0.01), and worse 1-year DFS (OR = 0.45; 95%CI = 0.21,0.93; p = 0.03). The rest of the comparisons failed to reach statistical significance.
CONCLUSION: ALPPS seems to induce the most rapid FLR hypertrophy, but no substantial differences regarding postoperative outcomes were observed. Further, ideally randomised, studies are necessary to draw clear and clinically relevant conclusions.
