What are the benefits and risks of a newer two-stage liver operation technique (called ALPPS) compared with the standard two-stage liver operation for people with large bowel cancer that has spread to the liver and cannot be completely removed in one o...

Key messages

Compared with standard two-stage hepatectomy,

• ALPPS (associating liver partition and portal vein ligation for staged hepatectomy) may result in little to no difference in risk of death within 90 days after operation and in the chance of cancer returning; in the longer term (93 months), ALPPS probably results in little to no difference in death from any cause;

• we are very uncertain of the effects of ALPPS on quality of life (QoL) or the risk of serious unwanted effects (including complications); and

• ALPPS probably increases the number of people who have all liver tumours removed, but it may make little to no difference to how long people live after completing the planned operation treatment.

What are two-stage hepatectomy and ALPPS?

When colorectal cancer (involving the large bowel, including the rectum, the last part of the bowel before the anus) spreads to the liver, there may be multiple liver tumours. Therefore, surgeons may need to remove a large part of it. The liver can regrow after the operation but, if too little is left, it may not work properly (risk of liver failure), cause serious complications or even death. To avoid it, surgeons operate in stages: they first help the part of the liver that will remain in the body grow larger, and then remove the other part.

The standard approach is 'two-stage hepatectomy'. In the first operation, surgeons remove any tumours from the part of the liver that will remain in the body after the complete surgical treatment. This ensures the remaining part of the liver is free of cancer as it grows. Surgeons also reduce the blood supply to the lobe planned for removal, either by surgical ligation (tying a blood vessel) during the operation or afterwards, using an X-ray-guided technique. Therefore, the healthy part of the liver grows larger. The removal of the part with reduced blood flow can be scheduled four to six weeks after the operation. However, delays are common due to insufficient growth in the waiting period; chemotherapy is often given during it, and some individuals cannot finish treatment because the cancer spreads while waiting.

ALPPS is like the two-stage hepatectomy, but in the first operation, the surgeon also divides the liver into two parts. This makes the healthy side grow rapidly, shortening the waiting time for liver growth and allowing the second operation during the same hospital stay.

Why is this important for people with colorectal liver metastases?

Surgery is the best chance of cure or long-term survival for people with liver metastases from colorectal cancer. Faster liver growth gives cancer less time to spread. ALPPS may help more people complete both stages of surgery.

What did we want to find out?

We wanted to find out how ALPPS, compared with two-stage hepatectomy, affects:

• the risk of death within 90 days after operation;

• the risk of death at long-term follow-up;

• people's quality of life (QoL);

• the risk of serious unwanted effects, including complications;

• how long people live after operation;

• how long people live without their cancer coming back; and

• the chances of successfully removing all liver tumours.

What did we do?

We searched for studies comparing ALPPS with two-stage hepatectomy in people with colorectal liver metastases.

What did we find?

We found one study, conducted in three Scandinavian countries, with 100 randomised people. Three people were excluded before treatment started: 48 underwent ALPPS, and 49 underwent two-stage hepatectomy.

Main results

Compared to two-stage hepatectomy, ALPPS:

• may make little to no difference to the risk of death within 90 days after operation;

• probably makes little to no difference in deaths at long-term follow-up;

• has an unclear effect on QoL and on serious unwanted effects by 30 days;

• probably has little to no difference to overall survival in people who have completed the planned operation treatment;

• may have little to no difference in the chances of their cancer coming back; and

• probably largely increases rates of successful removal of all tumours (92 out of 100 people compared to 57 out of 100 people).

What are the limitations of the evidence?

The participants and events in the only Scandinavian study were insufficient to draw firm conclusions. We lacked studies with data from low- and middle-income countries.

As people were aware of the treatments received, they may have answered the QoL questionnaire differently and numbers reduced over time. The included study reported data using a scale that analysed both survival and QoL.

We are not confident about the ALPPS' effects on serious unwanted effects. The study only analysed people who completed the operations, and more people in the ALPPS group did so. This may have made the two-stage hepatectomy group appear to have more serious unwanted effects.

Further well-designed studies could help clarify the true effects.

How up-to-date is this evidence?

The evidence is up-to-date to 4 December 2025.