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case_images: Computed tomography showed a tumor, 40 x 38 mm in diameter, enhanced in the arterial phase (a, b) and washed out in the portal phase (c, d) in segment 6 of the liver (arrow). The right intrahepatic bile duct was dilated and tumor thrombus in the bile duct was detected (arrow head c). Endoscopic retrograde cholangiography showed a filling defect from the right hepatic duct to the common hepatic duct (arrow, e).
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case_images: Computed tomography (CT) scans showed a tumor 40 mm in diameter located in segment 6 with TT in the common hepatic bile duct (Fig. 1). Endoscopic retrograde cholangiography (ERCP) showed TT in the right hepatic duct and the common bile duct (Fig. 1).
case_images: As initial operation, we performed thrombectomy in the bile duct, transection of the right hepatic bile duct, ligation of the right hepatic artery, and external drainage of the bile duct in the right lobe (a, b schema). Macroscopic findings showed tumor thrombus in the bile duct (c).
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case_images: One month after admission, the patient underwent thrombectomy in the bile duct, transection of the right hepatic bile duct and ligation of the right hepatic artery due to bleeding from the thrombus (Fig. 2).
case_images: Trends in liver function after initial surgery.
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case_images: The bilirubin level immediately improved, and he was discharged from the hospital (Fig. 3).
case_images: Computed tomography before the second operation showed the tumor in segment 6 decreased in size (arrow a, b: arterial phase, c, d: portal phase). However, a tumor thrombus had developed in the right main portal vein (arrow head b, d). 99mTc-GSA scintigraphy revealed a reduced accumulation of GSA in the right liver (e, f).
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case_images: TT in the right portal vein developed (Fig. 4) and he was admitted to the hospital for a second operation. The serum level of total bilirubin was 1.3 mg/dl and ICGR15 was 34% at the second admission. In addition, left liver hypertrophy was observed on GSA scintigraphy (Fig. 4).
case_images: Macroscopic (a) and microscopic (b) findings showed tumor thrombi in the right hepatic bile duct (arrow head) and the right hepatic portal vein (arrow).
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case_images: TT (Fig. 5).