PMC4486396_01
Preoperative imaging studies: (A) Contrast-enhanced computed tomography (CE-CT): Arrowheads show solid lesions in the left hepatic duct. (B) Endoscopic retrograde cholangiography (ERC): Arrowheads indicate filling defects in the left hepatic duct. (C-D) Peroral cholangioscopy: (C) Arrowheads indicate the orifice of the right hepatic duct. No tumor lesions are presented. Arrows indicate the orifice of the left hepatic duct which is completely filled with papillary tumors. (D) Arrowheads indicate papillary tumors located in the common hepatic duct.
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Contrast-enhanced computed tomography (CE-CT) showed dilatation of the intrahepatic bile duct in the left hemiliver and the extrahepatic bile ducts and a mass lesion in the left hepatic duct (Fig. 1A). Endoscopic retrograde cholangiography (ERC) revealed the presence of multiple blood clots at the ampulla of Vater and filling defects within the left hepatic duct (Fig. 1B). Peroral cholangioscopy (POCS) revealed papillary tumors without mucin production at the orifice of the left hepatic duct, while no tumor lesions were observed right hepatic duct (RHD; Fig. 1C). A papillary tumor was also detected in the common hepatic duct (CHD), which was located separately from the tumors in the left hepatic duct (Fig. 1D).
(A) Gross appearance of resected specimens: *,  , and   correspond to liver parenchyma of segment 2 + 3, liver parenchyma of segment 4, and common bile duct, respectively. The photograph enclosed by the solid line indicates magnification of the area enclosed by the dotted line. (B) Tumor microscopy image indicating the presence of pancreatobiliary-type adenocarcinoma.
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By gross appearance, two papillary tumors were observed in the left main hepatic duct and CHD in a discontinuous manner (Fig. 2A). Microscopically, these tumors were diagnosed as pancreatobiliary-type adenocarcinoma (Fig. 2B).
(A) Postoperative CE-CT imaging study: Arrowheads indicate dilatation of the intrahepatic duct of the posterior segment. (B-D) Postoperative imaging studies using double-balloon enteroscopy (DBE): (B) Arrowheads and arrow indicate the papillary tumors protruding from the anastomotic orifice of hepatic duct of segment 6 (B6) and segment 7 (B7), respectively. DBE-assisted direct cholangiography indicates filling defects throughout B6 (C) and B7 (D).
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Upon CT imaging, an anastomotic stenosis of the hepaticojejunostomy was suspected (Fig. 3A). Double-balloon enteroscopy (DBE) was performed, revealing papillary tumors protruding from the anastomotic orifice of the hepaticojejunostomy (Fig. 3B). DBE-assisted ERC showed filling defects throughout the posterior branch of the hepatic duct (Fig. 3C and D).