Ann Liver Transplant.  2022 May;2(1):78-85. 10.52604/alt.22.0006.

Right trisectionectomy with en bloc portal vein resection for perihilar cholangiocarcinoma after preoperative left portal vein stenting and sequential right portal and hepatic vein embolization

• Hwang S
• Ko GY

• KMID: 2560885
• DOI: http://doi.org/10.52604/alt.22.0006

Abstract

We present a case report of successful right trisectionectomy with en bloc portal vein (PV) resection for perihilar cholangiocarcinoma after endovascular stenting of the PV combined with sequential embolization of the right PV and hepatic vein. The case was a 74-year-old female patient with Bismuth-Corlette type IV perihilar cholangiocarcinoma with invasion of the left PV, right anterior PV, and right hepatic artery. Preoperative right portal vein embolization (PVE) was considered for future remnant liver regeneration. During right PVE, a wall stent was inserted to restore the left portal blood flow. One week later, right hepatic vein embolization was sequentially performed. At four weeks after PVE, right trisectionectomy with caudate lobectomy, bile duct resection, PV segmental resection with removal of endovascular stent and end-to-end anastomosis, and Roux-en-Y hepaticojejunostomy were uneventfully performed. The PV was segmentally resected with inclusion of a wall stent. PV defect was repaired through end-to-end anastomosis. Pathology report showed that all resection margins were tumor-negative. The patient recovered uneventfully. She has been doing well for one year with no evidence of tumor recurrence. Preoperative PV stenting might have benefited the patient because it enabled us to perform major hepatectomy successfully. Our experience could help surgical planning for hepatobiliary malignancy patients with PV invasion.

Keyword

Right trisectionectomy; Perihilar cholangiocarcinoma; Endovascular stent; Portal vein embolization; Hepatic vein embolization

Figure

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  Figure 1 Preoperative imaging study findings. (A, B) The hilar bile duct was deeply invaded by the tumor (arrows). (C, D) The left portal vein was stenotic due to tumor invasion (arrowheads).

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  Figure 2 Preoperative percutaneous portal vein stenting and embolization. (A) The left portal vein was stenotic on direct portogram (arrow). (B) Right portal vein was embolized with embolic materials.(C, D) A self-expandable wall stent was inserted into the left portal vein (arrowheads).

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  Figure 3 Preoperative percutaneous hepatic vein embolization. (A) The right hepatic vein was cannulated through a transjugular approach. A vascular plug occluded the right hepatic vein trunk (arrow; B) and its distal part was embolized (C). (D) Accessory right hepatic vein was additionally embolized with multiple coils (arrowhead).

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  Figure 4 Perioperative computed tomography (CT) follow-up image findings. Left portal vein stent (arrow) was visible at the preoperative CT (A). Postoperative CT scans were taken at 1 week (B), 2 weeks (C), and 11 months (D) after operation.

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  Figure 5 Intraoperative photographs for hepatoduodenal ligament dissection and hepatic parenchymal transection. The right liver was markedly shrunken with hypertrophy of the left liver (A). Dissection of the hepatoduodenal ligament was performed after transection of the distal common bile duct (B). The liver parenchyma was marked along the falciform ligament (C). The left hepatic duct was cut after parenchymal transection (D).

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  Figure 6 Intraoperative photographs for en bloc portal vein resection. (A) Single unified bile duct openings from the segments II and III were exposed (arrow). (B) The longitudinal axes of the left portal vein and main portal vein were marked. (C) The tumor-invaded portal vein portion was segmentally resected, leaving some of the endovascular stent (arrowhead). (D) The remnant endovascular stent was removed from the left portal vein stump.

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  Figure 7 Intraoperative photographs for portal vein anastomosis. The main portal vein stump and the left portal vein stump were approximated (A) and sutured continuously (B, C). The reconstructed portal vein appeared to be smooth streamlined without anastomotic tension (D).

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  Figure 8 Gross photograph showing the extent of surgical resection.

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  Figure 9 Intraoperative photographs for biliary reconstruction. (A) The posterior wall of the bile duct opening was anastomosed with continuous sutures. (B) The anterior wall was repaired with interrupted sutures.

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  Figure 10 Fig. 10 . Gross photograph of the resected specimen showing perihilar cholangiocarcinoma.

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