Risk factors for wound complications after associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) compared to repeated liver resection - a propensity score matching analysis

Risk factors for wound complications after associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) compared to repeated liver resection - a propensity score matching analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Risk factors for wound complications after associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) compared to repeated liver resection - a propensity score matching analysis Elias Khajeh, Nastaran Sabetkish, Ali Ramouz, Alexander Werba, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5158383/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 13 Nov, 2024 Read the published version in Langenbeck's Archives of Surgery → Version 1 posted 7 You are reading this latest preprint version Abstract Aim: Sufficient liver function is crucial in extracellular matrix growth, hemostasis, and wound healing. Repeated abdominal surgery is a known risk factor for the development of wound complications. This study aimed to evaluate this high-risk constellation in patients undergoing associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) and repeated liver resections (RLR) in comparison to single liver resection (SLR). Method: Forty patients who underwent ALPPS between 2011 and 2020 were evenly matched with patients undergoing RLR or SLR (n=40 per group) using propensity scores. Postoperative outcomes were compared and factors associated with wound complications were analyzed. Results: Postoperative wound complications were significantly more frequent in ALPPS group (p=0.001). The reoperation rate was not significantly different between the three groups (p=0.143). However, surgical reintervention due to wound complications occurred more frequently in the ALPPS group in relation to RLR and SLR (17.5% vs. 7.5% and 5% respectively). Length of stay was significantly longer in the ALPPS group (p=0.033). ALPPS was an independent risk factor for postoperative wound complication (OR= 8.55, 95% CI:1.07-68.44, p=0.043). Risk factor analysis identified age ≥60 years (OR=27.64, 95% CI:3.09-246.75, p=0.003), BMI≥30 kg/m 2 (OR=30.21, 95% CI:3.35-271.83, p=0.002), and low postoperative albumin levels (OR=168.41, 95% CI:7.76-3651.18, p=0.001) as independent predictors of postoperative wound complications after major liver resection. Conclusion: Patients undergoing ALPPS and RLR are faced with a high risk of developing wound complications. Older age, obesity, a history of previous abdominal surgery, and a decreased postoperative albumin level were independent risk factors for wound complications. incisional hernia surgical site infection wound healing liver surgery Figures Figure 1 Figure 2 Figure 3 Introduction While surgery remains the keystone in the treatment of liver malignancies ( 1 ), the risk of recurrence for primary or secondary liver malignancies is still as high as up to 40% with a growing patient population in need of extensive or repeated liver resections ( 2 ). In the past two decades, recent surgical advancements have made staged hepatectomy or repeated liver resections an option in patients with otherwise unresectable liver tumors or recurrent disease ( 3 ). Patients with potentially insufficient future liver remnant (FLR) are candidates for associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) which has been developed since 2007 to promote an accelerated FLR growth within 6–9 days ( 4 ). Although this technique has proven advantageous in achieving an R0 resection with a reduced risk of post-hepatectomy liver failure (PHLF), it still has a high risk of morbidity and mortality ( 5 ). Wound complications such as fascial dehiscence, incisional hernia, or surgical site infection (SSI) are common in patients undergoing major liver surgery. However, only little is known about wound complication rates and associated factors after the ALPPS procedure. Impaired liver function and repeated hepatic resections are important risk factors causing postoperative complications after major liver resection. ( 6 , 7 , 8 ). Major surgeries are generally associated with a diminishing subcutaneous collagen accumulation resulting in a reduced systemic wound-healing capacity ( 9 ). Repeated abdominal incisions and a history of previous surgery are also known risk factors for postoperative wound complications ( 10 ). Repeated incisions in combination with impaired liver function may affect wound healing at the highest level ( 11 , 12 , 13 ). As a result, patients undergoing either ALPPS or repeated metastasectomy may be confronted with postoperative surgical site infection (SSI) or fascial dehiscence, due to impaired wound healing. However, it is not known if performing repeated incisions in a short period, as in the ALPPS procedure, is an additional risk factor compared to repeated liver resections in longer intervals. The present study aimed to evaluate the occurrence of postoperative wound complications in patients undergoing ALPPS in comparison to repeated liver resections (RLR) for cancer recurrence after major liver resection and patients after a single major liver resection (SLR). Furthermore, we aimed to assess risk factors for surgical wound complications after repeated liver surgeries. Material and Methods Study population The data of 64 consecutive patients who underwent major liver resection through an ALPPS procedure between October 2011 and September 2020 at the Department of General, Visceral, and Transplantation Surgery of the University Heidelberg were extracted from our prospectively maintained database. Inclusion criteria were age >18 years, liver resection using a reverse L-shaped incision (rL-incision), and a minimum follow-up of 12 months. After exclusion of patients with perioperative mortality (up to 30 days) or short-term follow-up (n= 12), and those with incisions other than rL-incision (n= 12), data of 40 patients were analyzed. Data from adult patients with major open liver resection using an rL-incision during the same period were also collected (n= 458). Within this group, 133 patients underwent a repeat liver resection (RLR) due to recurrence, while the remaining 325 patients underwent a single liver resection (SLR) without any subsequent liver surgery. Propensity-score matching was meticulously performed to achieve a 1:1:1 ratio between patients in the ALPPS, RLR, and SLR groups, using gender, age, and the indication for surgery serving as matching variables (see Figure 1). The study was approved by the regional ethics committee of the medical faculty (approval number: S-754/2018). The study was conducted following the STROCSS 2021 reporting guidelines and the declaration of Helsinki. Patient Data Collection and Measurements Baseline demographic and clinical data including age, gender, body mass index (BMI), history of diabetes mellitus (DM), previous abdominal operations, diagnosis, preoperative laboratory data on the day before the surgery (albumin, bilirubin, and the international normalized ratio [INR]) as well as intra- and postoperative data (including the extent of resection, operation time, length of hospital stay, postoperative complications, re-operation, and length of follow-up) were extracted from a prospective liver surgery database. Wound complication was defined as the occurrence of one of the following: SSI, wound dehiscence, abdominal fascial dehiscence, or incisional hernia. SSI was defined according to Centers for Disease Control and Prevention (CDC) criteria (14, 15). Length of follow-up started from the second performed surgery in ALPPS and RLR groups. To assess the role of obesity in postoperative outcomes, a subgroup analysis was performed for patients with a BMI ≥30 kg/m². Statistical Analysis Statistical data analysis was performed with SPSS software (Version 25, SPSS Inc., Chicago, IL, USA). Categorical data are presented as proportions and percentages, and continuous data as the median and interquartile range (IQR). Categorical data are compared using the chi-square test of association or Fisher’s exact test. Continuous data are compared using one-way analysis of variance (ANOVA) followed by the Tukey posthoc test or Kruskal-Wallis H test. Propensity score-matching analysis was used to build a matched group of patients and minimize differences in confounders and baseline characteristics between the patients using age, gender, and surgical indication. The propensity score matching algorithm was performed using R, version 3.5.1 (The R Foundation for Statistical Computing, Vienna, Austria). Logistic regression analysis was used to estimate the propensity score. Patients were matched based on the logit of the propensity score by selecting the nearest available matching using a caliper width of 0.1 of the standard deviation of the estimated propensity score between study groups. Accordingly, a 1:1 matched analysis was conducted. Logistic binary regression analysis was used to calculate the multivariate odds ratios (OR) and 95% confidence intervals (95% CI). Variables with p<0.2 in the univariate analysis were entered into the multivariate regression analysis. All statistical tests were two-sided and a p <0.05 was considered significant. Results Perioperative data In total, 40 patients with a median age of 59.5 years (IQR = 11.75) undergoing ALPPS for various malignant diagnoses met the inclusion criteria within the study period. Another 40 matched patients with a median age of 59.0 years (IQR = 12.0) were included in the RLR group. The second control group included 40 individuals with a median age of 60.2 years (IQR = 14.0) who underwent an SLR. The majority of patients were male (n = 81, 67.5%) and the median BMI was 24.7 kg/m 2 . The baseline, intraoperative, and postoperative characteristics of patients in each group are summarized in Table 1 . Between the subgroups, there were no significant differences in preoperative characteristics including age, gender, BMI, DM, previous abdominal surgery, the indication of surgery, preoperative albumin, bilirubin, and INR levels. Table 1 Baseline characteristics and surgical data of patients undergoing major hepatectomy with single or multiple resections ALPPS (n = 40) RLR (n = 40) SLR (n = 40) P-value Age (year) median (Q1, Q3) 59.5 (53.2, 65.7) 59.0 (52.0, 64.0) 60 (52, 66) 0.549 Gender (female) n (%) 12 (30.0) 14 (35.0) 13 (32.0) 0.892 BMI median (Q1, Q3) 25.5 (23.0, 29.5) 24.2 (22.0, 30.3) 25 (22.1, 28,8) 0.732 Diabetes n (%) 14 (35) 7 (17.5) 6 (15.0) 0.066 Previous abdominal surgery n (%) 18 (45.0) 15 (37.5) 11 (27.5) 0.265 Indication n (%) HCC 3 (7.5) 3 (7.5) 3 (7.5) 0.877 CCC 16 (40.0) 12 (30.0) 16 (40.0) CRLM 21 (52.5) 25 (62.5) 21 (52.5) Preoperative Albumin median (Q1, Q3) 40.3 (37.7, 45.2) 42.4 (39.5, 44.0) 42.5 (38.9, 44.2) 0.750 Preoperative Bilirubin median (Q1, Q3) 0.7 (0.5, 1.6) 0.6 (0.4, 1.5) 1.4 (0.8, 1.6) 0.562 Preoperative INR median (Q1, Q3) 1.0 (0.9, 1.0) 1.0 (0.9, 1.0) 1.0 (0.9, 1.1) 0.281 Resection type n (%) Extended hepatectomy 31 (77.5) 13 (32.5) 10 (25.0) < 0.001 ⁑ Hemihepatectomy 9 (22.5) 27 (67.5) 30 (75.0) Operation time for stage 1 (min) median (Q1, Q3) 240.0 (204.7, 326.2) 201.5 (165.0, 240.0) 242.5 (182.5, 273.7) 0.020 * Operation time for stage 2 (min) median (Q1, Q3) 128.0 (95.0, 195.0) 202.5 (150.0, 260.7) - 0.001 Postoperative Albumin median (Q1, Q3) 27.5 (23.4, 30.8) 31.1 (28.2, 33.4) 30.8 (26.3, 35.1) 0.005 * § Postoperative Bilirubin median (Q1, Q3) 1.5 (0.9, 2.3) 1.3 (0 8, 2.3) 0.9 (0.7, 1.5) 0.029 § Postoperative INR median (Q1, Q3) 0.9 (0.5, 1.9) 1.2 (1.1, 1.3) 1.15 (1.11, 1.2) 0.134 Overall wound complications n (%) 15 (37.5) 9 (22.5) 5 (12.5) 0.032 * § In-hospital wound complications n (%) 6 (15.0) 2 (5.0) 1 (2.5) 0.485 Reoperation for wound complication n (%) 7 (17.5) 3 (7.5) 2 (5.0) 0.143 Total postoperative complications n (%) 15 (37.5) 6 ( 15 ) 4 ( 10 ) 0.005 * § Total ICU stays (day) median (Q1, Q3) 0 0 0 0.064 Total IMC stays (day) median (Q1, Q3) 6.5 (0, 10.7) 0 (0, 2) 0 (0, 2) < 0.001 * § Total hospital stays (ALPPS – first stage) (day) median (Q1, Q3) 29.0 (24.2, 36.0) 14.0 (9.0, 21.0) 13.0 (9.0, 23.2) < 0.001 * § Total hospital stays (ALPPS – second stage) (day) median (Q1, Q3) 20 (16.0, 20.0) 14.0 (9.0, 21.0) 13.0 (9.0, 23.2) 0.001 § Follow-up (month) median (Q1, Q3) 26.0 (17.2, 41.7) 22.5 (15.2, 35.5) 23.5 (16.0, 33.0) 0.258 Q1: Interquartile 1; Q3: Interquartile 3; ALPPS: Associating liver partition and portal vein ligation for staged hepatectomy; RLR: repeated liver resection; SLR: single liver resection; BMI: Body mass index; HCC: Hepatocellular carcinoma; CCC: Cholangiocarcinoma; CRLM: Colorectal liver metastasis; INR: International normalized ratio; SSI: surgical site infection * Significant difference between ALPPS and RLR, § Significant difference between ALPPS and SLR ⁑ Significant difference between RLR and SLR The operation duration was significantly different among these three groups (p = 0.001). Pairwise comparisons of the mean operation times revealed a significantly longer operation of the first stage of ALPPS compared to the RLR group (mean difference = 71.27 minutes, SE = 19.19, p < 0.001). Comparison between ALPPS and SLR (0.125) as well as RLR and SLR (p = 0.193) revealed no significant difference. However, when comparing the operation duration of the second stage of ALPPS, the surgical procedure was longer in the RLR group compared to ALPPS (213 vs. 150 minutes, p = 0.001). Postoperative data I. Wound outcomes Overall wound complications were significantly higher in the ALPPS group (37.5%) compared to RLR and SLR groups (22.5% and 12.5%, p = 0.032). However, when studying different subgroups of wound complication, the statistical analysis was not different among three surgical groups (p = 0.757 for SSI, p = 0.772 for wound dehiscence, p = 0.164 for abdominal fascial dehiscence, and p = 0.080 for incisional hernia). The most frequent complication was incisional hernia in ALPPS groups (15.0%); while SSI was the most common wound complication in RLR and SLR groups (12.5% and 7.5% respectively) (Fig. 2 ). There was no case of organ-space SSI in any group and all patients with superficial SSI were managed by antibiotic therapy. Our statistical analysis revealed no significant difference in terms of in-hospital or late complication occurrence. The overall mean interval between surgery and wound complication occurrence was 9.4 ± 16.45 months. When considering the short-term complications (in-hospital), 4 (10.0%), 5 (12.5%), and 3 (7.5%) patients had SSI in ALPPS, RLR, and SLR groups, respectively. Additionally, 2 (5.0%), 1 (2.5%), and 1 (2.5%) patients suffered wound dehiscence in the above-mentioned groups. Furthermore, fascial dehiscence occurred in 3 (7.5%) patients in the ALPSS and 1 (2.5%) patient in the RLR group during their hospital stay. We considered late complications as those occurring after the hospitalization that occurred in 6 (15.0%), 2 (5.0%), and 1 (2.5%) patients in the ALPPS, RLR, and SLR groups, respectively. The need for reoperation due to wound complications was highest in the ALPPS group (17.5% vs. 7.5% and 5.0% in the RLR and SLR, respectively). II. Laboratory findings The postoperative albumin levels were significantly different among the three groups (p = 0.005). A pairwise comparison revealed a significantly lower albumin level in ALPPS patients as compared to the RLR group (mean difference=-3.05, SE = 1.15, p = 0.025). Similarly, the albumin level was lower in ALPPS as compared to SLR (mean difference=-3.13, SE = 1.15, p = 0.021). There was no significant difference in terms of postoperative albumin level between the RLR and SLR groups (p = 0.997). The postoperative bilirubin level was significantly different among these three groups (p = 0.029). Pairwise comparisons showed a significant difference between the ALPPS and SLR groups (mean difference=-0.47, SE = 0.18, p = 0.034). Comparison between ALPPS and RLR (0.845) and RLR and SLR (p = 0.1243) revealed no significant difference in postoperative bilirubin level. Postoperative INR levels were not statistically significant among groups (p = 0.455). The median interval between the two surgeries in the RLR group was 9 months (range 6 to 59 months). III. Overall complications Statistical analysis revealed a significantly higher rate of postoperative total complications in ALPPS compared to the other two groups (p = 0.005). 7.5%, 5%, and 25% of patients in the ALPPS group had a postoperative biliary leakage, bleeding, or non-surgical complication. The rate of these complications in the RLR group was 5%, 2.5%, and 7.5%, respectively. However, 5%, 2.5%, and 4.5% of patients in the SLR group had the above-mentioned postoperative complications. IV. Intensive care and hospital-stay Even though ICU stay was similar among groups, IMC stay was significantly higher in patients who underwent ALPPS (p < 0.001). Pairwise comparisons showed a higher IMC stay in ALPPS compared to both the SLR (mean difference = 4.82, SE = 0.81, p < 0.001) and RLR (mean difference = 5.35, SE = 0.81, p < 0.001) groups. Furthermore, statistical analysis revealed no significant difference in the length of IMC stay between the RLR and SLR groups in terms of hospital stay (p = 0.798). The median duration of the follow-up was 22.5 months (range: 12–102 months). There was no significant difference in terms of follow-up duration among the groups (p = 0.190). The hospital stay was significantly different among these three groups when considering the second stage of ALPPS as the initial day of hospitalization in this subgroup (20, 14, and 13 days in the ALPPS, RLR, and SLR groups, respectively, p < 0.001). Our analysis revealed a significantly longer hospital stay in the ALPPS as compared to the SLR group (mean difference = 9.47, SE = 3.82, p = 0.039). However, the result of our statistical analysis revealed no significant difference neither between the ALPPS and RLR groups (p = 0.093) nor between the RLR and SLR groups (p = 0.932) concerning hospital stay. Similarly, patients were hospitalized in the ALPPS compared to the SLR group (mean difference = 17.65, SE = 3.80, p < 0.001). However, no significant difference was detected between the RLR and SLR groups in terms of hospital stay (p = 0.951). Factors associated with postoperative wound complications Univariate analysis of predictive factors of postoperative wound complications revealed that age ≥ 60 (< 0.001), BMI ≥ 30 (p < 0.001), DM (p < 0.001), previous abdominal surgery (p < 0.001), ALPPS (p = 0.013), preoperative bilirubin level (0.178), and postoperative albumin levels (p < 0.001) were significantly correlated with postoperative wound complications. Multivariable regression analysis was performed on these six variables. Age ≥ 60 years (OR = 27.64, 95% CI: 3.09-246.75, p = 0.003), BMI higher than 30 kg/m2 (OR = 30.21, 95% CI: 3.35-271.83, p = 0.002), undergoing ALPPS surgery (OR = 8.55, 95% CI: 1.07–68.44, p = 0.043), and decreasing of postoperative albumin to less than 30 g/dL (OR = 168.41, 95% CI: 7.76-3651.18, p = 0.001) were identified as independent predictors of posthepatectomy wound complications (Table 2 ). Table 2 Univariate and multivariate analysis of predictive factors of postoperative wound healing complications after major hepatectomy with single or multiple resections Univariate Multivariate OR 95% CI p OR 95% CI p Age, years (≥ 60) 7.68 2.68–21.99 < 0.001 27.64 3.09-246.75 0.003 BMI, kg/m 2 (≥ 30) 7.79 2.97–20.41 < 0.001 30.21 3.35-271.83 0.002 Gender 1.09 0.44–2.68 0.847 - - - Diabetes 8.95 3.40-23.51 < 0.001 4.52 0.76–26.79 0.096 Previous abdominal surgery 7.76 3.02–19.90 < 0.001 3.71 0.57–24.15 0.170 Surgery type (compared to SLR) ALPPS 4.20 1.35–13.06 0.013 8.55 1.07–68.44 0.043 RLR 2.03 0.61–6.71 0.245 2.81 0.31–24.81 0.351 Resection type (Extended) 0.90 0.40–2.19 0.948 - - - Operation time, min (≥ 180) 0.61 0.26–1.41 0.251 - - - Preoperative Albumin, g/L ( 1) 0.55 0.23–1.31 0.178 0.71 0.12–4.01 0.698 Preoperative INR (> 1.1) 0.93 0.23–3.65 0.923 - - - Postoperative Albumin, g/L (< 30) 63.00 8.16-486.31 1) 1.34 0.57–3.15 0.501 - - - Postoperative INR (> 1.1) 1.35 0.52–3.41 0.517 - - - OR: Odds ratio; BMI: Body mass index; ALPPS: Associating liver partition and portal vein ligation for staged hepatectomy; RLR: repeated liver resection; INR: International normalized ratio * For ALPPS and RLR the operation time for the second stage was considered. Subgroup analysis in patients with obesity A total of 26 patients had a BMI ≥ 30 kg/m² of whom 8 (30.8%), 10 (38.5%), and 8 (30.8%) patients underwent ALPPS, RLR, and SLR, respectively. Results of the subgroup analysis revealed no significant difference in preoperative characteristics in patients with and without obesity except diabetes which was significantly higher in patients with obesity (p = 0.028). Intraoperative variables were similar in both groups. The evaluation of postoperative wound complications is depicted in Fig. 3 . Similarly, wound dehiscence (p = 0.008), incisional hernia (p = 0.001), and total wound complications (p < 0.001) were significantly higher in patients with a BMI ≥ 30 kg/m². Additional need for reoperation caused by wound complications was significantly higher in patients with obesity (p = 0.001). Discussion In this study, patients undergoing ALPPS, repeated, and non-repeated major liver resections were compared for the first time regarding short- and long-term wound complications with a special focus on determining risk factors. Analyses showed that wound complications were significantly higher in patients undergoing ALPPS followed by RLR and SLR. High age (older than 60 years old), obesity (BMI higher than 30 kg/m 2 ), undergoing ALPPS, and lower postoperative albumin were identified as independent risk factors for post-hepatectomy wound complications. The underlying cause of wound complications is known to be multifactorial (16). However, age, obesity, DM, surgical technique, method of closure, surgical complications, immunosuppressive therapy, infectious postoperative complications, and repeated surgical interventions have been determined as potent postoperative risk factors, influencing the development of post-surgical abdominal wound complications (17, 18). Relaparotomies are believed to carry a higher risk for long-term complications such as incisional hernia (19). Adhesiolysis, which is commonly performed in re-laparotomies, is believed to increase the risk of intraabdominal injuries, wound infections, and length of hospital stay. Furthermore, this procedure leads to a twofold risk of incisional hernia, increasing costs and reducing the quality of life (12, 19, 20). Similarly, the present study revealed a significantly higher prevalence of wound complications in patients undergoing ALPPS and RLR. The multivariable regression analysis showed that ALPPS is an independent predictor of wound healing complications in patients undergoing major liver resection. Results of a recent study revealed that patients’ age and preoperative albumin, as well as operative time, could be considered significant predictors of surgical morbidity (21). Similar results were obtained in a recent study by Wong et al, indicating that the albumin-bilirubin ratio was a precise predictor of severe posthepatectomy liver failure and 30-day mortality in patients undergoing hepatectomy (22). The presented multivariable regression analysis results show that low postoperative albumin is an independent predictor of wound healing complications in patients undergoing major liver resection. Previous laparotomy and disturbed wound healing were found to be of significant influence on the development of incisional hernia (23). Although the majority of patients with postoperative abdominal wall complications could be managed with less invasive modalities such as antibiotics and simple dressings, a considerable number of cases may need additional intervention with up to 25% of patients needing reoperation in a collective undergoing renal transplantation (24). However, the results of the multivariate analysis revealed that previous abdominal surgery may not be considered as a risk factor for wound complications in these patients. For patients who are at a high risk of sustaining a significant abdominal wall complication, both perioperative and postoperative managements could be amended in a way to prevent the occurrence of wound complications and/or further abdominal wall dehiscence. The effectiveness of prophylactic mesh reinforcement in the reduction of incisional hernia rate has been previously discussed (25). Results of a recent study after kidney transplantation revealed that mesh reinforcement decreases SSI and overall wound complications (26). Promising outcomes in reducing parastomal hernia with mesh placement have also been reported (27). The use of biomaterials for abdominal wall repair has markedly modified the postoperative course of wound healing in the last few decades resulting in a reduction in recurrence rates, from up to 50% to less than 20% (28, 29). Another preventive modality may be negative pressure wound therapy (NPWT) which is applied for complex soft tissue wounds and affects the reconstruction process by shortening the healing time (30). To date, a notable gap in the existing literature is the absence of studies examining wound complications in patients undergoing ALPPS. Furthermore, we conducted a comparative analysis of postoperative wound complications between ALPPS, RLR, and SLR. Our findings revealed distinct characteristics associated with ALPPS. Specifically, ALPPS was associated with a lengthier duration of the first-stage operation, elevated postoperative levels of albumin and bilirubin, an increased incidence of overall wound complications, and consequently, prolonged total hospital stays. Furthermore, our analysis indicated that older patients with higher Body Mass Index (BMI) undergoing ALPPS, particularly those with reduced postoperative albumin levels, may be at a heightened risk of experiencing postoperative wound healing complications. Nevertheless, this study has several limitations, primarily owing to its retrospective nature and inherent heterogeneity within the study groups. To mitigate this, we employed propensity-matching techniques, carefully selecting comparable groups based on age, gender, and surgical indication. It is worth noting that the variability in skin, subcutaneous tissue, and fascial closure techniques employed during the study period may introduce some statistical uncertainty. Addressing the need for more comprehensive investigations, further studies are warranted to bridge the knowledge gap concerning the standard of care and the consequences of relaparotomies. Nonetheless, it is important to highlight that the presented ALPPS cohort stands as the most extensive to date and offers crucial insights into wound complications, potential risk factors, and strategies for prevention. In conclusion, while ALPPS remains a compelling surgical option for major liver resections in patients with previously unresectable tumors, it does pose an elevated risk of wound complications when compared to SLR and RLR procedures. Independent risk factors identified for post-hepatectomy wound complications include older age, obesity, the utilization of ALPPS as the surgical technique, and lower postoperative albumin levels. Consequently, meticulous patient selection is advised to enhance postoperative outcomes, particularly in high-risk procedures such as ALPPS and among patients undergoing RLR. Declarations Funding Statement: None Author Contribution Elias Khajeh : Conception and design of the work; Revising the work critically for important intellectual content; Approving the version to be published; Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.Nastaran Sabetkish : Acquisition, analysis, or interpretation of data; Drafting the work; Approving the version to be published; Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.Ali Ramouz : Acquisition, analysis, or interpretation of data: Revising the work critically for important intellectual content; Approving the version to be published; Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.Alexander Werba : Acquisition, analysis, or interpretation of data: Revising the work critically for important intellectual content: Approving the version to be published; Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.Rosa Klotz : Acquisition, analysis, or interpretation of data; Revising the work critically for important intellectual content; Approving the version to be published; Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.Christoph W. Michalski : Conception and design of the work; Revising the work critically for important intellectual content; Approving the version to be published; Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.Arianeb Mehrabi : Conception and design of the work; Revising the work critically for important intellectual content; Approving the version to be published; Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.Frank Pianka : Conception and design of the work; Revising the work critically for important intellectual content; Approving the version to be published; Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. COI/Disclosures: The authors declare no conflicts of interest. Financial Support: This research did not receive any specific grant from funding agencies in the public, commercial, or not-to-profit sectors. References Maki H, Hasegawa K. Advances in the surgical treatment of liver cancer. Biosci Trends. 2022;16(3):178-88. Konopke R, Volk A, Gastmeier J, Ehehalt F, Distler M, Saeger HD, et al. [Recurrent colorectal liver metastases: who benefits from a second hepatic resection?]. Zentralbl Chir. 2014;139(2):226-34. Díaz Vico T, Granero Castro P, Alcover Navarro L, Suárez Sánchez A, Mihic Góngora L, Montalvá Orón EM, et al. Two stage hepatectomy (TSH) versus ALPPS for initially unresectable colorectal liver metastases: A systematic review and meta-analysis. European journal of surgical oncology : the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology. 2022. Vennarecci G, Grazi GL, Sperduti I, Busi Rizzi E, Felli E, Antonini M, et al. ALPPS for primary and secondary liver tumors. International journal of surgery (London, England). 2016;30:38-44. Khajeh E, Ramouz A, Moghadam AD, Aminizadeh E, Ghamarnejad O, Ali-Hassan-Al-Saegh S, et al. Efficacy of Technical Modifications to the Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) Procedure: A Systematic Review and Meta-Analysis. LWW; 2022. p. e221. Marasco G, Alemanni LV, Colecchia A, Festi D, Bazzoli F, Mazzella G, et al. Prognostic Value of the Albumin-Bilirubin Grade for the Prediction of Post-Hepatectomy Liver Failure: A Systematic Review and Meta-Analysis. Journal of clinical medicine. 2021;10(9). Maehira H, Iida H, Mori H, Nitta N, Maekawa T, Takebayashi K, et al. Preoperative predictive nomogram based on alanine aminotransferase, prothrombin time activity, and remnant liver proportion (APART score) to predict post-hepatectomy liver failure after major hepatectomy. European surgical research Europaische chirurgische Forschung Recherches chirurgicales europeennes. 2022. Park HJ, Seo KI, Kim SJ, Lee SU, Yun BC, Han BH, et al. Effectiveness of Albumin-bilirubin Score as a Predictor of Post-hepatectomy Liver Failure in Patients with Hepatocellular Carcinoma. The Korean journal of gastroenterology = Taehan Sohwagi Hakhoe chi. 2021;77(3):115-22. Jorgensen LN, Kallehave F, Karlsmark T, Gottrup F. Reduced collagen accumulation after major surgery. The British journal of surgery. 1996;83(11):1591-4. Strik C, Stommel MW, Schipper LJ, van Goor H, Ten Broek RP. Risk factors for future repeat abdominal surgery. Langenbecks Arch Surg. 2016;401(6):829-37. Probst P, Tran DT, Hüttner FJ, Harnoss JC, Heger P, Ritter AS, et al. Randomised-controlled feasibility trial on abdominal wall closure techniques in patients undergoing relaparotomy (ReLap study; DRKS00013001). Langenbecks Arch Surg. 2020;405(4):427-34. van Ramshorst GH, Eker HH, Hop WC, Jeekel J, Lange JF. Impact of incisional hernia on health-related quality of life and body image: a prospective cohort study. American journal of surgery. 2012;204(2):144-50. Hempel S, Kalauch A, Oehme F, Wolk S, Welsch T, Weitz J, et al. Wound complications after primary and repeated midline, transverse and modified Makuuchi incision: A single-center experience in 696 patients. Medicine (Baltimore). 2021;100(20):e25989. Horan TC, Andrus M, Dudeck MAJAjoic. CDC/NHSN surveillance definition of health care–associated infection and criteria for specific types of infections in the acute care setting. 2008;36(5):309-32. Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TGJIC, Epidemiology H. CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. 1992;13(10):606-8. Lau NS, Ahmadi N, Verran D. Abdominal wall complications following renal transplantation in adult recipients - factors associated with interventional management in one unit. BMC surgery. 2019;19(1):10. Mehrabi A, Fonouni H, Wente M, Sadeghi M, Eisenbach C, Encke J, et al. Wound complications following kidney and liver transplantation. Clinical transplantation. 2006;20 Suppl 17:97-110. Samartsev VA, Gavrilov VA, Kuznetsova MV, Kuznetsova MP. [Risk factors of abdominal wound dehiscence in abdominal surgery]. Khirurgiia. 2020(10):68-72. Lamont PM, Ellis H. Incisional hernia in re-opened abdominal incisions: an overlooked risk factor. The British journal of surgery. 1988;75(4):374-6. ten Broek RP, Strik C, Issa Y, Bleichrodt RP, van Goor H. Adhesiolysis-related morbidity in abdominal surgery. Annals of surgery. 2013;258(1):98-106. Heise D, Bednarsch J, Kroh A, Schipper S, Eickhoff R, Lang S, et al. Operative Time, Age, and Serum Albumin Predict Surgical Morbidity After Laparoscopic Liver Surgery. Surgical innovation. 2021;28(6):714-22. Wong WG, Perez Holguin RA, Tarren AY, Shen C, Vining C, Peng JS, et al. Albumin-bilirubin score is superior to platelet-albumin-bilirubin score and model for end-state liver disease sodium for predicting posthepatectomy liver failure. Journal of surgical oncology. 2022;126(4):667-79. Höer J, Lawong G, Klinge U, Schumpelick V. [Factors influencing the development of incisional hernia. A retrospective study of 2,983 laparotomy patients over a period of 10 years]. Der Chirurg; Zeitschrift fur alle Gebiete der operativen Medizen. 2002;73(5):474-80. Barba J, Algarra R, Romero L, Tienza A, Velis JM, Robles JE, et al. Recipient and donor risk factors for surgical complications following kidney transplantation. Scandinavian journal of urology. 2013;47(1):63-71. Depuydt M, Allaeys M, de Carvalho LA, Vanlander A, Berrevoet F. Prophylactic Mesh After Midline Laparotomy: Evidence is out There, but why do Surgeons Hesitate? World journal of surgery. 2021;45(5):1349-61. Michalski CW, Mohammadi S, Khajeh E, Ghamarnejad O, Sabagh M, Pianka F, et al. Prophylactic onlay reinforcement with absorbable mesh (polyglactin) is associated with less early wound complications after kidney transplantation: A preliminary study. Journal of biomedical materials research Part B, Applied biomaterials. 2020;108(1):67-72. Pianka F, Probst P, Keller AV, Saure D, Grummich K, Büchler MW, et al. Prophylactic mesh placement for the PREvention of paraSTOmal hernias: The PRESTO systematic review and meta-analysis. PloS one. 2017;12(2):e0171548. Conze J, Binnebösel M, Junge K, Schumpelick V. [Incisional hernia - how do I do it? Standard surgical approach]. Der Chirurg; Zeitschrift fur alle Gebiete der operativen Medizen. 2010;81(3):192-200. Nessel R, Löffler T, Rinn J, Lösel P, Voss S, Heuveline V, et al. Primary and Recurrent Repair of Incisional Hernia Based on Biomechanical Considerations to Avoid Mesh-Related Complications. Frontiers in surgery. 2021;8:764470. Shrestha BM. Systematic review of the negative pressure wound therapy in kidney transplant recipients. World journal of transplantation. 2016;6(4):767-73. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 13 Nov, 2024 Read the published version in Langenbeck's Archives of Surgery → Version 1 posted Editorial decision: Revision requested 21 Oct, 2024 Reviews received at journal 21 Oct, 2024 Reviewers agreed at journal 29 Sep, 2024 Reviewers invited by journal 29 Sep, 2024 Editor assigned by journal 29 Sep, 2024 Submission checks completed at journal 26 Sep, 2024 First submitted to journal 26 Sep, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5158383","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":368688681,"identity":"d2a9a626-a9cf-4cc9-a38b-b5341e8e5ff8","order_by":0,"name":"Elias Khajeh","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Elias","middleName":"","lastName":"Khajeh","suffix":""},{"id":368688682,"identity":"b2a7b664-f620-455d-941e-29d8fa7be776","order_by":1,"name":"Nastaran Sabetkish","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Nastaran","middleName":"","lastName":"Sabetkish","suffix":""},{"id":368688683,"identity":"9aa3708f-6a28-435e-b66e-7987e503d737","order_by":2,"name":"Ali Ramouz","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Ali","middleName":"","lastName":"Ramouz","suffix":""},{"id":368688684,"identity":"2ca7b231-8eb9-42da-a071-afb0f13fd6e0","order_by":3,"name":"Alexander Werba","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Alexander","middleName":"","lastName":"Werba","suffix":""},{"id":368688685,"identity":"46400787-34a7-4212-bbf3-511bf37b159f","order_by":4,"name":"Rosa Klotz","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Rosa","middleName":"","lastName":"Klotz","suffix":""},{"id":368688686,"identity":"4b774dda-9743-41fa-9266-5d5cadf3e835","order_by":5,"name":"Christoph W. Michalski","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Christoph","middleName":"W.","lastName":"Michalski","suffix":""},{"id":368688687,"identity":"d6fd44aa-1407-4833-90e8-afbe44c556ab","order_by":6,"name":"Arianeb Mehrabi","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Arianeb","middleName":"","lastName":"Mehrabi","suffix":""},{"id":368688688,"identity":"e55db536-9651-4749-a0de-ecf05f83254f","order_by":7,"name":"Frank Pianka","email":"data:image/png;base64,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","orcid":"","institution":"","correspondingAuthor":true,"prefix":"","firstName":"Frank","middleName":"","lastName":"Pianka","suffix":""}],"badges":[],"createdAt":"2024-09-26 11:38:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5158383/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5158383/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00423-024-03540-4","type":"published","date":"2024-11-13T15:57:26+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":68531826,"identity":"1806711c-6211-4f93-a675-b36d5c1305f5","added_by":"auto","created_at":"2024-11-08 09:18:45","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":83477,"visible":true,"origin":"","legend":"\u003cp\u003ePatients allocation in different major liver resection techniques after propensity score matching\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5158383/v1/0abf5087e86976c84c58534a.jpg"},{"id":68531828,"identity":"1ac0032f-3522-47d5-8043-03b89dee9c8d","added_by":"auto","created_at":"2024-11-08 09:18:45","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":59831,"visible":true,"origin":"","legend":"\u003cp\u003eWound outcomes in different major liver resection techniques\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5158383/v1/7e6ff43501443f65f577d5f1.jpg"},{"id":68531825,"identity":"7c0aee94-1167-4f38-8c4c-3acaa68feb55","added_by":"auto","created_at":"2024-11-08 09:18:45","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":48587,"visible":true,"origin":"","legend":"\u003cp\u003eWound outcomes in patients with and without obesity\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5158383/v1/f9296194c77732f568645d87.jpg"},{"id":69286015,"identity":"e6227417-718c-4e02-9d12-08fdaef34bb5","added_by":"auto","created_at":"2024-11-18 19:28:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1174765,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5158383/v1/f22d8fa2-2a25-436a-ad28-118ff149223e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Risk factors for wound complications after associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) compared to repeated liver resection - a propensity score matching analysis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eWhile surgery remains the keystone in the treatment of liver malignancies (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e), the risk of recurrence for primary or secondary liver malignancies is still as high as up to 40% with a growing patient population in need of extensive or repeated liver resections (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). In the past two decades, recent surgical advancements have made staged hepatectomy or repeated liver resections an option in patients with otherwise unresectable liver tumors or recurrent disease (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Patients with potentially insufficient future liver remnant (FLR) are candidates for associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) which has been developed since 2007 to promote an accelerated FLR growth within 6\u0026ndash;9 days (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Although this technique has proven advantageous in achieving an R0 resection with a reduced risk of post-hepatectomy liver failure (PHLF), it still has a high risk of morbidity and mortality (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Wound complications such as fascial dehiscence, incisional hernia, or surgical site infection (SSI) are common in patients undergoing major liver surgery. However, only little is known about wound complication rates and associated factors after the ALPPS procedure.\u003c/p\u003e \u003cp\u003eImpaired liver function and repeated hepatic resections are important risk factors causing postoperative complications after major liver resection. (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Major surgeries are generally associated with a diminishing subcutaneous collagen accumulation resulting in a reduced systemic wound-healing capacity (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Repeated abdominal incisions and a history of previous surgery are also known risk factors for postoperative wound complications (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Repeated incisions in combination with impaired liver function may affect wound healing at the highest level (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). As a result, patients undergoing either ALPPS or repeated metastasectomy may be confronted with postoperative surgical site infection (SSI) or fascial dehiscence, due to impaired wound healing. However, it is not known if performing repeated incisions in a short period, as in the ALPPS procedure, is an additional risk factor compared to repeated liver resections in longer intervals.\u003c/p\u003e \u003cp\u003eThe present study aimed to evaluate the occurrence of postoperative wound complications in patients undergoing ALPPS in comparison to repeated liver resections (RLR) for cancer recurrence after major liver resection and patients after a single major liver resection (SLR). Furthermore, we aimed to assess risk factors for surgical wound complications after repeated liver surgeries.\u003c/p\u003e"},{"header":"Material and Methods","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStudy population\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data of 64 consecutive patients who underwent major liver resection through an ALPPS procedure\u0026nbsp;between October 2011 and September 2020\u0026nbsp;at the Department of General, Visceral, and Transplantation Surgery of the University Heidelberg were extracted from our prospectively maintained database.\u0026nbsp;Inclusion criteria were age \u0026gt;18 years, liver resection using a reverse L-shaped incision (rL-incision), and a minimum follow-up of 12 months. After exclusion of patients with perioperative mortality (up to 30 days) or short-term follow-up (n= 12), and those with incisions other than rL-incision (n= 12), data of 40 patients were analyzed. Data from adult patients with major open liver resection using an rL-incision during the same period were also collected (n= 458). Within this group, 133 patients underwent a repeat liver resection (RLR) due to recurrence, while the remaining 325 patients underwent a single liver resection (SLR) without any subsequent liver surgery. Propensity-score matching was meticulously performed to achieve a 1:1:1 ratio between patients in the ALPPS, RLR, and SLR groups, using gender, age, and the indication for surgery serving as matching variables (see Figure 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe study was approved by the regional ethics committee of the medical faculty (approval number: S-754/2018). The study was conducted following the STROCSS 2021 reporting guidelines and the declaration of Helsinki.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient Data Collection and Measurements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBaseline demographic and clinical data\u0026nbsp;including age, gender, body mass index (BMI), history of diabetes mellitus (DM), previous abdominal operations, diagnosis, preoperative laboratory data on the day before the surgery (albumin, bilirubin, and the international normalized ratio [INR]) as well as \u003cem\u003eintra- and postoperative data\u003c/em\u003e (including the extent of resection, operation time, length of hospital stay, postoperative complications, re-operation, and length of follow-up) were extracted from a prospective liver surgery database.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWound complication was defined as the occurrence of one of the following: SSI, wound dehiscence, abdominal fascial dehiscence, or incisional hernia. SSI was defined according to Centers for Disease Control and Prevention (CDC) criteria\u0026nbsp;(14, 15). Length of follow-up started from the second performed surgery in ALPPS and RLR groups. To assess the role of obesity in postoperative outcomes, a subgroup analysis was performed for patients with a BMI ≥30 kg/m².\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStatistical data analysis was performed with SPSS software (Version 25, SPSS Inc., Chicago, IL, USA). Categorical data are presented as proportions and percentages, and continuous data as the median and interquartile range (IQR). Categorical data are compared using the chi-square test of association or Fisher’s exact test. Continuous data are compared using one-way analysis of variance (ANOVA) followed by the Tukey posthoc test or Kruskal-Wallis H test. Propensity score-matching analysis was used to build a matched group of patients and minimize differences in confounders and baseline characteristics between the patients using age, gender, and surgical indication. The propensity score matching algorithm was performed using R, version 3.5.1 (The R Foundation for Statistical Computing, Vienna, Austria). Logistic regression analysis was used to estimate the propensity score. Patients were matched based on the logit of the propensity score by selecting the nearest available matching using a caliper width of 0.1 of the standard deviation of the estimated propensity score between study groups. Accordingly, a 1:1 matched analysis was conducted. Logistic binary regression analysis was used to calculate the multivariate odds ratios (OR) and 95% confidence intervals (95% CI). Variables with p\u0026lt;0.2 in the univariate analysis were entered into the multivariate regression analysis. All statistical tests were two-sided and a p \u0026lt;0.05 was considered significant.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n \u003ch2\u003ePerioperative data\u003c/h2\u003e\n \u003cp\u003eIn total, 40 patients with a median age of 59.5 years (IQR\u0026thinsp;=\u0026thinsp;11.75) undergoing ALPPS for various malignant diagnoses met the inclusion criteria within the study period. Another 40 matched patients with a median age of 59.0 years (IQR\u0026thinsp;=\u0026thinsp;12.0) were included in the RLR group. The second control group included 40 individuals with a median age of 60.2 years (IQR\u0026thinsp;=\u0026thinsp;14.0) who underwent an SLR. The majority of patients were male (n = 81, 67.5%) and the median BMI was 24.7 kg/m\u003csup\u003e2\u003c/sup\u003e. The baseline, intraoperative, and postoperative characteristics of patients in each group are summarized in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. Between the subgroups, there were no significant differences in preoperative characteristics including age, gender, BMI, DM, previous abdominal surgery, the indication of surgery, preoperative albumin, bilirubin, and INR levels.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eBaseline characteristics and surgical data of patients undergoing major hepatectomy with single or multiple resections\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"6\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eALPPS (n\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eRLR (n\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSLR (n\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (year) median (Q1, Q3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e59.5 (53.2, 65.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e59.0 (52.0, 64.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e60 (52, 66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.549\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender (female) n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (30.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 (35.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13 (32.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.892\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI median (Q1, Q3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25.5 (23.0, 29.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24.2 (22.0, 30.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25 (22.1, 28,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.732\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiabetes n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 (35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (17.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (15.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.066\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrevious abdominal surgery n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18 (45.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15 (37.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (27.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.265\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eIndication n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHCC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (7.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (7.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (7.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003e0.877\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCCC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16 (40.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (30.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16 (40.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCRLM\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21 (52.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25 (62.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21 (52.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreoperative Albumin median (Q1, Q3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40.3 (37.7, 45.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42.4 (39.5, 44.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42.5 (38.9, 44.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.750\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreoperative Bilirubin median (Q1, Q3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.7 (0.5, 1.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.6 (0.4, 1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.4 (0.8, 1.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.562\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreoperative INR median (Q1, Q3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.0 (0.9, 1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.0 (0.9, 1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.0 (0.9, 1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.281\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eResection type n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eExtended hepatectomy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31 (77.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13 (32.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 (25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003csup\u003e⁑\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHemihepatectomy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (22.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27 (67.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30 (75.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eOperation time for stage 1 (min) median\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Q1, Q3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e240.0\u003c/p\u003e\n \u003cp\u003e(204.7, 326.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e201.5\u003c/p\u003e\n \u003cp\u003e(165.0, 240.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e242.5\u003c/p\u003e\n \u003cp\u003e(182.5, 273.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.020\u003c/strong\u003e \u003csup\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eOperation time for stage 2 (min) median\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Q1, Q3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e128.0\u003c/p\u003e\n \u003cp\u003e(95.0, 195.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e202.5\u003c/p\u003e\n \u003cp\u003e(150.0, 260.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostoperative Albumin median\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Q1, Q3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27.5\u003c/p\u003e\n \u003cp\u003e(23.4, 30.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31.1\u003c/p\u003e\n \u003cp\u003e(28.2, 33.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30.8\u003c/p\u003e\n \u003cp\u003e(26.3, 35.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.005\u003c/strong\u003e \u003csup\u003e\u003cstrong\u003e*\u003c/strong\u003e\u0026sect;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostoperative Bilirubin median\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Q1, Q3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.5\u003c/p\u003e\n \u003cp\u003e(0.9, 2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003cp\u003e(0 8, 2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003cp\u003e(0.7, 1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.029\u003c/strong\u003e\u003csup\u003e\u0026sect;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostoperative INR median (Q1, Q3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.9 (0.5, 1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.2 (1.1, 1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.15 (1.11, 1.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.134\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall wound complications n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15 (37.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (22.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.032\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e*\u003c/strong\u003e\u0026sect;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eIn-hospital wound complications n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (15.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (5.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (2.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.485\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eReoperation for wound complication n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (17.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (7.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (5.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.143\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal postoperative complications n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15 (37.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.005\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e*\u003c/strong\u003e\u0026sect;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal ICU stays (day) median (Q1, Q3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.064\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal IMC stays (day) median (Q1, Q3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.5 (0, 10.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0, 2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0, 2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e*\u003c/strong\u003e\u0026sect;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal hospital stays (ALPPS \u0026ndash; first stage) (day) median (Q1, Q3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29.0\u003c/p\u003e\n \u003cp\u003e(24.2, 36.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.0\u003c/p\u003e\n \u003cp\u003e(9.0, 21.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.0\u003c/p\u003e\n \u003cp\u003e(9.0, 23.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e*\u003c/strong\u003e\u0026sect;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal hospital stays (ALPPS \u0026ndash; second stage) (day) median (Q1, Q3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003cp\u003e(16.0, 20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.0\u003c/p\u003e\n \u003cp\u003e(9.0, 21.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.0\u003c/p\u003e\n \u003cp\u003e(9.0, 23.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003csup\u003e\u0026sect;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eFollow-up (month) median (Q1, Q3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26.0 (17.2, 41.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22.5 (15.2, 35.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23.5 (16.0, 33.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.258\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003eQ1: Interquartile 1; Q3: Interquartile 3; ALPPS: Associating liver partition and portal vein ligation for staged hepatectomy; RLR: repeated liver resection; SLR: single liver resection; BMI: Body mass index; HCC: Hepatocellular carcinoma; CCC: Cholangiocarcinoma; CRLM: Colorectal liver metastasis; INR: International normalized ratio; SSI: surgical site infection\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003e\u003csup\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/sup\u003e Significant difference between ALPPS and RLR, \u003csup\u003e\u0026sect;\u003c/sup\u003e Significant difference between ALPPS and SLR \u003csup\u003e⁑\u003c/sup\u003e Significant difference between RLR and SLR\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eThe operation duration was significantly different among these three groups (p\u0026thinsp;=\u0026thinsp;0.001). Pairwise comparisons of the mean operation times revealed a significantly longer operation of the first stage of ALPPS compared to the RLR group (mean difference\u0026thinsp;=\u0026thinsp;71.27 minutes, SE\u0026thinsp;=\u0026thinsp;19.19, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Comparison between ALPPS and SLR (0.125) as well as RLR and SLR (p\u0026thinsp;=\u0026thinsp;0.193) revealed no significant difference. However, when comparing the operation duration of the second stage of ALPPS, the surgical procedure was longer in the RLR group compared to ALPPS (213 vs. 150 minutes, p\u0026thinsp;=\u0026thinsp;0.001).\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePostoperative data\u003c/strong\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003cp\u003e\u003cstrong\u003eI. Wound outcomes\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eOverall wound complications were significantly higher in the ALPPS group (37.5%) compared to RLR and SLR groups (22.5% and 12.5%, p\u0026thinsp;=\u0026thinsp;0.032). However, when studying different subgroups of wound complication, the statistical analysis was not different among three surgical groups (p\u0026thinsp;=\u0026thinsp;0.757 for SSI, p\u0026thinsp;=\u0026thinsp;0.772 for wound dehiscence, p\u0026thinsp;=\u0026thinsp;0.164 for abdominal fascial dehiscence, and p\u0026thinsp;=\u0026thinsp;0.080 for incisional hernia). The most frequent complication was incisional hernia in ALPPS groups (15.0%); while SSI was the most common wound complication in RLR and SLR groups (12.5% and 7.5% respectively) (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). There was no case of organ-space SSI in any group and all patients with superficial SSI were managed by antibiotic therapy. Our statistical analysis revealed no significant difference in terms of in-hospital or late complication occurrence.\u003c/p\u003e\n \u003cp\u003eThe overall mean interval between surgery and wound complication occurrence was 9.4\u0026thinsp;\u0026plusmn;\u0026thinsp;16.45 months. When considering the short-term complications (in-hospital), 4 (10.0%), 5 (12.5%), and 3 (7.5%) patients had SSI in ALPPS, RLR, and SLR groups, respectively. Additionally, 2 (5.0%), 1 (2.5%), and 1 (2.5%) patients suffered wound dehiscence in the above-mentioned groups. Furthermore, fascial dehiscence occurred in 3 (7.5%) patients in the ALPSS and 1 (2.5%) patient in the RLR group during their hospital stay. We considered late complications as those occurring after the hospitalization that occurred in 6 (15.0%), 2 (5.0%), and 1 (2.5%) patients in the ALPPS, RLR, and SLR groups, respectively. The need for reoperation due to wound complications was highest in the ALPPS group (17.5% vs. 7.5% and 5.0% in the RLR and SLR, respectively).\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eII. Laboratory findings\u003c/h3\u003e\n\u003cp\u003eThe postoperative albumin levels were significantly different among the three groups (p\u0026thinsp;=\u0026thinsp;0.005). A pairwise comparison revealed a significantly lower albumin level in ALPPS patients as compared to the RLR group (mean difference=-3.05, SE\u0026thinsp;=\u0026thinsp;1.15, p\u0026thinsp;=\u0026thinsp;0.025). Similarly, the albumin level was lower in ALPPS as compared to SLR (mean difference=-3.13, SE\u0026thinsp;=\u0026thinsp;1.15, p\u0026thinsp;=\u0026thinsp;0.021). There was no significant difference in terms of postoperative albumin level between the RLR and SLR groups (p\u0026thinsp;=\u0026thinsp;0.997). The postoperative bilirubin level was significantly different among these three groups (p\u0026thinsp;=\u0026thinsp;0.029). Pairwise comparisons showed a significant difference between the ALPPS and SLR groups (mean difference=-0.47, SE\u0026thinsp;=\u0026thinsp;0.18, p\u0026thinsp;=\u0026thinsp;0.034). Comparison between ALPPS and RLR (0.845) and RLR and SLR (p\u0026thinsp;=\u0026thinsp;0.1243) revealed no significant difference in postoperative bilirubin level. Postoperative INR levels were not statistically significant among groups (p\u0026thinsp;=\u0026thinsp;0.455). The median interval between the two surgeries in the RLR group was 9 months (range 6 to 59 months).\u003c/p\u003e\n\u003ch3\u003eIII. Overall complications\u003c/h3\u003e\n\u003cp\u003eStatistical analysis revealed a significantly higher rate of postoperative total complications in ALPPS compared to the other two groups (p\u0026thinsp;=\u0026thinsp;0.005). 7.5%, 5%, and 25% of patients in the ALPPS group had a postoperative biliary leakage, bleeding, or non-surgical complication. The rate of these complications in the RLR group was 5%, 2.5%, and 7.5%, respectively. However, 5%, 2.5%, and 4.5% of patients in the SLR group had the above-mentioned postoperative complications.\u003c/p\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eIV. Intensive care and hospital-stay\u003c/h2\u003e\n \u003cp\u003eEven though ICU stay was similar among groups, IMC stay was significantly higher in patients who underwent ALPPS (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Pairwise comparisons showed a higher IMC stay in ALPPS compared to both the SLR (mean difference\u0026thinsp;=\u0026thinsp;4.82, SE\u0026thinsp;=\u0026thinsp;0.81, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and RLR (mean difference\u0026thinsp;=\u0026thinsp;5.35, SE\u0026thinsp;=\u0026thinsp;0.81, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) groups. Furthermore, statistical analysis revealed no significant difference in the length of IMC stay between the RLR and SLR groups in terms of hospital stay (p\u0026thinsp;=\u0026thinsp;0.798). The median duration of the follow-up was 22.5 months (range: 12\u0026ndash;102 months). There was no significant difference in terms of follow-up duration among the groups (p\u0026thinsp;=\u0026thinsp;0.190). The hospital stay was significantly different among these three groups when considering the second stage of ALPPS as the initial day of hospitalization in this subgroup (20, 14, and 13 days in the ALPPS, RLR, and SLR groups, respectively, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Our analysis revealed a significantly longer hospital stay in the ALPPS as compared to the SLR group (mean difference\u0026thinsp;=\u0026thinsp;9.47, SE\u0026thinsp;=\u0026thinsp;3.82, p\u0026thinsp;=\u0026thinsp;0.039). However, the result of our statistical analysis revealed no significant difference neither between the ALPPS and RLR groups (p\u0026thinsp;=\u0026thinsp;0.093) nor between the RLR and SLR groups (p\u0026thinsp;=\u0026thinsp;0.932) concerning hospital stay. Similarly, patients were hospitalized in the ALPPS compared to the SLR group (mean difference\u0026thinsp;=\u0026thinsp;17.65, SE\u0026thinsp;=\u0026thinsp;3.80, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). However, no significant difference was detected between the RLR and SLR groups in terms of hospital stay (p\u0026thinsp;=\u0026thinsp;0.951).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eFactors associated with postoperative wound complications\u003c/h2\u003e\n \u003cp\u003eUnivariate analysis of predictive factors of postoperative wound complications revealed that age\u0026thinsp;\u0026ge;\u0026thinsp;60 (\u0026lt;\u0026thinsp;0.001), BMI\u0026thinsp;\u0026ge;\u0026thinsp;30 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), DM (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), previous abdominal surgery (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), ALPPS (p\u0026thinsp;=\u0026thinsp;0.013), preoperative bilirubin level (0.178), and postoperative albumin levels (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) were significantly correlated with postoperative wound complications. Multivariable regression analysis was performed on these six variables. Age\u0026thinsp;\u0026ge;\u0026thinsp;60 years (OR\u0026thinsp;=\u0026thinsp;27.64, 95% CI: 3.09-246.75, p\u0026thinsp;=\u0026thinsp;0.003), BMI higher than 30 kg/m2 (OR\u0026thinsp;=\u0026thinsp;30.21, 95% CI: 3.35-271.83, p\u0026thinsp;=\u0026thinsp;0.002), undergoing ALPPS surgery (OR\u0026thinsp;=\u0026thinsp;8.55, 95% CI: 1.07\u0026ndash;68.44, p\u0026thinsp;=\u0026thinsp;0.043), and decreasing of postoperative albumin to less than 30 g/dL (OR\u0026thinsp;=\u0026thinsp;168.41, 95% CI: 7.76-3651.18, p\u0026thinsp;=\u0026thinsp;0.001) were identified as independent predictors of posthepatectomy wound complications (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eUnivariate and multivariate analysis of predictive factors of postoperative wound healing complications after major hepatectomy with single or multiple resections\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"7\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eUnivariate\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eMultivariate\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAge, years (\u0026ge;\u0026thinsp;60)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e7.68\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e2.68\u0026ndash;21.99\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e27.64\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e3.09-246.75\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI, kg/m\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/sup\u003e \u003cstrong\u003e(\u0026ge;\u0026thinsp;30)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e7.79\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e2.97\u0026ndash;20.41\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e30.21\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e3.35-271.83\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.002\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.44\u0026ndash;2.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.847\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiabetes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e8.95\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e3.40-23.51\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.76\u0026ndash;26.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.096\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrevious abdominal surgery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e7.76\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e3.02\u0026ndash;19.90\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.57\u0026ndash;24.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.170\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurgery type (compared to SLR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eALPPS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e4.20\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.35\u0026ndash;13.06\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.013\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e8.55\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.07\u0026ndash;68.44\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.043\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eRLR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.61\u0026ndash;6.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.245\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.31\u0026ndash;24.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.351\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eResection type (Extended)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.40\u0026ndash;2.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.948\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eOperation time, min (\u0026ge;\u0026thinsp;180)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.26\u0026ndash;1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.251\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreoperative Albumin, g/L (\u0026lt;\u0026thinsp;40)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.47\u0026ndash;2.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.792\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreoperative Bilirubin, mg/dL (\u0026gt;\u0026thinsp;1)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.55\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.23\u0026ndash;1.31\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.178\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.12\u0026ndash;4.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.698\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreoperative INR (\u0026gt;\u0026thinsp;1.1)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.23\u0026ndash;3.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.923\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostoperative Albumin, g/L (\u0026lt;\u0026thinsp;30)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e63.00\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e8.16-486.31\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e168.41\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e7.76-3651.18\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostoperative Bilirubin, mg/dL (\u0026gt;\u0026thinsp;1)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.57\u0026ndash;3.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.501\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostoperative INR (\u0026gt;\u0026thinsp;1.1)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.52\u0026ndash;3.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.517\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003eOR: Odds ratio; BMI: Body mass index; ALPPS: Associating liver partition and portal vein ligation for staged hepatectomy; RLR: repeated liver resection; INR: International normalized ratio\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003e* For ALPPS and RLR the operation time for the second stage was considered.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003eSubgroup analysis in patients with obesity\u003c/h2\u003e\n \u003cp\u003eA total of 26 patients had a BMI\u0026thinsp;\u0026ge;\u0026thinsp;30 kg/m\u0026sup2; of whom 8 (30.8%), 10 (38.5%), and 8 (30.8%) patients underwent ALPPS, RLR, and SLR, respectively. Results of the subgroup analysis revealed no significant difference in preoperative characteristics in patients with and without obesity except diabetes which was significantly higher in patients with obesity (p\u0026thinsp;=\u0026thinsp;0.028). Intraoperative variables were similar in both groups. The evaluation of postoperative wound complications is depicted in Fig. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e. Similarly, wound dehiscence (p\u0026thinsp;=\u0026thinsp;0.008), incisional hernia (p\u0026thinsp;=\u0026thinsp;0.001), and total wound complications (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) were significantly higher in patients with a BMI\u0026thinsp;\u0026ge;\u0026thinsp;30 kg/m\u0026sup2;. Additional need for reoperation caused by wound complications was significantly higher in patients with obesity (p\u0026thinsp;=\u0026thinsp;0.001).\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, patients undergoing ALPPS, repeated, and non-repeated major liver resections were compared for the first time regarding short- and long-term wound complications with a special focus on determining risk factors. Analyses showed that wound complications were significantly higher in patients undergoing ALPPS followed by RLR and SLR.\u0026nbsp;High age (older than 60 years old), obesity\u0026nbsp;(BMI higher than 30 kg/m\u003csup\u003e2\u003c/sup\u003e), undergoing ALPPS, and lower postoperative albumin were identified as independent risk factors for post-hepatectomy wound complications.\u003c/p\u003e\n\u003cp\u003eThe underlying cause of wound complications is known to be multifactorial\u0026nbsp;(16). However, age, obesity, DM, surgical technique, method of closure, surgical complications, immunosuppressive therapy, infectious postoperative complications, and repeated surgical interventions have been determined as potent postoperative risk factors, influencing the development of post-surgical abdominal wound complications\u0026nbsp;(17, 18). Relaparotomies are believed to carry a higher risk for long-term complications such as incisional hernia\u0026nbsp;(19). Adhesiolysis, which is commonly performed in re-laparotomies, is believed to increase the risk of intraabdominal injuries, wound infections, and length of hospital stay. Furthermore, this procedure leads to a twofold risk of incisional hernia, increasing costs and reducing the quality of life\u0026nbsp;(12, 19, 20). Similarly, the present study revealed a significantly higher prevalence of wound complications in patients undergoing ALPPS and RLR. The multivariable regression analysis showed that ALPPS is an independent predictor of wound healing complications in patients undergoing major liver resection.\u003c/p\u003e\n\u003cp\u003eResults of a recent study revealed that patients’ age and preoperative albumin, as well as operative time, could be considered significant predictors of surgical morbidity\u0026nbsp;(21). Similar results were obtained in a recent study by Wong et al, indicating that the albumin-bilirubin ratio was a precise predictor of severe posthepatectomy liver failure and 30-day mortality in patients undergoing hepatectomy\u0026nbsp;(22). The presented multivariable regression analysis results show that low postoperative albumin is an independent predictor of wound healing complications in patients undergoing major liver resection.\u003c/p\u003e\n\u003cp\u003ePrevious laparotomy and disturbed wound healing were found to be of significant influence on the development of incisional hernia\u0026nbsp;(23). Although the majority of patients with postoperative abdominal wall complications could be managed with less invasive modalities such as antibiotics and simple dressings, a considerable number of cases may need additional intervention with up to 25% of patients needing reoperation in a collective undergoing renal transplantation\u0026nbsp;(24). However, the results of the multivariate analysis revealed that previous abdominal surgery may not be considered as a risk factor for wound complications in these patients.\u003c/p\u003e\n\u003cp\u003eFor patients who are at a high risk of sustaining a significant abdominal wall complication, both perioperative and postoperative managements could be amended in a way to prevent the occurrence of wound complications and/or further abdominal wall dehiscence. The effectiveness of prophylactic mesh reinforcement in the reduction of incisional hernia rate has been previously discussed\u0026nbsp;(25). Results of a recent study after kidney transplantation revealed that mesh reinforcement decreases SSI and overall wound complications\u0026nbsp;(26). Promising outcomes in reducing parastomal hernia with mesh placement have also been reported\u0026nbsp;(27). The use of biomaterials for abdominal wall repair has markedly modified the postoperative course of wound healing in the last few decades resulting in a reduction in recurrence rates, from up to 50% to less than 20%\u0026nbsp;(28, 29). Another preventive modality may be negative pressure wound therapy (NPWT) which is applied for complex soft tissue wounds and affects the reconstruction process by shortening the healing time\u0026nbsp;(30).\u003c/p\u003e\n\u003cp\u003eTo date, a notable gap in the existing literature is the absence of studies examining wound complications in patients undergoing ALPPS. Furthermore, we conducted a comparative analysis of postoperative wound complications between ALPPS, RLR, and SLR.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur findings revealed distinct characteristics associated with ALPPS. Specifically, ALPPS was associated with a lengthier duration of the first-stage operation, elevated postoperative levels of albumin and bilirubin, an increased incidence of overall wound complications, and consequently, prolonged total hospital stays. Furthermore, our analysis indicated that older patients with higher Body Mass Index (BMI) undergoing ALPPS, particularly those with reduced postoperative albumin levels, may be at a heightened risk of experiencing postoperative wound healing complications.\u003c/p\u003e\n\u003cp\u003eNevertheless, this study has several limitations, primarily owing to its retrospective nature and inherent heterogeneity within the study groups. To mitigate this, we employed propensity-matching techniques, carefully selecting comparable groups based on age, gender, and surgical indication. It is worth noting that the variability in skin, subcutaneous tissue, and fascial closure techniques employed during the study period may introduce some statistical uncertainty.\u003c/p\u003e\n\u003cp\u003eAddressing the need for more comprehensive investigations, further studies are warranted to bridge the knowledge gap concerning the standard of care and the consequences of relaparotomies. Nonetheless, it is important to highlight that the presented ALPPS cohort stands as the most extensive to date and offers crucial insights into wound complications, potential risk factors, and strategies for prevention.\u003c/p\u003e\n\u003cp\u003eIn conclusion, while ALPPS remains a compelling surgical option for major liver resections in patients with previously unresectable tumors, it does pose an elevated risk of wound complications when compared to SLR and RLR procedures. Independent risk factors identified for post-hepatectomy wound complications include older age, obesity, the utilization of ALPPS as the surgical technique, and lower postoperative albumin levels.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsequently, meticulous patient selection is advised to enhance postoperative outcomes, particularly in high-risk procedures such as ALPPS and among patients undergoing RLR.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding Statement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eElias Khajeh : Conception and design of the work; Revising the work critically for important intellectual content; Approving the version to be published; Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.Nastaran Sabetkish : Acquisition, analysis, or interpretation of data; Drafting the work; Approving the version to be published; Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.Ali Ramouz : Acquisition, analysis, or interpretation of data: Revising the work critically for important intellectual content; Approving the version to be published; Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.Alexander Werba : Acquisition, analysis, or interpretation of data: Revising the work critically for important intellectual content: Approving the version to be published; Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.Rosa Klotz : Acquisition, analysis, or interpretation of data; Revising the work critically for important intellectual content; Approving the version to be published; Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.Christoph W. Michalski : Conception and design of the work; Revising the work critically for important intellectual content; Approving the version to be published; Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.Arianeb Mehrabi : Conception and design of the work; Revising the work critically for important intellectual content; Approving the version to be published; Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.Frank Pianka : Conception and design of the work; Revising the work critically for important intellectual content; Approving the version to be published; Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCOI/Disclosures:\u003c/strong\u003e\u0026nbsp; The authors declare no conflicts of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFinancial Support:\u003c/strong\u003e This research did not receive any specific grant from funding agencies in the public, commercial, or not-to-profit sectors.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eMaki H, Hasegawa K. Advances in the surgical treatment of liver cancer. Biosci Trends. 2022;16(3):178-88.\u003c/li\u003e\n \u003cli\u003eKonopke R, Volk A, Gastmeier J, Ehehalt F, Distler M, Saeger HD, et al. [Recurrent colorectal liver metastases: who benefits from a second hepatic resection?]. Zentralbl Chir. 2014;139(2):226-34.\u003c/li\u003e\n \u003cli\u003eD\u0026iacute;az Vico T, Granero Castro P, Alcover Navarro L, Su\u0026aacute;rez S\u0026aacute;nchez A, Mihic G\u0026oacute;ngora L, Montalv\u0026aacute; Or\u0026oacute;n EM, et al. Two stage hepatectomy (TSH) versus ALPPS for initially unresectable colorectal liver metastases: A systematic review and meta-analysis. European journal of surgical oncology : the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology. 2022.\u003c/li\u003e\n \u003cli\u003eVennarecci G, Grazi GL, Sperduti I, Busi Rizzi E, Felli E, Antonini M, et al. ALPPS for primary and secondary liver tumors. International journal of surgery (London, England). 2016;30:38-44.\u003c/li\u003e\n \u003cli\u003eKhajeh E, Ramouz A, Moghadam AD, Aminizadeh E, Ghamarnejad O, Ali-Hassan-Al-Saegh S, et al. Efficacy of Technical Modifications to the Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) Procedure: A Systematic Review and Meta-Analysis. LWW; 2022. p. e221.\u003c/li\u003e\n \u003cli\u003eMarasco G, Alemanni LV, Colecchia A, Festi D, Bazzoli F, Mazzella G, et al. Prognostic Value of the Albumin-Bilirubin Grade for the Prediction of Post-Hepatectomy Liver Failure: A Systematic Review and Meta-Analysis. Journal of clinical medicine. 2021;10(9).\u003c/li\u003e\n \u003cli\u003eMaehira H, Iida H, Mori H, Nitta N, Maekawa T, Takebayashi K, et al. Preoperative predictive nomogram based on alanine aminotransferase, prothrombin time activity, and remnant liver proportion (APART score) to predict post-hepatectomy liver failure after major hepatectomy. European surgical research Europaische chirurgische Forschung Recherches chirurgicales europeennes. 2022.\u003c/li\u003e\n \u003cli\u003ePark HJ, Seo KI, Kim SJ, Lee SU, Yun BC, Han BH, et al. Effectiveness of Albumin-bilirubin Score as a Predictor of Post-hepatectomy Liver Failure in Patients with Hepatocellular Carcinoma. The Korean journal of gastroenterology = Taehan Sohwagi Hakhoe chi. 2021;77(3):115-22.\u003c/li\u003e\n \u003cli\u003eJorgensen LN, Kallehave F, Karlsmark T, Gottrup F. Reduced collagen accumulation after major surgery. The British journal of surgery. 1996;83(11):1591-4.\u003c/li\u003e\n \u003cli\u003eStrik C, Stommel MW, Schipper LJ, van Goor H, Ten Broek RP. Risk factors for future repeat abdominal surgery. Langenbecks Arch Surg. 2016;401(6):829-37.\u003c/li\u003e\n \u003cli\u003eProbst P, Tran DT, H\u0026uuml;ttner FJ, Harnoss JC, Heger P, Ritter AS, et al. Randomised-controlled feasibility trial on abdominal wall closure techniques in patients undergoing relaparotomy (ReLap study; DRKS00013001). Langenbecks Arch Surg. 2020;405(4):427-34.\u003c/li\u003e\n \u003cli\u003evan Ramshorst GH, Eker HH, Hop WC, Jeekel J, Lange JF. Impact of incisional hernia on health-related quality of life and body image: a prospective cohort study. American journal of surgery. 2012;204(2):144-50.\u003c/li\u003e\n \u003cli\u003eHempel S, Kalauch A, Oehme F, Wolk S, Welsch T, Weitz J, et al. Wound complications after primary and repeated midline, transverse and modified Makuuchi incision: A single-center experience in 696 patients. Medicine (Baltimore). 2021;100(20):e25989.\u003c/li\u003e\n \u003cli\u003eHoran TC, Andrus M, Dudeck MAJAjoic. CDC/NHSN surveillance definition of health care\u0026ndash;associated infection and criteria for specific types of infections in the acute care setting. 2008;36(5):309-32.\u003c/li\u003e\n \u003cli\u003eHoran TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TGJIC, Epidemiology H. CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. 1992;13(10):606-8.\u003c/li\u003e\n \u003cli\u003eLau NS, Ahmadi N, Verran D. Abdominal wall complications following renal transplantation in adult recipients - factors associated with interventional management in one unit. BMC surgery. 2019;19(1):10.\u003c/li\u003e\n \u003cli\u003eMehrabi A, Fonouni H, Wente M, Sadeghi M, Eisenbach C, Encke J, et al. Wound complications following kidney and liver transplantation. Clinical transplantation. 2006;20 Suppl 17:97-110.\u003c/li\u003e\n \u003cli\u003eSamartsev VA, Gavrilov VA, Kuznetsova MV, Kuznetsova MP. [Risk factors of abdominal wound dehiscence in abdominal surgery]. Khirurgiia. 2020(10):68-72.\u003c/li\u003e\n \u003cli\u003eLamont PM, Ellis H. Incisional hernia in re-opened abdominal incisions: an overlooked risk factor. The British journal of surgery. 1988;75(4):374-6.\u003c/li\u003e\n \u003cli\u003eten Broek RP, Strik C, Issa Y, Bleichrodt RP, van Goor H. Adhesiolysis-related morbidity in abdominal surgery. Annals of surgery. 2013;258(1):98-106.\u003c/li\u003e\n \u003cli\u003eHeise D, Bednarsch J, Kroh A, Schipper S, Eickhoff R, Lang S, et al. Operative Time, Age, and Serum Albumin Predict Surgical Morbidity After Laparoscopic Liver Surgery. Surgical innovation. 2021;28(6):714-22.\u003c/li\u003e\n \u003cli\u003eWong WG, Perez Holguin RA, Tarren AY, Shen C, Vining C, Peng JS, et al. Albumin-bilirubin score is superior to platelet-albumin-bilirubin score and model for end-state liver disease sodium for predicting posthepatectomy liver failure. Journal of surgical oncology. 2022;126(4):667-79.\u003c/li\u003e\n \u003cli\u003eH\u0026ouml;er J, Lawong G, Klinge U, Schumpelick V. [Factors influencing the development of incisional hernia. A retrospective study of 2,983 laparotomy patients over a period of 10 years]. Der Chirurg; Zeitschrift fur alle Gebiete der operativen Medizen. 2002;73(5):474-80.\u003c/li\u003e\n \u003cli\u003eBarba J, Algarra R, Romero L, Tienza A, Velis JM, Robles JE, et al. Recipient and donor risk factors for surgical complications following kidney transplantation. Scandinavian journal of urology. 2013;47(1):63-71.\u003c/li\u003e\n \u003cli\u003eDepuydt M, Allaeys M, de Carvalho LA, Vanlander A, Berrevoet F. Prophylactic Mesh After Midline Laparotomy: Evidence is out There, but why do Surgeons Hesitate? World journal of surgery. 2021;45(5):1349-61.\u003c/li\u003e\n \u003cli\u003eMichalski CW, Mohammadi S, Khajeh E, Ghamarnejad O, Sabagh M, Pianka F, et al. Prophylactic onlay reinforcement with absorbable mesh (polyglactin) is associated with less early wound complications after kidney transplantation: A preliminary study. Journal of biomedical materials research Part B, Applied biomaterials. 2020;108(1):67-72.\u003c/li\u003e\n \u003cli\u003ePianka F, Probst P, Keller AV, Saure D, Grummich K, B\u0026uuml;chler MW, et al. Prophylactic mesh placement for the PREvention of paraSTOmal hernias: The PRESTO systematic review and meta-analysis. PloS one. 2017;12(2):e0171548.\u003c/li\u003e\n \u003cli\u003eConze J, Binneb\u0026ouml;sel M, Junge K, Schumpelick V. [Incisional hernia - how do I do it? Standard surgical approach]. Der Chirurg; Zeitschrift fur alle Gebiete der operativen Medizen. 2010;81(3):192-200.\u003c/li\u003e\n \u003cli\u003eNessel R, L\u0026ouml;ffler T, Rinn J, L\u0026ouml;sel P, Voss S, Heuveline V, et al. Primary and Recurrent Repair of Incisional Hernia Based on Biomechanical Considerations to Avoid Mesh-Related Complications. Frontiers in surgery. 2021;8:764470.\u003c/li\u003e\n \u003cli\u003eShrestha BM. Systematic review of the negative pressure wound therapy in kidney transplant recipients. World journal of transplantation. 2016;6(4):767-73.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"langenbecks-archives-of-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"laos","sideBox":"Learn more about [Langenbeck's Archives of Surgery](http://link.springer.com/journal/423)","snPcode":"423","submissionUrl":"https://submission.nature.com/new-submission/423/3","title":"Langenbeck's Archives of Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"incisional hernia, surgical site infection, wound healing, liver surgery ","lastPublishedDoi":"10.21203/rs.3.rs-5158383/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5158383/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eAim:\u0026nbsp;\u003c/strong\u003eSufficient liver function is crucial in extracellular matrix growth, hemostasis, and wound healing. Repeated abdominal surgery is a known risk factor for the development of wound complications. This study aimed to evaluate this high-risk constellation in patients undergoing associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) and repeated liver resections (RLR) in comparison to single liver resection (SLR).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod:\u0026nbsp;\u003c/strong\u003eForty patients who underwent ALPPS between 2011 and 2020 were evenly matched with patients undergoing RLR or SLR (n=40 per group) using propensity scores. Postoperative outcomes were compared and factors associated with wound complications were analyzed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u0026nbsp;\u003c/strong\u003ePostoperative wound complications were significantly more frequent in ALPPS group (p=0.001). The reoperation rate was not significantly different between the three groups (p=0.143). However, surgical reintervention due to wound complications occurred more frequently in the ALPPS group in relation to RLR and SLR (17.5% vs. 7.5% and 5% respectively). Length of stay was significantly longer in the ALPPS group (p=0.033). ALPPS was an independent risk factor for postoperative wound complication (OR= 8.55, 95% CI:1.07-68.44, p=0.043). Risk factor analysis identified age ≥60 years (OR=27.64, 95% CI:3.09-246.75, p=0.003), BMI≥30 kg/m\u003csup\u003e2\u003c/sup\u003e (OR=30.21, 95% CI:3.35-271.83, p=0.002), and low postoperative albumin levels (OR=168.41, 95% CI:7.76-3651.18, p=0.001) as independent predictors of postoperative wound complications after major liver resection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003ePatients undergoing ALPPS and RLR are faced with a high risk of developing wound complications. Older age, obesity, a history of previous abdominal surgery, and a decreased postoperative albumin level were independent risk factors for wound complications.\u003c/p\u003e","manuscriptTitle":"Risk factors for wound complications after associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) compared to repeated liver resection - a propensity score matching analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-08 09:18:40","doi":"10.21203/rs.3.rs-5158383/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-10-21T16:43:12+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-21T15:17:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"219722657437535208483002465868265470743","date":"2024-09-29T13:06:55+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-09-29T12:14:23+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-09-29T12:11:20+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-09-26T23:48:16+00:00","index":"","fulltext":""},{"type":"submitted","content":"Langenbeck's Archives of Surgery","date":"2024-09-26T11:23:15+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"langenbecks-archives-of-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"laos","sideBox":"Learn more about [Langenbeck's Archives of Surgery](http://link.springer.com/journal/423)","snPcode":"423","submissionUrl":"https://submission.nature.com/new-submission/423/3","title":"Langenbeck's Archives of Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"d1930e01-7090-4249-9f6f-8de5784b006d","owner":[],"postedDate":"November 8th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-11-18T19:23:11+00:00","versionOfRecord":{"articleIdentity":"rs-5158383","link":"https://doi.org/10.1007/s00423-024-03540-4","journal":{"identity":"langenbecks-archives-of-surgery","isVorOnly":false,"title":"Langenbeck's Archives of Surgery"},"publishedOn":"2024-11-13 15:57:26","publishedOnDateReadable":"November 13th, 2024"},"versionCreatedAt":"2024-11-08 09:18:40","video":"","vorDoi":"10.1007/s00423-024-03540-4","vorDoiUrl":"https://doi.org/10.1007/s00423-024-03540-4","workflowStages":[]},"version":"v1","identity":"rs-5158383","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5158383","identity":"rs-5158383","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}