Liver partition and portal vein ligation in staged hepatectomy (ALPPS) as a savage procedure after failed portal embolization in colorectal liver metastases

Background: Portal vein embolization (PVE) is indicated when future liver remnant (FLR) is smaller than 30% after chemotherapy, one major concern with PVE is the growth rate is usually slow and there is risk of tumor progression or the growth of FLR might be insufficient and a large number of patients will never be resected, the ALPPS could be an option for rescue in failing PVE. Case report: A 45 years-old female with sigmoid cancer and synchronous multiple liver metastases received neoadjuvant chemotherapy (8 cycles FOLFOX) followed by primary resection. CT volumetry revealed small FLR 234 ml, 23% of total liver volume, percutaneous PVE was performed, CT (Week 4) after embolization showed partial patency of the right vein considering failure to PVE. We performed ALPPS, during first stage, the liver was partitioned and right portal vein ligated, right hepatic artery, duct and vein were secured with loops CT on postoperative day 10 showed increase of 234 to 659 ml .FLR increase from 23% to 60%. The second stage of ALPPS was on postoperative day 12 completing the right hepatectomy without complications. The patient was discharged 7 days after second step. Is alive and disease free 8 months after surgery. Discussion: The mortality rate is higher in ALPPS compared to PVE. ALPPS seems offer more liver resection with increase mortality. The role of ALPPS is not clear, maybe it is most suitable for colorectal liver metastases failing to PVE. Conclusions: ALPPS could be the only option in patients failing to PVE.