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Malerba et al. Hepatoma Res 2021;7:19 I http://dx.doi.org/10.20517/2394-5079.2020.131 Page 5 of 9

Figure 2. Series of contrast-enhanced computed tomography (in the arterial and portal phases) showing the development of the FLR
after each procedure. FLR: future liver remnant; PVE: portal vein embolization; HVE: hepatic vein embolization.

At this point, although 35% could have been considered sufficient for performing a major liver resection in
some cases, in this specific case, an upfront right hepatectomy was considered at high risk for PHLF, due to
liver function impairment indicated by a persistently elevated R15 value in the ICG test.

A rescue ALPPS was ultimately considered as a final salvage attempt in this case. The most recognized
advantages of ALPPS are the significant increase in FLR volume and the short time interval necessary to
[26]
achieve it . It is an excellent salvage procedure but can also be associated with significant postoperative
[27]
morbidities and mortality rates , probably due to the fact that the fast liver hypertrophy following ALPPS
does not necessarily correspond to a rapid liver function improvement. In the current case, however, the
further increase in FLR volume was satisfactory.

To reduce the risk of infectious complication following the first step of ALPPS in a right liver already
deprived of its portal inflow and venous outflow, we opted for a mini-ALPPS, consisting in a less aggressive