Deprivation of portal flow decreases liver function and interferes functional recovery from obstructive jaundice. Patients with perihilar malignancy combined with occlusion of the main portal vein (PV) are usually not indicated for major hepatectomy because major liver resection of the icteric liver is associated with high risk of post-hepatectomy liver failure. If the portal blood flow is restored through percutaneous PV stenting, it provides an opportunity to recover the liver function preoperatively and decreases the risk of post-hepatectomy liver failure. In the literature, there were only two reports on preoperative PV embolization after PV stenting in patients with gallbladder cancer and perihilar cholangiocarcinoma with severe PV tumor invasion and stenosis [1,2]. Herein we present a case report of successful right trisectionectomy with en bloc PV resection for perihilar cholangiocarcinoma after endovascular stenting of the left PV combined with sequential embolization of the right PV and hepatic vein.

The case was a 74-year-old female patient with perihilar cholangiocarcinoma. Initial evaluation revealed Bismuth-Corlette type IV perihilar cholangiocarcinoma with invasion of the left PV, right anterior PV, and right hepatic artery (Fig. 1). Percutaneous transhepatic biliary drainage was performed for biliary decompression. Preplanned extent of surgery included right trisectionectomy and caudate lobe resection combined with bile duct resection. Because the future remnant liver appeared to not be enough considering her poor general condition and old age, we considered preoperative right portal vein embolization (PVE). However, the left PV was markedly stenotic due to tumor invasion, which might affect post-PVE liver regeneration (Fig. 1C, D). To ensure regeneration of the future remnant liver, we performed right PVE combined with left PV stenting (Fig. 2). One week later, additional right hepatic vein embolization was performed to facilitate left liver regeneration (Fig. 3).

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).

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).

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).

At four weeks after PVE, serum total bilirubin level was lowered to be around 2 mg/dL and future remnant left lateral section was markedly hypertrophied (Fig. 4A). Thus, 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 performed. The operation began with mini-laparotomy to examine whether peritoneal seeding was present or not. The right liver was markedly shrunken due to right PVE and hepatic vein embolization. The left liver appeared to be markedly hypertrophied (Fig. 5A). The distal bile duct was dissected first and transected to assess the status of tumor invasion. The distal bile duct resection margin was found to be tumor-free. Dissection continued toward the hepatic hilum. However, the main PV was invaded by the tumor. Left PV was gently dissected to assess whether tumor-free left hepatic duct resection margins could be obtained and whether the left PV stump was suitable for vascular anastomosis (Fig. 5B). After these assessment procedures, we finally decided to perform right trisectionectomy with en bloc PV resection and end-to-end anastomosis.

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.

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).

The liver parenchyma was transected along the falciform ligament (Fig. 5C). The left hepatic duct was then cut (Fig. 5D). Single unified bile duct openings from segments II and III were exposed (Fig. 6A). Intraoperative frozen-section biopsy revealed that left hepatic duct resection margins were tumor-free. After meticulous dissection of the left PV branch close to the umbilical portion (Fig. 6B), the transverse portion of the left PV was transected (Fig. 6C). Since the endovascular stent was inserted deep into the umbilical portion of the left PV, the left PV was transected, leaving a 1.5 cm-long portion of the stent at the remnant left PV stump. The fragmented wire network of the disrupted wall stent was gently pulled out under loose clamping of the left PV stump by a vascular clamp (Fig. 6D). After extensive dissection of the main PV, the main PV stump and the left PV stump were approximated directly without tension. Thus, end-to-end anastomosis was performed (Fig. 7).

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.

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).

After that, hepatic transection continued toward the dorsal part of the liver and the left caudate lobe was completely removed. After the right-trisection liver specimen was delivered outside, extensive lymphadenectomy was performed from the posterior side of the pancreas to the celiac axis (Fig. 8). Intraoperative Doppler ultrasonography showed strong PV flow, implicating uneventful PV reconstruction not requiring additional endovascular stenting. Single Roux-en-Y hepaticojejunostomy was then performed as the last step of the surgery (Fig. 9).

Figure 8. Gross photograph showing the extent of surgical resection.

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.

The pathology report presented that the tumor was a 3 cm-sized moderately-differentiated adenocarcinoma (Fig. 10). The tumor was extended to the hepatic parenchyma with the depth of invasion of 7 mm from the surface epithelia. The main PV was involved with the tumor. Lymphovascular invasion and perivascular invasion were present. There was metastasis in 3 of 5 regional lymph nodes. The left hepatic duct and distal bile duct resection margins were tumor-free.

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

The patient recovered uneventfully. She was discharged on the fourteenth postoperative day (Fig. 4). The patient underwent adjuvant chemotherapy because of the advanced tumor with extensive lymph node metastasis. The patient has been doing well for one year without any evidence of tumor recurrence.

Advanced perihilar cholangiocarcinoma can invade the hilar PV, resulting in PV stenosis and a decrease in hepatopetal portal flow. Such PV invasion is usually accompanied by obstructive jaundice from hilar bile duct obstruction. Deprivation of PV blood flow interferes with functional recovery of the liver function from obstructive jaundice. Adequate PV blood flow is essential during recovery of liver function and resolution of obstructive jaundice.

To the best of our knowledge, there were only two reports on preoperative PV embolization after preoperative PV stenting to cope with severe PV tumor invasion and stenosis involving one case of gallbladder cancer [1] and four cases of perihilar cholangiocarcinoma [2]. In the present case, right PVE and additional right hepatic vein embolization were sequentially performed to enhance contralateral hepatic regeneration [3-5]. We have previously presented a case of PV stenting and en bloc resection for far advanced intrahepatic cholangiocarcinoma [6]. In that case, right PVE was unnecessary due to pre-existing right PV occlusion by tumor invasion [6].

Preoperative PV stenting has been rarely performed in patients awaiting hepatectomy [1,2,6]. In contrast, intraoperative and postoperative PV stenting has been more frequently performed in patients undergoing PV reconstruction during liver transplantation and hepatobiliary surgery if anastomotic PV stenosis occurs [7-10]. Zhou et al. [7] have reported that reasons for PV stent placement in 59 patients with hepatobiliary and pancreatic cancers in our institution were tumor recurrence (n=30), PV resection and anastomosis (n=18), and postoperative inflammatory changes (n=11). We have reported the efficacy of intraoperative PV stenting during living donor liver transplantation [8-10].

In the literature, there was no report on intraoperative en bloc removal of the PV stent except for our precedent case [6]. The three-dimensional structure of a self-expandable wall stent is disrupted when it is transected midway, in which stent wires can be extracted under loose clamping. We experienced similar extraction of stent wires during liver transplantation in patients who had undergone transjugular intrahepatic portosystemic shunt. Since wall stent wires were located deeply at the umbilical portion of the left PV in our previous case [6], its removal induced significant intimal damage of the remnant left PV. Such intimal injury was thrombogenic. Thus, unexplainable early PV thrombus developed during operation. In the present case, we paid special attention to prevent endothelial damage during extraction of the wall stent from the remnant left PV stump. We also checked the PV flow twice after right liver removal and before abdominal wall closure as in living donor liver transplantation.

The patient is currently alive for more than one year without tumor recurrence after aggressive surgery, although the tumor was far advanced and lymph node metastasis was present. The preoperative PV stenting might have benefited the patient because it enabled us to perform major hepatectomy successfully. Our experience will facilitate surgical planning for hepatobiliary malignancy patients with PV invasion.

There was no funding related to this study.

All authors have no conflicts of interest to declare.

Conceptualization: All. Data curation: All. Methodology: All. Visualization: SH. Writing - original draft: All. Writing - review & editing: All.