PMC4408310_01
CT scan of this patient, showing multiple liver metastases in the liver.
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Fig1
CT revealed synchronous multiple liver metastases, mainly in the right lobe (Figure 1).
Diffusion weighted MRI of this patient, showing liver metastases in the right lobe and in segment 3.
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Fig2
R0 resection therefore required right hepatectomy and partial resection of segment 3 (Figure 2).
The first stage of ALPPS. (a,b) Shown are the right hepatic artery (yellow arrow), ligated right portal vein (white arrow), right hepatic duct (blue arrow), right hepatic vein (red arrow) and middle hepatic vein (purple arrow).
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Fig3
The resulting partitioned right lobe retained artery inflow, biliary outflow, and hepatic outflow, but had no portal vein inflow (Figure 3).
CT scan (a) before and (b) 6 days after the initial ALPPS, showing marked FLR enlargement. (c,d) arterial phase imaging. An arterioportal shunt was formed in the right Glissonian pedicle (yellow arrow).
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Fig4
AST at 1415 IU/l, ALT at 871 IU/l, LDH at 1091 IU/l and PT-INR at 1.17, with all showing gradual improvement. A CT scan on postoperative day 6 showed sufficient FLR enlargement, from 364 ml to 573 ml, or from 0.61% to 0.96% of total body weight (Figure 4).
Histological findings of the right hepatectomy specimen. (a,b) multiple liver metastases (arrow) and cut surface (triangle). (c) tubular adenocarcinoma, (d) zone 3 (centrilobular) necrosis.
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Fig5
The right hepatic vein was separated in the same way, followed by removal of the right hepatectomy specimen (Figure 5). The multiple nodules were microscopically diagnosed as liver metastases from a known rectal adenocarcinoma (Figure 5b). Histological examination showed zone 3 (centrilobular) necrosis, a finding not observed in the adjacent (segment 3) specimen (Figure 5c).
Perioperative laboratory tests. (a) AST, ALT and LDH. (b) T-Bil, D-Bil, APTT and PT. (c) CRP, WBC and PLT. (d) Alb, ChE and TCH.
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Fig6
Other laboratory tests showed nothing particularly abnormal (Figure 6).