ALPPS for Left Trisectionectomy with Reconstruction of the Hepato-caval Junction Using a Peritoneal Patch Under Total Vascular Exclusion

Background Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) may rescue remnant liver hypertrophy after failure of portal vein embolization (PVE). 1 Venous reconstruction is unusual during the first step of ALPPS. 2 We report herein an ALPPS for colorectal liver metastases with reconstruction of the hepato-caval junction during the first step. Methods After failure of left PVE, a total ALPPS procedure was performed to achieve left trisectionectomy. A complete transection of the parenchyma was done to avoid extensive dissection during the second step in the context of the venous reconstruction. Total vascular exclusion (TVE) was applied selectively during venous reconstruction using a peritoneal patch. 3 Results The first step lasted 285 min with 200 ml of blood loss, and 29 min of TVE. On postoperative day (POD) 5 there was a good recovery of liver function [prothrombin time 75%; bilirubin 25 µmol/L]. On POD 14, imaging showed an increase of the future remnant liver volume and function to 50% and 48%, respectively. The second step of ALPPS lasted 120 min, with transfusion of one unit of blood, allowing resection of seven liver metastases. Postoperative course experienced a biliary fistula, the patient was discharged on POD 31 and received adjuvant chemotherapy. There was recurrence of one liver metastasis, treated by percutaneous ablation before later resection of the primary. The patient was free of recurrence 12 months after ALPPS. Conclusion Hepato-caval junction reconstruction can be performed during the first step of an ALPPS procedure, facilitated by the availability of a peritoneum patch.