This study examines the evolution of ALPPS (Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy) as a model for structured surgical innovation within the IDEAL framework (Idea, Development, Exploration, Assessment, Long-term follow-up). Introduced in 2012 to enable resection of previously unresectable liver tumors, ALPPS initially faced high morbidity and mortality, sparking intense debate about its safety and utility.
Through the establishment of the international ALPPS registry, collecting over 1300 cases from 146 centers in 46 countries and an early consensus conference (2015, Hamburg), data-driven refinements improved patient selection and technique, reducing 90-day mortality from >15% to <5% in expert centers. The registry enabled multiple analyses identifying risk factors, refining indications (particularly for colorectal liver metastases), and supporting technical modifications such as partial or mini-ALPPS.
Progress through the IDEAL stages was marked by the LIGRO randomized controlled trial, which demonstrated significantly higher resectability (92% vs. 57%) compared with portal vein embolization, with comparable morbidity and mortality. Long-term registry data showed improved survival (median OS ~39 - 46 months for ALPPS vs. 26 months for conventional approaches).
The authors compared ALPPS with other disruptive surgical innovations - laparoscopic cholecystectomy and robotic surgery - illustrating how structured evaluation and international collaboration can transform controversial procedures into accepted standards.
Ultimately, ALPPS exemplifies how early registry creation, consensus building, benchmarking, and RCT validation can accelerate safe adoption of novel surgical methods. The authors propose ALPPS as a template for future innovations under the IDEAL paradigm, emphasizing the ongoing need for registries, consensus evaluation, RCT and benchmarking in the era of artificial intelligence and big data.
Interview with Michael Linecker (Zurich)
What inspired you to conduct this study?
We were motivated by the controversy surrounding ALPPS after its introduction, particularly the high early morbidity and mortality. This presented an opportunity to examine how structured evaluation could guide a disruptive surgical innovation. We aimed to show how the IDEAL framework can support safe, evidence-based adoption of new procedures.
Were there any unexpected findings?
An unexpected finding was the speed at which outcomes improved once the international registry facilitated large-scale data sharing and consensus development. The reduction in mortality from over 15% to below 5%, along with a marked decrease in complications, occurred more rapidly than anticipated, underscoring the impact of collaborative refinement. These improved results were closely linked to technical modifications and more rigorous patient selection.
What is the direct impact on the surgeon’s work ?
Surgeons now have clearer indications, standardized techniques, and risk stratification tools for ALPPS. This results in safer patient selection, more predictable outcomes, and improved benchmarking across institutions. It also highlights the importance of contributing to and using real-time registry data.
What is your learning point from this project?
The key learning point is that early, structured data collection and collaborative evaluation are essential for safely implementing complex surgical innovations. Registries and consensus processes can dramatically accelerate improvements in outcomes. Applying IDEAL principles provides a reliable roadmap for future innovations.
Are there any subsequent projects planned ?
Yes, future work will focus on applying the IDEAL principles and registry-based methodology to the evaluation of other emerging surgical procedures. Planned projects include developing structured assessment frameworks for disruptive techniques, establishing multicenter registries early in their adoption, and creating standardized benchmarking tools to monitor safety and effectiveness. These initiatives aim to generalize the lessons learned from ALPPS to accelerate and safeguard the introduction of novel surgical innovations.
