portal vein embolization ( pve ) is a well - established technique to enhance functional hepatic reserves of segments ii and iii before curative extended right hepatectomy for tumors of the right liver lobe . however , an adequate hepatopetal flow of the left lateral portal vein branches is required for a sufficient pve - associated hypertrophy . here , we report a 65-year old patient suffering from a locally advanced intrahepatic cholangiocarcinoma in the right liver lobe and segment iv . a curative extended right hepatectomy after preoperative pve of liver segments iv  viii was initially impossible because of partial thrombosis of the left lateral portal vein branches resulting in an ischemic - type atrophy of segments ii and iii . however , due to a massive hypertrophy of the caudate lobe following pve of liver segments iv  viii , subsequent extended right hepatectomy with intraoperative thrombectomy of segments ii and iii was made possible . to our knowledge this is the first case in which an extended right hepatectomy for a liver malignancy , in the presence of atrophic left lateral section , was made possible by a massive pve - associated hypertrophy of the caudate lobe . extended right hepatectomy is required to obtain tumor - free surgical margins in up to one - third of oncological liver resections [ 1 , 2 ] . however , major hepatectomies are associated with increased morbidity and mortality because of postoperative liver failure ( plf ) [ 3 , 4 ] . intrahepatic cholangiocarcinoma ( ihc ) represents the second most common primary liver cancer and its incidence has risen over the past decades in western countries . curative resection represents the treatment of choice for ihc , as it is the only chance of long - term survival with 5-year survival rates ranging between 21 and 35  % [ 610 ] . results of radio- and conventional chemotherapy are limited with a median survival of 12  months [ 1114 ] . due to the mass - forming character of this tumor entity and the late onset of symptoms , patients are frequently diagnosed at an advanced tumor stage with the need of an extended right hepatectomy . in case of a predicted too low future liver remnant volume ( flrv ) of left lateral liver segments ii and iii , the safety of major hepatic resection can be significantly improved by preoperative selective portal vein embolization ( pve ) of the right liver lobe . an adequate hepatopetal flow of the left lateral portal vein branches is required for an effective pve - associated hypertrophy of segments ii and iii . here , we report a patient with an advanced ihc in the right liver lobe and segment iv and a partial portal vein thrombosis of liver segments ii and iii after selective pve of liver segments iv  viii resulting in an ischemic - type left lateral liver atrophy . however , extended right hepatectomy following pve was made possible due to a massive hypertrophy of the caudate lobe . a 65-year old female patient was referred to our center in april 2010 with a histopathologically confirmed , moderately differentiated cholangiocarcinoma of the right liver lobe and segment iv . the patient appeared to be in a good general condition and , except for a cholecystolithiasis , no further diseases were evident . the blood tests revealed elevated serum levels for carbohydrate antigen 19 - 9 ( 136  u / ml ) , normal findings for alpha-1-fetoprotein and carcinoembryonic antigen , and slightly elevated liver enzymes with a normal bilirubin level ( table  1).table  1liver function 1  day before and after pve as well as 1  day before hepatic resection and  on postoperative days 2 ( pod 2 ) and 14 ( pod 14)normal valuespvehepatic resection1  day before1  day after1  day beforepod 2pod 14bilirubin<17.1 mol / l5.911.4812.611.4total protein in serum66.087.0  g / l69.972.575.260.159.3albumin in serum3552  g / l44.544.447.73029.5asat0.170.60 ukat / l 
 0.711.280.635.080.53alat0.170.60 ukat / l0.641.540.676.790.75ap0.581.74 ukat / l2.933.193.211.641.66ggt<0.65 ukat / l3.443.674.281.952.14lipase<1.0 ukat / l0.630.560.971.881.26creatinine4584 mol / l5048564391prothrombin time>70  % 1181221136991 
 asat aspartate amino transferase , alat alanine amino transferase , ap alkaline phosphatase , ggt gamma glutamyl transferase liver function 1  day before and after pve as well as 1  day before hepatic resection and  on postoperative days 2 ( pod 2 ) and 14 ( pod 14 ) 
 asat aspartate amino transferase , alat alanine amino transferase , ap alkaline phosphatase , ggt gamma glutamyl transferase computed tomography ( ct ) of the abdomen showed a tumor spreading over liver segments iv  viii with a maximum diameter of 9  cm ( fig . consecutive ct volumetry of the liver revealed a total liver volume ( tlv ) of 1,800  cm and an flrv ( liver segments i  iii ) of only 300  cm . this made a ratio of flrv per tlv excluding tumor volume of 21.9  % . in addition , a preoperatively performed biopsy of the liver revealed fibrotic tissue and intracytoplasmatic siderosis . furthermore , the portal vein branch to segment i diverted in direct proximity to the bifurcation of the main portal vein trunk ( fig . due to insufficient flrv an embolization of the portal branches to liver segments iv  viii was performed ( fig . 1d , e ) . because of an increased risk for an accidental embolization of the left - sided portal vein branches to segments ii and iii we did not perform initial embolization of segment i. furthermore , an embolization of the caudate lobe would have additionally deprived the future liver remnant ( flr ) from valuable healthy volume . histoacryl coils or vascular plugs were also avoided because of the risk of accidental embolization of the left - sided liver segments , which might eventually compromise a successful hypertrophy and render the hepatic resection impossible.fig .  1 
 a computed tomography ( ct ) of the abdomen displaying an extended tumor manifestation prior to portal vein embolization . b ct of the abdomen 3  weeks after portal vein embolization . c ct of the abdomen 8  weeks after pve and directly before extended right hepatectomy . d antegrade transhepatic portography ( with 4f pigtail catheter in the main portal vein trunk ) showing normal contrasting of the patient s liver . e antegrade transhepatic portography ( with 4f sidewinder catheter in the main portal vein trunk ) showing no more contrasting of the right - sided liver parenchyma . f ct of the abdomen 3  months after extended right hepatectomy and curative resection . black arrow tumor - free portal vein branches to segments ii and iii ( a ) ; a tumor - related partial thrombosis of the portal vein branches to segments ii and iii ( b ) . block arrow segment i prior to embolization ( a ) , after extensive hypertrophy following embolization ( b , c ) . dashed line border between segment ii / iii and segment i. t tumor , seg i liver segment i 
 a computed tomography ( ct ) of the abdomen displaying an extended tumor manifestation prior to portal vein embolization . c ct of the abdomen 8  weeks after pve and directly before extended right hepatectomy . d antegrade transhepatic portography ( with 4f pigtail catheter in the main portal vein trunk ) showing normal contrasting of the patient s liver . e antegrade transhepatic portography ( with 4f sidewinder catheter in the main portal vein trunk ) showing no more contrasting of the right - sided liver parenchyma . f ct of the abdomen 3  months after extended right hepatectomy and curative resection . black arrow tumor - free portal vein branches to segments ii and iii ( a ) ; a tumor - related partial thrombosis of the portal vein branches to segments ii and iii ( b ) . block arrow segment i prior to embolization ( a ) , after extensive hypertrophy following embolization ( b , c ) . dashed line border between segment ii / iii and segment i. t tumor , seg i liver segment i three weeks after embolization a ct volumetry of the liver displayed a flrv of liver segments i  iii of 380  cm and a tlv of 1,709  cm . interestingly , liver hypertrophy was evident only in the caudate lobe , but not in liver segments ii and iii where the ct scan revealed a constriction of the portal branches to liver segments ii and iii to be likely responsible for an inadequate left lateral hypertrophy . prior to surgery it remained unclear whether the constriction of the left portal branches was due to tumor - related thrombosis or infiltration . it was decided to perform an explorative laparotomy , where the tumor manifestation in liver segments iv  viii was confirmed ( fig . further exploration confirmed a massive hypertrophy of the caudate lobe with a pre - existing atrophy of liver segments ii and iii ( fig . thrombosis of the portal vein to segment ii and iii , as suspected in the ct scan , was confirmed by intraoperative ultrasound.fig .  2 
 a tumor manifestation in the right liver lobe before resection . b extensive hypertrophy of segment i , atrophic left lateral section ( segment ii and iii ) and the already isolated right hepatic artery prior to division . c situs after hepatic resection with prominent caudate lobe , atrophic segments ii and iii and stump of the right hepatic artery after division . t tumor , o m omentum majus , block arrow segment i , black arrow segments ii and iii , r h a right hepatic artery , s stomach 
 a tumor manifestation in the right liver lobe before resection . b extensive hypertrophy of segment i , atrophic left lateral section ( segment ii and iii ) and the already isolated right hepatic artery prior to division . c situs after hepatic resection with prominent caudate lobe , atrophic segments ii and iii and stump of the right hepatic artery after division . t tumor , o m omentum majus , block arrow segment i , black arrow segments ii and iii , r h a right hepatic artery , s stomach preparation and exposition of the portal vein bifurcation was completed , followed by a thrombectomy of the left portal vein . a lymphadenectomy from the hepatic hilum to the celiac trunk was also performed . even after portal thrombectomy , a very low blood flow was noted in the portal branches to liver segments ii and iii , likely due to a tumor - associated portal vein stenosis . the caudate lobe displayed a significant hypertrophy with powerful perfusion via both portal vein and proper hepatic artery . the operation was terminated as an exploratory laparotomy due to the ischemic - type atrophy of segments ii and iii associated with an expected marginal residual liver function of the flr and an increased risk of plf . the analysis of the intraoperative frozen sections and the definite histology of the thrombus and the excised lymph nodes showed no evidence of tumor manifestation . a control magnetic resonance imaging of the liver displayed a renewed closure of the portal vein branches to segments ii and iii . four weeks after the laparotomy and 7  weeks after pve , another ct scan of the abdomen was performed for re - staging and renewed volumetric analysis . again the ct scan revealed a partial thrombosis of the portal branches to segments ii and iii ( fig . 1b ) ; however , the tumor showed no progression with no tumor extension to segments ii and iii or to the caudate lobe . the ct volumetry revealed a flrv for liver segments i  iii of 400  cm and a tlv of 1,250  cm ( tumor volume excluded ) . this made a ratio of flrv per tlv excluding tumor volume of 32  % . hypertrophy of the flr was solely due to an enlargement of segment i ( figs . ii and iii we decided to perform an extended right hepatectomy with curative intent . during the second operation , we explored the abdominal cavity and excluded extrahepatic tumor manifestations . parenchymal transection was performed using an ultrasonic dissection device ( cavitron ultrasonic surgical aspirator , cusa , valleylab , boulder , co , usa ) without any intraoperative complications . due to a risk of biliary leakage a t drain was routinely inserted in the main bile duct for decompression and easy access cholangiography . in the postoperative course no signs of insufficient liver function were notable . during the postoperative stay in the intensive care unit ten days after resection , the patient developed a small abscess at the resection surface which was successfully treated by percutaneous drainage . the postoperative duplex ultrasound of the liver revealed a powerful orthotopic flow of the left hepatic artery and of the hepatic veins and no evidence for central portal vein thrombosis but a persistent thrombosis in the left portal vein trunk . the conclusive pathological result showed a poorly differentiated cholangiocarcinoma without lymph node metastases ( uicc stage ii ) , hepatocellular steatosis and siderosis as well as cholestasis and cholangitis . 1f ; 2c , d ) . after a total postoperative hospitalization of 30  days the follow - up visits at 6 , 12 and 18  months after resection revealed normal liver function and no evidence of recurrent disease . liver resection represents the only curative treatment option for ihc and is currently considered as the treatment of choice in this tumor entity . studies about the efficacy of liver resection in patients with ihc showed long - term survival rates ranging from 3060  % at 5  years after resection [ 1517 ] . even in the presence of a more advanced tumor stage , partial hepatectomy can provide long - term survival in a considerable share of patients and the growing experience in liver surgery facilitates extended hepatectomies and provides a chance of cure in formerly non - resectable liver malignancies . the published results of large series of patients who received liver resection within the last 2  years underlined not only the therapeutic efficacy of this treatment but also its safety . the mortality rate even after major liver resections is mostly < 5  % in high - volume centers . hepatic surgery in the current era is regarded as a safe procedure , and its role in primary and secondary liver cancers is well established . however , plf remains a potentially life - threatening complication and often proves fatal , especially after major hepatectomy . the risk of plf depends on the quality of the parenchyma and the volume of the remnant liver . once liver failure is established , no reliable disease - specific therapy is currently available and liver transplantation is mostly contraindicated in these patients , resulting in reported mortality rates of 6080  % [ 20 , 21 ] . thus , a sufficient flrv is crucial for the success of major hepatectomies in these patients . few treatment modalities are established to minimize the risk of postoperative liver insufficiency by improving liver function and the remnant volume before major hepatectomies , such as pve and selective biliary decompression in patients with biliary stasis . recently , novel strategies have been proposed , i.e. , inclusive cd133 + hematopoietic stem cells therapy , which seems to positively impact overall outcomes after extended right hepatectomy or in situ split techniques in combination with portal vein ligature [ 2325 ] . here , we propose a selective hypertrophy of the caudate lobe as a novel approach to facilitate extended right hepatectomy in patients with large tumors of the right liver lobe . extended right hepatectomy may be considered impossible in cases of ischemic - type atrophy of left lateral segments . however , in contrast to liver segments ii and iii , the caudate lobe appeared well perfused and of good parenchymal quality in the present patient . due to a significant hypertrophy of segment i during the post - interventional course following pve , extended right hepatetcomy became feasible with no major complications apparent postoperatively . in particular , the liver function did not reveal any signs of significant insufficiency in spite of the atrophy of segments ii and iii . this case is of major interest for patients with severely limited left lateral liver function scheduled for uni- or bilobular hepatectomies . these patients are widely excluded from curative treatment strategies due to the anticipated risk of plf . therefore , an induction of hypertrophy of segment i could be a promising approach and , unless the diagnosis is hilar cholangiocarcinoma , may provide a sufficient remnant liver function to perform curative liver resection . aware of the fact that isolated , massive hypertrophy of segment i following pve is possible , initial embolization of this segment could be avoided . in selected patients , one could consider initial embolization of segments 48 only , thus awaiting potential hypertrophy induction of segment i. in conclusion , extended right hepatectomy in the presence of thrombosis of the left portal vein branches to segments ii and iii is feasible if liver segment i reveals an adequate hypertrophy . to our knowledge , this is the first case in which an extended right hepatectomy was made possible by massive pve - associated hypertrophy of the caudate lobe . therefore , atrophy of segments ii and iii may not represent a general contraindication to extended right hepatectomy .
abstract 
 introductionportal vein embolization ( pve ) is a well - established technique to enhance functional hepatic reserves of segments ii and iii before curative extended right hepatectomy for tumors of the right liver lobe . 
 however , an adequate hepatopetal flow of the left lateral portal vein branches is required for a sufficient pve - associated hypertrophy.case reporthere , we report a 65-year old patient suffering from a locally advanced intrahepatic cholangiocarcinoma in the right liver lobe and segment iv . a curative extended right hepatectomy after preoperative pve of liver segments iv  viii was initially impossible because of partial thrombosis of the left lateral portal vein branches resulting in an ischemic - type atrophy of segments ii and iii . however , due to a massive hypertrophy of the caudate lobe following pve of liver segments iv  viii , subsequent extended right hepatectomy with intraoperative thrombectomy of segments ii and iii was made possible.conclusionsto our knowledge this is the first case in which an extended right hepatectomy for a liver malignancy , in the presence of atrophic left lateral section , was made possible by a massive pve - associated hypertrophy of the caudate lobe .