In Situ Split of the Liver When Portal Venous Embolization Fails to Induce Hypertrophy: A Report of Two Cases

Introduction. Associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been reported as an efficient alternative to portal vein embolization (PVE) to induce growth of the future liver remnant (FLR). This method combines portal vein ligation with splitting of the liver parenchyma. Although shown to be efficient in introducing growth of the FLR and allowing for resection of the deportalized part of the liver one to two weeks after the first operation, this approach carries a significant mortality. Presentation of Case. ALPPS was applied to two elderly patients where PVE failed to stimulate sufficient growth of the FLR. In both cases, subsequent growth of the FLR allowed for successful resection of the liver lesions. The postoperative course was uneventful for both patients. Discussion. In both cases, the growth of the FLR was similar to what was previously reported when ALPPS has been performed, both patients underwent radical resections that would probably not have been safe after only the PVE. Conclusion. ALPPS used as rescue technique when PVE fails to stimulate sufficient growth of the FLR can be expected to deliver similar results as ALPPS "Up front". These cases also suggest that ALPPS is applicable to the elderly population.