ALPPS for perihilar cholangiocarcinoma in a patient with cirrhosis and cardiopulmonary comorbidities: a case report.

INTRODUCTION: Perihilar cholangiocarcinoma accounts for over 50% of biliary tract cancers, with only 35% eligible for curative resection, the sole long-term survival option. Yet cirrhotic patients require >40% FLR to avoid post-hepatectomy liver failure. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) induces rapid FLR hypertrophy, yet its use in cirrhotic patients with cardiopulmonary comorbidities remains rarely reported. We report a successful high-risk open ALPPS case. PRESENTATION OF CASE: A 68-year-old woman with 20-year hepatitis B cirrhosis presented with a liver mass. Preoperative FLR was 37.17% of standard liver volume (SLV), below the 40% cirrhotic threshold. Comorbidities included coronary disease, emphysema, interstitial fibrosis, and ICG-R15 of 30%. ALPPS stage 1 (portal vein ligation plus in situ split) was performed on 29 April 2025. By postoperative day 13, left liver volume increased by 34% to >48% of SLV, enabling stage 2 right hemihepatectomy. Postoperatively, she developed acute liver failure, bile leak, and cardiac dysfunction, all of which resolved with intensive care. At the 12-month follow-up, she remained recurrence-free. DISCUSSION: This case demonstrates that ALPPS can effectively induce FLR hypertrophy and achieve R0 resection in high-risk patients with cirrhosis and cardiopulmonary insufficiency, albeit with a substantially elevated complication risk. FLR volume increase does not fully equate to functional recovery; stage 2 timing should integrate functional scores with volumetric assessment. The open approach retains its value, and multidisciplinary management remains essential. CONCLUSION: In strictly selected high-risk patients with perihilar cholangiocarcinoma, ALPPS offers an effective curative strategy. Thorough functional liver reserve assessment and robust perioperative complication management are mandatory.