PMC5573781_01
Finding of preoperative CT. CT showed a 5-cm HCC in segment 7-8 of the liver (arrow) (a) and a 2-cm HCC in segment 6 of the liver (arrowhead) (b).
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Child-Pugh scoring system. CT showed early enhancement of two tumors in the segments 7-8 (5 cm) and 6 (2 cm) of the liver, and hepatocellular carcinomas (HCCs) were suspected (Fig. 1a, b).
The macroscopic and pathological findings of two tumors. Both tumors showed nodule-in-nodule appearance. The tumor in segment 7-8 was moderately to poorly differentiated HCC which size was 45 x 45 x 30 mm with invasion to minor branch of hepatic vein (a). The tumor in segment 6 was well to moderately differentiated HCC which size was 20 x 17 x 15 mm (b).
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The pathological diagnosis of tumors were well to poorly differentiated HCCs which size were 45 x 45 x 30 mm (Fig. 2a) and 20 x 17 x 15 mm (Fig. 2b) with invasion to minor branch of hepatic vein. Against Cancer (UICC) pTNM Staging System was T2, N0, M0 and stage II. According to Japanese classification, it was T4, N0, M0 and stage IVa (Fig. 2a, b).
Finding of CT at postoperative day 9. CT showed the fluid collection in the right subphrenic space (arrow).
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POD 9, CT examination showed abdominal fluid collection in the area of hepatectomy (Fig. 3). Percutaneous intra-abdominal fluid drainage was performed.
Findings of DIC-CT (a-c) and enhanced CT of portal phase (d). The DIC-CT showed the bile duct from the Spiegel lobe (dotted arrow) and the bile leakage from Spiegel lobe (arrows). The enhanced CT showed the portal veins to Spiegel lobe (arrowhead). The portal veins in the Spiegel lobe branched from the left first branch.
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On POD 27, enhanced-CT and drip infusion cholangiographic (DIC)-CT showed bile duct leakage from the Spiegel lobe and that the bile duct and the portal veins of the Spiegel lobe did not run together (Fig. 4a-d).
Finding of endoscopic retrograde cholangiography. No bile leakage from another portion and the bile duct from the Spiegel lobe was not found.
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Endoscopic retrograde cholangiography did not clearly show bile leakage (Fig. 5); however, in combination with the DIC-CT examination confirmed excluded segmental bile duct leakage from the Spiegel lobe (Fig. 4c).