PMC6487366_01
Patient 1: Preoperative contrast-enhanced CT (a,b) shows liver metastasis of the right lobe of the liver (white arrows), well encroaching on the plane of the middle hepatic vein (black arrow).. Post-stage-1 unenhanced CT on postoperative day 7 (c,d) shows the liver partition plane metallic clips and postoperative fluid (black arrowheads) with normal liver parenchyma separating it from the lesion (white arrows).. Post-stage-2 contrast-enhanced CT at 4 months post stage 2 (e,f) shows obvious increase in size of the remaining liver.
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A contrast-enhanced computed tomography (CT) scan and magnetic resonance imaging (MRI) confirmed presence of two liver lesions in segment VIII and segment VI, with only peripheral enhancement in the venous phase, but they could not characterize them (Fig. 1a and b). CT volumetry was done on postoperative day 7 and showed an FLR volume of 705 ml and total liver volume of 2059 ml (Fig. 1c and d). The patient had a follow up CT scan at 4 months (Fig. 1e and f) after surgery and a PET-CT scan at 6 months, and both demonstrated enormous regeneration of the liver remnant.
Patient 1: Intraoperative photograph of the liver after parenchymal division during the first stage. The right bile duct and the right hepatic artery are slung by vascular tape, while the right portal vein has been divided by a vascular stapler.
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Thunderbeat  (Fig. 2).
Patient 1: Intraoperative photograph of the liver after completion of the second stage. The disease right liver was resected, and the remnant left liver shows significant hypertrophy when compared to stage 1.
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The operation lasted for about 2 h, with no blood loss (Fig. 3).
PMC6487366_02
Patient 2: Preoperative contrast-enhanced CT (a,b) shows liver metastasis of the right lobe of the liver (white arrows), intimately related to the middle hepatic vein (black arrow).. Post-stage-1 unenhanced CT on postoperative day 6 (c,d) shows the liver partition plane metallic clips (black arrowheads).. Post-stage-2 unenhanced T1-weighted MRI at 6 months post stage 2 (e,f) shows obvious increase in size of the remaining liver.
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The lesion was located in the angle between the middle and right hepatic veins at their junction with the Inferior Vena Cava (IVC), abutting them and making resection impossible without division of both veins (Fig. 4a and b). The liver was found to be markedly fatty on imaging that was mostly related to chemotherapy, and extended liver resection would be unsafe and would put the patient at risk of post-hepatectomy liver failure. Follow up CT on postoperative day 6 demonstrated good hypertrophy of the FLR to 35.7% (Fig. 4c and d). Last follow-up at 6 months after surgery revealed that the patient remained well with no complications and no evidence of tumor recurrence on imaging (Fig. 4e and f).
Patient 2: Preoperative contrast-enhanced CT shows new metastasis of the right lobe of the liver (Black arrow). The RFA treated old lesion is marked with a white arrow.
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Follow up images four months after the ablation showed a maintained complete response of the ablated lesion, but a new lesion was seen in segment 8 (Fig. 5).
Patient 2:: Intraoperative photograph at the end of stage 2. A catheter is seen passing into the remnant of the right bile duct for a completion cholangiogram to confirm the anatomy and patency of the remaining biliary system.
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A healthy remnant liver with good hypertrophy was confirmed intra-operatively (Fig. 6).