Simultaneous bile duct and portal venous branch ligation in two-stage hepatectomy

Figure 1 Barium enema findings. A filling defect caused by a tumor in the cecum was observed.

Figure 2 Preoperative findings from contrast-enhanced computer tomography of the abdomen. Multiple metastatic nodules with 2-6 cm diameter were observed in the right hepatic lobe and three nodules measuring 3-3.5 cm diameter in the left hepatic lobe. A preoperative volume rate of the right hepatic lobe was 56.3%.

Figure 3 Initial operation scheme. Right hemicolectomy was performed. At the same time, the metastatic tumor in segment 3 was resected and the metastatic tumors in segments 2 and 4 were coagulated using MCT (90 W, 60 s). Furthermore, the right bile duct and right branch of the portal vein were ligated simultaneously. MCT: Microwave coagulation therapy.

Figure 4 Findings from contrast-enhanced computer tomography of the abdomen at 1 wk after surgery. Two coagulated areas in the left hepatic lobe and dilation of the right bile duct were observed. Ligation of the right branch of the portal vein resulted in a complementary increase in the right hepatic arterial blood flow. The volume rate of the right hepatic lobe was 55.0%, which was similar to the preoperative rate.

Figure 5 Findings from contrast-enhanced computer tomography of the abdomen at 1 mo after surgery. The volume rate of the right hepatic lobe decreased to 44.3% and the volume of left hepatic lobe underwent compensatory hypertrophy. This liver volume shift was approximately 12% from the right to the left lobe. There were no viable tumors in the left hepatic lobe.

Figure 6 Intraoperative findings from the secondary operation. A: There were 10 nodules with 1-4 cm diameter in the right hepatic lobe; B: Resection was performed using the suture of the right bile duct and the right branch of the portal vein.

Figure 7 Postoprative course. The serum levels of carcinoembryonic antigen and carbohydrate antigen 19-9 decreased to 36.3 ng/dL and 96 U/mL, respectively. But further recurrence was observed in the remaining liver, and at 1 year and 8 mo after the initial operation, the patient developed liver failure and died. TS-1: Tegafur, gimeracil, and oteracil.