Right trisectionectomy with en bloc portal vein resection for cholangiocarcinoma after preoperative stenting for main portal vein occlusion

Abstract

Deprivation of portal blood flow decreases the hepatic function, thus hepatobiliary cancer patients with total occlusion of the main portal vein (PV) are usually not indicated for major hepatectomy. We herein present a 37-year-old male patient with advanced intrahepatic cholangiocarcinoma, in whom right trisectionectomy was indicated. However, the main PV was nearly completely occluded by tumor invasion, thus resolution of jaundice was markedly slow. To restore the liver function through PV recanalization, a wall stent was inserted percutaneously. Jaundice resolved progressively after PV stenting. Right trisectionectomy, caudate lobectomy, bile duct resection, and en bloc PV segmental resection with iliac vein homograft interposition were performed. However, PV thrombosis developed at the site of PV stent removal, thus a new wall stent was inserted during the operation. The pathology report presented that the tumor was a 5.2 cm-sized well-differentiated adenocarcinoma of periductal infiltrating type with lymph node metastasis. During the follow-up, the interposed PV segment with a wall stent was gradually occluded with development of portal collaterals. At 5 years after surgery, the PV stent was completely occluded and collaterals developed. The patient experienced repetition of febrile episodes of unknown causes. He is currently alive for 8 years with no evidence of tumor recurrence. The detailed surgical procedures were presented with a supplementary video clip of 5 minutes.