High incidence of biliary stricture after associating liver partition and portal vein ligation for staged hepatectomy

Background: Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a two-stage procedure most frequently applied in the setting of an extended right-sided hemi-hepatectomy. Initial reports of high mortality have sparked debate regarding the safety and efficacy of the procedure. We describe a higher incidence of early post-operative bile duct strictures after ALPPS, a complication rarely seen after conventional liver resection. Methods: An institutional review was conducted to assess the incidence of post-operative biliary strictures following conventional right-sided or extended right-sided hemi-hepatectomy and ALPPS. Patient demographics and operative data were obtained from the patient database of Karolinska University Hospital. Results: Between 2010 and 2015, 528 hemi-hepatectomies or extended hemi-hepatectomies were performed, of which 500 were conventional liver resections and 28 were ALPPS. The incidence of post-operative biliary stricture was 10.7% (n = 3) following ALPPS, 1.4% (n = 2) following extended right-sided hepatectomy (P = 0.023; OR = 8.46; 95% CI 1.35–53.2) and 1.1% following formal right-sided hepatectomy (P = 0.004; OR = 11.0; 95% CI 2.11–57.6). All biliary strictures were at the level of the hilum affecting the left hepatic duct. Pre-operative comorbidity was less in the ALPPS group and post-operative complications were more severe following ALPPS. Conclusion: Iatrogenic biliary strictures following conventional liver resection is an uncommon complication. It does, however, occur more frequently following ALPPS and is associated with an increased morbidity. Caution should therefore be exercised when dividing the right hilar pedicle at stage 2 of ALPPS.