PMC9400787_01
Contrast-enhanced MDCT (left) shows segmental biliary duct dilatation (arrows) in the right lobe, without demonstration of a tumor; (Right) of note is the small liver segments 2/3 with a volume of 256 mL. MDCT: multidetector CT
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F1
Follow-up computed tomography (CT) of the chest, abdomen, and pelvis showed dilated intrahepatic bile ducts in the right lobe, but no definite tumor (Figure 1).
A. MRCP shows stenosis of the right hepatic duct (big solid arrow) extending into the segmental ducts of the right lobe (small solid arrows) with significant biliary dilatation; B. gadolinium-enhanced MRI (left) shows dilated segmental ducts (arrows) converging towards a faintly hyperintense mass anterior to the right portal vein. In the subtracted image (right) the small hypervascular tumor (open arrows) encroaching upon the right portal vein branch is much better seen
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F2
Magnetic resonance cholangiopancreatography (MRCP) and contrast-enhanced magnetic resonance imaging (MRI) showed a hilar tumor, which compressed the right hepatic duct extending to the segmental ducts and showed contact with the right portal vein (Figure 2A, 2B).
A. PVE: a part of the right portal vein and the branches of segments 7 and 8 (open arrows) are already filled with embolization material (Glubran 2/Lipiodol), in contrast, the percutaneous accessed branches of segments 5 and 6 are not embolized but opacified with contrast media at the time of DSA (open arrows); B. occlusion of the right hepatic vein (left): venogram of the percutaneously punctured right hepatic vein. An Amplatzer vascular plug 2 with 16 mm diameter (large open arrows) has already been detached. Small open arrows point at 2 other vascular plugs detached in two (non-opacified) tributaries of the right hepatic vein. Post-intervention CT in the coronal plane (right) shows the vascular plugs (open arrows) and the right hepatic vein completely filled with embolization material. DSA: digital subtraction angiography
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F3
Italy) and Lipiodol (Guerbet, France) at a ratio of 1:5 (Figure 3A). In addition, the right liver vein was also percutaneous accessed and all three branches of the right liver vein were occluded using three Amplatzer vascular plugs (Abott Cardiovascular, USA) and embolized with Glubran 2/Lipiodol. The LVD procedure was finished uneventfully (Figure 3B).
MDCT scan two weeks after LVD procedure demonstrates significant hypertrophy of segments 2/3 (FRL of 552 mL)
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F4
The contrast-enhanced CT scan showed shrinkage of the embolized right liver as well as significant hypertrophy of segments 2 and 3 with sufficient remnant liver parenchyma (552 mL) (Figure 4).
Intraoperative view of the transected liver parenchyma with the left hepatic duct cannulated (arrow)
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F5
To proceed with an extended right hepatectomy (Figure 5). A right trisegmentectomy with Roux-Y hepatico-jejunostomy was performed (Figure 5).