Ann Hepatobiliary Pancreat Surg.  2020 Aug;24(3):339-344. 10.14701/ahbps.2020.24.3.339.

Hepatic atrophy treatment with portal vein embolization to control intrahepatic duct stenosis-associated cholangitis

• Hwang S
• Ko GY
• Gwon DI

• KMID: 2505348
• DOI: http://doi.org/10.14701/ahbps.2020.24.3.339

Abstract

We present two cases of hepatic atrophy treatment with portal vein embolization (PVE) to control intractable cholangitis. The first case was a 60-year-old male who was admitted for repeated episodes of cholangitis. He had undergone cholecystectomy and Roux-en-Y choledochojejunostomy 2 years earlier. Imaging studies showed left intrahepatic duct dilatation and anastomotic site stricture. The patient was reluctant to undergo another surgery. Thus, we decided to perform left PVE to induce atrophy of the left liver. The left liver shrank and stayed silent for 5 years, but a radiological intervention was necessary to treat symptomatic anastomotic stenosis. The patient has done well for 12 years after PVE. The second case was a 51-year-old female who was also admitted for repeated episodes of cholangitis. She had undergone excision of type I choledochal cyst 2 years earlier. Imaging studies showed right hepatic duct stenosis. Cholangitis developed repeatedly. Thus, radiologic interventions were performed 8 times over 9 years. Finally, she was referred for surgery, but she was very reluctant to undergo another surgery. We planned a wait-and-see strategy following right PVE. After PVE, the right liver progressively shrank. Three months after PVE, we decided to wait for a longer period until further atrophy of the right liver. The patient has been doing well for 14 months after PVE without any episode of cholangitis. In conclusion, experience from our two cases suggests that hepatic parenchymal induction therapy through percutaneous PVE can be a therapeutic option for patients with perihilar biliary stenosis-associated cholangitis.

Keyword

Biliary stenosis; cholangitis; liver atrophy; Portal vein embolization; radiological intervention

Figure

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  Fig. 1 In image findings of the Case 1. (A) Computed tomography showed left intrahepatic duct dilatation with abrupt luminal narrowing around the surgical anastomosis site and suspicious high attenuating lesion in the left proximal intrahepatic duct. (B) Hepatobiliary scintigraphy showed delayed biliary excretion of the left liver.

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  Fig. 2 Left portal vein embolization of the Case 1 (A) and computed tomography taken after 5 days (B).

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  Fig. 3 Follow-up computed tomography scan of the Case 1 at 7 days (A), 2 years (B) and 4 years (C) after portal vein embolization. Hepatobiliary scintigraphy taken at 4 years showed normal biliary excretion (D).

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  Fig. 4 Follow-up imaging studies of the Case 1 at 5 years after portal vein embolization. (A) The left hepatic ducts were dilated. (B) Percutaneous transhepatic biliary drainage was performed. (C) The left hepatic ducts were decompressed. (D) The left liver was shrunken.

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  Fig. 5 Follow-up imaging studies of the Case 1 at 6 years after portal vein embolization. (A) There was cholangiohepatitis in the right liver and a 1 cm-sized stone at the choledochojejunostomy site. (B-D) Percutaneous transhepatic biliary drainage and repeated balloon dilatation were performed. (E) Cholangitis was controlled. (F) Hepatobiliary scintigraphy showed normal biliary excretion.

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  Fig. 6 Preoperative imaging studies of the Case 2 showing choledochal cyst of type I (A) and no marked dilatation of the intrahepatic ducts (B).

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  Fig. 7 Initial image findings of the Case 2. (A and B) Computed tomography and magnetic resonance cholangiography showed right intrahepatic duct stones with biliary dilatation. (C and D) Intrahepatic stones were removed through percutaneous transhepatic cholangioscopy.

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  Fig. 8 Right portal vein embolization of the Case 2 before (A) and after (B) embolization.

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  Fig. 9 Follow-up computed tomography (CT) scans of the Case 2 during the first 1 year after portal vein embolization showing progressive atrophy of the right liver. CT scans were taken at 7 days (A), 1 month (B), 3 months (C) and 12 months (D) after portal vein embolization.

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