PMC10235763_01
Contrast-enhanced computed tomography after chemotherapy showed tumor thrombus in portal vein trunk and growth of cavernous transformation.
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F1
Chemotherapy was initiated with the SIOPEL-4 regimen, which resulted in tumor shrinkage, but no improvement in the portal obstruction (Figure 1).
Upper: intraoperative ICG fluorescence method. (A) Visible light photo shows portal vein trunk (PVT: arrow) and cavernous transformation of the portal vein (CTPV: triangle). (B) Positive fluorescence was detected only from PVT, suggesting existence of viable tumor tissue. No fluorescence was detected from CTPV. Lower: Making a Rex bypass. (C) The umbilical vein was detected in the round ligament. (D) Recanalized umbilical vein was anastomosed to portal vein trunk stump.
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F2
Intraoperatively, the indocyanine green (ICG) fluorescence demonstrated fluorescence in the main trunk of the portal vein, suggesting the presence of viable tumor tissue (Figure 2). However, because hepatopetal blood flow through the CTPV was insufficient for the remaining left lobe, a Rex bypass was constructed by anastomosing the umbilical vein directly to the portal trunk stump (Figure 2).
A schema of this operation is shown. The main trunk of the portal vein containing the tumor thrombus was resected. The umbilical vein leading to the portal umbilical portion was recanalized and an iliac vein graft was interposed and anastomosed to the portal vein stump.
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F3
An external iliac vein graft was interposed and re-anastomosed, resulting in a good blood supply (Figure 3).