LAUSR

We would like to thank Dr. Deshayes et al for their insightful comments to our article on assessment of liver volume and function in associating liver partition and portal vein ligation for staged hepatectomy (ALPPS).While we acknowledge the potential bias in the limited number of analyzed patients and that a majority was rescue ALPPS after insufficient portal vein occlusion, our study still constitutes the largest published series of ALPPS with functional assessment with hepatobiliary scintigraphy before and after both stages of the procedure. The rate of ALPPS procedures performed at our institution has decreased, and it is mainly used as a rescue method after failed portal vein occlusion in patients with colorectal liver metastases that has responded to chemotherapy. So, the adjunct of hepatic vein embolization to increase the effect of a portal vein embolization is a compelling concept, especially if a similar increase in volume and function can be corroborated in more than three patients. The need to proceed to stage 2 of the ALPPS procedure as early as 7 days after stage 1 is justly challenged by the authors, especially in the setting of colorectal liver metastases responding to neoadjuvant chemotherapy. We currently advocate functional assessment before both stages and do not hesitate to postpone stage 2 if functional evaluation demands a longer inter-stage period. Even if there are strong proponents of additional embolization of segment IV portal venous branches, others question the claimed superiority of this concept. In any case, even if this concept can be proved as superior to conventional portal vein embolization (with or without additional embolization of the corresponding hepatic vein), ALPPS will still have a role to play in the arsenal used in order to offer patients with advanced hepatobiliary tumors, a potentially curative treatment. With that said, we do agree with Dr. Deshayes et al. that the future role of ALPPS will most probably be more limited than first anticipated.