Reviewer ’s report  
 
Title: Partial ALPPS versus Complete ALPPS for Staged Hepatectomy  
 
Version: 0 Date: 25 Jul 2019  
 
Reviewer: Gabriele Spoletini  
 
Reviewer's report:  
 
The topic is of interest also  considering the growing enthusiasm around ALPPS and the many 
variations that have been described in the attempt to make it a more successful procedure.  
I have a few comments and general reservations regarding the results and the conclusions that 
can be drawn from a meta -analysis comparing partial and complete ALPPS.  
 
Abstract:  
Background: I would avoid saying ALPPS is "generally accepted … to be more suitable … ". 
Firstly because there is no strong evidence that it is superior (e.g. functional hypertroph y and 
outcomes) than classic two stage hepatectomy. Second, because the authors have not stated what 
they are comparing it to (i.e. better than what?). I would rather emphasize it has become very 
popular for achieving fast hypertrophy and high rates of com pletion of the two stages of the 
resection (e.g. there is up to 40% drop out rate after the first stage with classic two stage 
hepatectomy).  
 
Language: language is relatively informal for a scientific publication. I would avoid 
abbreviations and apostrophe s such as haven't instead of have not and so on. Several sentences 
need rephrasing by a mother tongue editor. A few examples:  
- 1.Background, third paragraph: "In the light of ALPPS registry, the mortality dropped to 9% 
and serious complication rate droppe d to 27% by patient selection" could be reconsidered in 
favor of "Since the creation of the ALPPS Registry and the adoption of more stringent selection 
criteria, the mortality rate dropped to 9% and serious complication (Clavien Dindo > grade 3) 
rate to 27 %". 
- 3.2.Characteristics of the included trials and studies: "Four articles were included[8 -10, 13], 
containing 62 patients accepted partial ALPPS and 62 patients accepted complete ALPPS." I 
would suggest replacing "accepted" with "undergoing" or similar.  
 
Methods:  
- Search strategy: seems accurate. Newcastle Ottawa Scale has been applied.  
- "We attempted to contact the authors to obtain original information which couldn't (be) 
extracted from articles." It is not clear whether there was any reply from the  authors. Please 
expand.  
 
Results:  
The scarcity of available literature comparing Partial and Complete ALPPS and the exiguous 
number of patients included in the four articles selected, hamper the quality of the results and 
therefore it is not possible to  draw firm conclusions. Also, main indication for ALPPS are 
inevitably heterogeneous across the studies included and these are not examined in detail in the 
meta -analysis.  
 
Discussion:  
The discussion should emphasize more clearly and from the beginning the  limitations of this 
systematic review due to the aforementioned issues.  
The discrepancy with the mortality rate between Partial and Complete ALPPS has been 
mitigated by some Groups who reported lower mortality rates with complete ALPPS after 
applying more  stringent selection criteria. This should be mentioned in the discussion.  
Discussion, 2nd paragraph: "In our studies, partial ALPPS induced comparable FLR hypertrophy 
with lower postoperative complications rate, which were similar with the previous studie s." I 
would replace "our studies" with "the articles included in the analysis".  
Altogether, this meta -analysis is of interest. However, more details need to be extrapolated from 
the data of the selected articles in order to improve completeness of information and to highlight 
the limitations of the conclusions that can be drawn from t he available data. The risk is that, by 
grouping together too many different entities (e.g. indications, background liver condition, 
hemihepatectomies vs extended hepatectomies, etc.), the information can be misleading.   
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which c ontrols are required in your comments to the authors.  
 
No 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further  
assessment in your comments to the editors.  
 
I recommend additional statistical review  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some language corrections before being published  
 
Declaration of competing interests  
Please complete a declaration of competin g interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an  
organisation that may in any way gain or lose financially from the publication of this  
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose  
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents relating t o the content of the  
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds  or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have  no competing interests' 
below. If your reply is yes to any, please give details below.  
 
I declare that I have  no competing interests  
 
I agree to the open peer review policy of the journal. I understand that my name will be included  
on my report to the authors and, if the manuscript is accepted for publication, my named report  
including any attachments I upload will be posted on the website along with the authors' 
responses. I agree for my report to be made available under an Open Access Creative Commons  
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand t hat any comments  
which I do not wish to be included in my named report can be included as confidential comments  
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
Reviewer ’s report  
 
Title: Partial ALPPS versus Complete ALPPS for Staged Hepatectomy  
 
Version: 0 Date: 25 Jul 2019  
 
Reviewer: Gabriele Spoletini  
 
Reviewer's report:  
 
The topic is of interest also  considering the growing enthusiasm around ALPPS and the many 
variations that have been described in the attempt to make it a more successful procedure.  
I have a few comments and general reservations regarding the results and the conclusions that 
can be drawn from a meta -analysis comparing partial and complete ALPPS.  
 
Abstract:  
Background: I would avoid saying ALPPS is "generally accepted … to be more suitable … ". 
Firstly because there is no strong evidence that it is superior (e.g. functional hypertroph y and 
outcomes) than classic two stage hepatectomy. Second, because the authors have not stated what 
they are comparing it to (i.e. better than what?). I would rather emphasize it has become very 
popular for achieving fast hypertrophy and high rates of com pletion of the two stages of the 
resection (e.g. there is up to 40% drop out rate after the first stage with classic two stage 
hepatectomy).  
 
Language: language is relatively informal for a scientific publication. I would avoid 
abbreviations and apostrophe s such as haven't instead of have not and so on. Several sentences 
need rephrasing by a mother tongue editor. A few examples:  
- 1.Background, third paragraph: "In the light of ALPPS registry, the mortality dropped to 9% 
and serious complication rate droppe d to 27% by patient selection" could be reconsidered in 
favor of "Since the creation of the ALPPS Registry and the adoption of more stringent selection 
criteria, the mortality rate dropped to 9% and serious complication (Clavien Dindo > grade 3) 
rate to 27 %". 
- 3.2.Characteristics of the included trials and studies: "Four articles were included[8 -10, 13], 
containing 62 patients accepted partial ALPPS and 62 patients accepted complete ALPPS." I 
would suggest replacing "accepted" with "undergoing" or similar.  
 
Methods:  
- Search strategy: seems accurate. Newcastle Ottawa Scale has been applied.  
- "We attempted to contact the authors to obtain original information which couldn't (be) 
extracted from articles." It is not clear whether there was any reply from the  authors. Please 
expand.  
 
Results:  
The scarcity of available literature comparing Partial and Complete ALPPS and the exiguous 
number of patients included in the four articles selected, hamper the quality of the results and 
therefore it is not possible to  draw firm conclusions. Also, main indication for ALPPS are 
inevitably heterogeneous across the studies included and these are not examined in detail in the 
meta -analysis.  
 
Discussion:  
The discussion should emphasize more clearly and from the beginning the  limitations of this 
systematic review due to the aforementioned issues.  
The discrepancy with the mortality rate between Partial and Complete ALPPS has been 
mitigated by some Groups who reported lower mortality rates with complete ALPPS after 
applying more  stringent selection criteria. This should be mentioned in the discussion.  
Discussion, 2nd paragraph: "In our studies, partial ALPPS induced comparable FLR hypertrophy 
with lower postoperative complications rate, which were similar with the previous studie s." I 
would replace "our studies" with "the articles included in the analysis".  
Altogether, this meta -analysis is of interest. However, more details need to be extrapolated from 
the data of the selected articles in order to improve completeness of information and to highlight 
the limitations of the conclusions that can be drawn from t he available data. The risk is that, by 
grouping together too many different entities (e.g. indications, background liver condition, 
hemihepatectomies vs extended hepatectomies, etc.), the information can be misleading.   
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which c ontrols are required in your comments to the authors.  
 
No 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further  
assessment in your comments to the editors.  
 
I recommend additional statistical review  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some language corrections before being published  
 
Declaration of competing interests  
Please complete a declaration of competin g interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an  
organisation that may in any way gain or lose financially from the publication of this  
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose  
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents relating t o the content of the  
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds  or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have  no competing interests' 
below. If your reply is yes to any, please give details below.  
 
I declare that I have  no competing interests  
 
I agree to the open peer review policy of the journal. I understand that my name will be included  
on my report to the authors and, if the manuscript is accepted for publication, my named report  
including any attachments I upload will be posted on the website along with the authors' 
responses. I agree for my report to be made available under an Open Access Creative Commons  
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand t hat any comments  
which I do not wish to be included in my named report can be included as confidential comments  
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
Please review this paper.
user
Reviewer ’s report  
 
Title: Partial ALPPS versus Complete ALPPS for Staged Hepatectomy  
 
Version: 0 Date: 25 Jul 2019  
 
Reviewer: Gabriele Spoletini  
 
Reviewer's report:  
 
The topic is of interest also  considering the growing enthusiasm around ALPPS and the many 
variations that have been described in the attempt to make it a more successful procedure.  
I have a few comments and general reservations regarding the results and the conclusions that 
can be drawn from a meta -analysis comparing partial and complete ALPPS.  
 
Abstract:  
Background: I would avoid saying ALPPS is "generally accepted … to be more suitable … ". 
Firstly because there is no strong evidence that it is superior (e.g. functional hypertroph y and 
outcomes) than classic two stage hepatectomy. Second, because the authors have not stated what 
they are comparing it to (i.e. better than what?). I would rather emphasize it has become very 
popular for achieving fast hypertrophy and high rates of com pletion of the two stages of the 
resection (e.g. there is up to 40% drop out rate after the first stage with classic two stage 
hepatectomy).  
 
Language: language is relatively informal for a scientific publication. I would avoid 
abbreviations and apostrophe s such as haven't instead of have not and so on. Several sentences 
need rephrasing by a mother tongue editor. A few examples:  
- 1.Background, third paragraph: "In the light of ALPPS registry, the mortality dropped to 9% 
and serious complication rate droppe d to 27% by patient selection" could be reconsidered in 
favor of "Since the creation of the ALPPS Registry and the adoption of more stringent selection 
criteria, the mortality rate dropped to 9% and serious complication (Clavien Dindo > grade 3) 
rate to 27 %". 
- 3.2.Characteristics of the included trials and studies: "Four articles were included[8 -10, 13], 
containing 62 patients accepted partial ALPPS and 62 patients accepted complete ALPPS." I 
would suggest replacing "accepted" with "undergoing" or similar.  
 
Methods:  
- Search strategy: seems accurate. Newcastle Ottawa Scale has been applied.  
- "We attempted to contact the authors to obtain original information which couldn't (be) 
extracted from articles." It is not clear whether there was any reply from the  authors. Please 
expand.  
 
Results:  
The scarcity of available literature comparing Partial and Complete ALPPS and the exiguous 
number of patients included in the four articles selected, hamper the quality of the results and 
therefore it is not possible to  draw firm conclusions. Also, main indication for ALPPS are 
inevitably heterogeneous across the studies included and these are not examined in detail in the 
meta -analysis.  
 
Discussion:  
The discussion should emphasize more clearly and from the beginning the  limitations of this 
systematic review due to the aforementioned issues.  
The discrepancy with the mortality rate between Partial and Complete ALPPS has been 
mitigated by some Groups who reported lower mortality rates with complete ALPPS after 
applying more  stringent selection criteria. This should be mentioned in the discussion.  
Discussion, 2nd paragraph: "In our studies, partial ALPPS induced comparable FLR hypertrophy 
with lower postoperative complications rate, which were similar with the previous studie s." I 
would replace "our studies" with "the articles included in the analysis".  
Altogether, this meta -analysis is of interest. However, more details need to be extrapolated from 
the data of the selected articles in order to improve completeness of information and to highlight 
the limitations of the conclusions that can be drawn from t he available data. The risk is that, by 
grouping together too many different entities (e.g. indications, background liver condition, 
hemihepatectomies vs extended hepatectomies, etc.), the information can be misleading.   
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which c ontrols are required in your comments to the authors.  
 
No 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further  
assessment in your comments to the editors.  
 
I recommend additional statistical review  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some language corrections before being published  
 
Declaration of competing interests  
Please complete a declaration of competin g interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an  
organisation that may in any way gain or lose financially from the publication of this  
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose  
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents relating t o the content of the  
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds  or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have  no competing interests' 
below. If your reply is yes to any, please give details below.  
 
I declare that I have  no competing interests  
 
I agree to the open peer review policy of the journal. I understand that my name will be included  
on my report to the authors and, if the manuscript is accepted for publication, my named report  
including any attachments I upload will be posted on the website along with the authors' 
responses. I agree for my report to be made available under an Open Access Creative Commons  
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand t hat any comments  
which I do not wish to be included in my named report can be included as confidential comments  
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
assistant