PMC4353938_01
Preoperative imaging studies.. (A) Endoscopic retrograde cholangiopancreatography showed an approximately 2 cm stricture of the common bile duct (arrow).. (B) The tumor is seen to be infiltrating the upper pancreas (arrow) and is very close to the proper hepatic artery (arrowhead).. (C) Axial image of contrast-enhanced CT scan showed that the left hepatic artery (arrow) originated from the left gastric artery (arrowhead).
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Endoscopic retrograde cholangiopancreatography showed an approximately 2 cm stricture in the mid-distal bile duct (Fig. 1A). Contrast-enhanced CT scan revealed existence of tumor in mid-distal bile duct infiltrating to upper pancreas and the distance between tumor and the proper hepatic artery was as close as 3 mm and infiltration was suspected (Fig. 1B). A replaced left hepatic artery originated from the left gastric artery (Fig. 1C).
Vascular imaging studies before and after embolization.. (A) Celiac angiography revealed that the replaced left hepatic artery originated from the left gastric artery.. (B) Following embolization of the proper hepatic artery (coils seen on this study), celiac arteriography shows that the replaced left hepatic artery now provides flow to the middle and right hepatic arteries. There are no obvious shunts seen from the retroperitoneum or pancreaticoduodenal vessels.. PHA, proper hepatic artery; MHA, middle hepatic artery; RHA, right hepatic artery; CHA, common hepatic artery; GDA, gastroduodenal artery; CA, celiac artery, LHA left hepatic artery. (C) Three dimensional CT scan image shows blood flow through an intra hepatic shunt to the middle hepatic artery (arrowhead) and right hepatic artery (arrow).
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In order to promote the development of collateral blood flow from the replaced left hepatic artery to the right side of the liver after excision of the hepatic artery, preoperative segmental embolization of the proper hepatic artery with coils was performed (Fig. 2A). Following embolization, flow is seen from the left hepatic artery to the right and middle hepatic arteries (Fig. 2B). Thirteen days after embolization, enlargement of the replaced left hepatic artery and blood flow through an intra-hepatic shunt to the middle hepatic artery and the right hepatic artery was observed (Fig. 2C).
The transection lines of the right, middle and common hepatic arteries and the common bile duct are shown. The position of the coils is shown in blue.
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PPPD was performed at 33 days after embolization (Fig. 3).
Microscopic findings in the resected specimen show a moderately differentiated adenocarcinoma of the bile duct (above the dotted line), with very close approximation to the proper hepatic artery (circled dotted line).
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Pathologic findings after resection showed very close approximation of the tumor to the proper hepatic artery (Fig. 4).
Computed tomography scan of the liver seven days postoperatively shows flow from the left hepatic artery (arrow) to the distal right hepatic artery (arrowhead).
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Seven days postoperatively, a CT scan was obtained which showed flow in the replaced left hepatic artery and the distal portion of the right hepatic artery (Fig. 5), which is similar to the flow shown in Fig. 2B, after embolization.