Percutaneous Microwave Ablation Liver Partition and Portal Vein Embolization for Rapid Liver Regeneration

To the Editor S ince its introduction by Schnitzbauer et al 1 in 2012, associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) became a promising strategy for patients with insufficient future liver remnant (FLR). Despite the efficacy of ALPPS in triggering rapid hypertrophy of FLR, high incidence of postoperative morbidity and mortality poses a major drawback, especially for those hepatocellular carcinomas (HCCs) with liver cirrhosis. We read the paper with great interest by Gringeri et al describing a new minimally invasive laparoscopic microwave ablation and portal vein ligation for staged hepatectomy (LAPS) on the future transection plane, resulting in a satisfactory hypertrophy of FLR and an easier second step in HCC. Since anatomic hepatectomy (right/extended right hemihepatectomy or right trisectionectomy) was usually applied for huge HCC, with a relatively lower hypertrophic rate as 48.7% compared with colorectal liver metastasis (CRLM) in ALPPS or modified ALPPS, and considering the enormous stress upon patients enduring 2 laparotomies, we present a novel minimally invasive approach implementing percutaneous microwave ablation liver partition and portal vein embolization (PALPP) instead of the first step of ALPPS for rapid liver regeneration. A 43-year-old man (weight 67 kg; height 170 cm; body mass index 23.3 kg/m) was admitted with a liver mass discovered incidentally by ultrasound. Medical history was significant for 15 years of hepatitis B virus infection. Serum a-fetoprotein (AFP) was 885.2 ng/L. Dynamic enhanced computed tomography (CT) imaging revealed multiple masses in the right lobe, a 2.0 cm 1.5 cm intrahepatic metastasis in segment III (sIII), and a 1.5 cm 1.5 cm intrahepatic metastasis in segment IV (sIV) (Fig. 1A, B). The patient’s Stevenson body surface area was 1.74 m, with standard liver volume (SLV) of 1231.2 mL in Urata format. Liver volumetric CT scan measured the FLR at 355.6 mL, which was accounting for 28.9% of the total SLV. Since the inadequate FLR could not allow for a 1-step right trisectionectomy in combination with tumor resection in