Ann Hepatobiliary Pancreat Surg.  2017 Nov;21(4):223-227. 10.14701/ahbps.2017.21.4.223.

ALPPS in a patient with periductal infiltrating intrahepatic cholangiocarcinoma

• Ha S
• Alshahrani AA
• Hwang S

• KMID: 2397803
• DOI: http://doi.org/10.14701/ahbps.2017.21.4.223

Abstract

Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) is a novel method to prevent post-hepatectomy hepatic failure. We present a case of periductal infiltrating intrahepatic cholangiocarcinoma undergone ALPPS, that was conducted as intraoperative choice instead of conducting preoperative portal vein embolization (PVE). A 65-year-old male patient was to undergo extended right posterior sectionectomy, but the operation plan was changed to conduct right hepatectomy with/without bile duct resection due to invasion of the right hepatic duct. After deciding to conduct ALPPS, we stopped further perihilar dissection and liver was transected. The right portal vein was ligated and Surgicel was densely packed between the transected hemilivers. There was rapid regeneration of the left liver on computed tomography follow-up, thus the second-stage right hepatectomy was conducted 10 days after the first-stage operation. Bile duct resection (BDR) was not performed due to heavy perihilar adhesion and inflammation, but fortunately tumor-negative bile duct resection margin was achieved after meticulous dissection. This patient recovered uneventfully and discharged nine days after the second-stage right hepatectomy. Thereafter he underwent concurrent chemoradiation therapy. He is doing well so far without evidence of tumor recurrence for 20 months after operation. In conclusion, this case suggests that ALPPS may be applied to an unexpected situation requiring PVE, but ALPPS is not recommend for treatment of perihilar malignancy requiring BDR.

Keyword

Infiltrating intrahepatic cholangiocarcinoma; Hepatic failure; Hepatectomy; Portal vein embolization; Liver partition

MeSH Terms

Aged
Bile Ducts
Cholangiocarcinoma*
Follow-Up Studies
Hepatectomy
Hepatic Duct, Common
Humans
Inflammation
Ligation
Liver
Liver Failure
Male
Methods
Portal Vein
Recurrence
Regeneration

Figure

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  Fig. 1 Preoperative imaging study findings. (A) Liver computed tomography scan reveals ill-defined mass with dilatation of the right posterior hepatic duct; and (B) Magnetic resonance imaging reveals segmental dilatation of the right posterior hepatic duct.

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  Fig. 2 Intraoperative photographs. (A) Liver parenchyma was transected and the right portal vein was encircled with 1-0 black silk (arrow); and (B) Ligation of the right portal vein induces dark discoloration of the right liver.

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  Fig. 3 Image findings after the first-stage operation. (A) Liver dynamic computed tomography (CT) taken at four days after liver partition revealed rapid regeneration of the left liver and packing of Surgicel between the transected hemilivers; (B) A 4-day CT image reveals complete deprivation of the right portal vein flow (an arrow indicates the site of portal vein ligation); (C) CT taken at eight days revealed further regeneration of the left liver; and (D) Gross photograph of the resected right liver specimen.

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  Fig. 4 Postoperative imaging study findings reveal regeneration of the remnant left liver taken at six days (A) and 18 months (B) after the second-stage operation.

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