PMC6218703_01
Contrast-enhanced CT showed an extensive PC, involving the middle and right hepatic arteries (white arrow); however, the posterior branch of the hepatic artery had not been invaded (a). Three-dimensional surgical planning images and fusion images composed of the planning images and cholangiographic images showed locally advanced PC, involving bile ducts, hepatic arteries, and the portal vein (the trunk and bilateral branches) (the blue area indicated by the thick white arrow) (b). The tumor had also invaded the anterior sectional bile duct as well as the anterior sectional hepatic artery and portal vein (black arrow), but the posterior equivalents of these structures had not been affected by the tumor. The proper hepatic artery had not been invaded by the tumor (thin white arrow). The volume of the future remnant liver (green area) was predicted to be 48% of the original liver volume.
gr1.jpg
PMC6218703_01_gr1.jpg
fig0005
Contrast-enhanced abdominal computed tomography (CT) combined with three-dimensional imaging and cholangiography showed a perihilar mass lesion together with extensive stenosis of the intra- and extra-hepatic bile ducts (Fig. 1a and b). The right hepatic artery and portal vein were transected along the scheduled incision line (yellow lines in Fig. 1B) (Fig. 3B).
The encircled area shows the tumor mass (A). The arrow indicates the posterior hepatic artery (BD = bile duct, PHA = proper hepatic artery).. The border between the posterior and anterior sectors of the liver is indicated by the arrow (PC = perihilar cholangiocarcinoma, LT = left trisectionectomy) (B).
gr2.jpg
PMC6218703_01_gr2.jpg
fig0010
Although a hard and fixed PC lesion was present (Fig. 2A), we attempted to sample some swollen lymph nodes and the tissues surrounding the posterior hepatic artery. After transecting the left and middle hepatic arteries, a clear demarcation between the ischemic and well perfused tissue was seen (Fig. 2B).
Severe adhesion between the hilar bile duct and right hepatic artery was observed (arrowhead) (A), and the resected specimen showed that the PC was only connected to the portal vein (PV) and right hepatic artery (pHA = posterior branch of the hepatic artery, PHA = proper hepatic artery) (B). Anastomosis of the portal vein (PV) was performed (arrow) (C). An arterial anastomosis was conducted under microscopy (D) (rGEA = right gastro-epiploic artery).
gr3.jpg
PMC6218703_01_gr3.jpg
fig0015
Hepatic parenchymal transection along the right hepatic vein was performed, and the left and middle hepatic veins and the posterior hepatic duct were transected (Fig. 3A). Next, a portal anastomosis was created between the posterior branch of the portal trunk, even though the orifices of these blood vessels differed markedly in size (Fig. 3C). After confirming the presence of good portal flow, an arterial anastomosis between a tiny branch of the portal vein and a branch of the right gastro-epiploic artery was created by a plastic surgeon under microscopy (Fig. 3D).
A delayed liver abscess developed in segment 7 (arrow), which caused the accumulation of perihepatic free fluid (arrowhead) (A). After intra-abscess drainage via percutaneous puncture (using an abdominal drainage tube), the abscess was relieved, and intra-hepatic arterial (arrow) and portal flow (arrowhead) were maintained (B).
gr4.jpg
PMC6218703_01_gr4.jpg
fig0020
However, after being discharged the patient developed an intra-hepatic abscess in segment 7, and perihepatic free fluid started to accumulate (Fig. 4A and B), which was treated with drainage on day 91.