# A Case of Right Hepatic Vein Thrombus with Spontaneous Peripheral Shunt Successfully Treated via Left Trisectionectomy with Bile Duct Resection

## TL;DR

A patient with a rare liver condition was successfully treated with a complex surgery after a spontaneous vein shunt formed.

## Contribution

Demonstrates successful left trisectionectomy in a case with hepatic vein thrombosis and spontaneous shunt formation.

## Key findings

- Left trisectionectomy was safely performed after spontaneous peripheral shunt formation in a patient with right hepatic vein thrombosis.
- The patient remained cancer-free for 38 months following surgery and adjuvant treatment.
- Continuous imaging was critical for assessing resectability over time.

## Abstract

Left trisectionectomy with bile duct resection is a high-risk procedure that requires thorough preoperative evaluation to prevent postoperative liver failure. In addition, there are a few reports of highly invasive hepatectomy in cases where hepatic vein thrombosis is present preoperatively.

In a 58-year-old man, papillary epithelium was detected in the left hepatic duct during a bile duct biopsy, and the anterior segment of Glisson's capsule was compressed by the cystic components. Left trisectionectomy with bile duct resection was planned, based on a diagnosis of intraductal papillary neoplasm of the bile duct (IPNB). In our department, portal vein embolization (PVE) is essential when considering left trisectionectomy with bile duct resection, so surgery was scheduled after PVE. However, CT after PVE showed thrombus formation in the right hepatic vein (RHV), which persisted despite the initiation of anticoagulant therapy. Owing to the absence of a major drainage vein and the risk of postoperative liver failure, the patient was treated with gemcitabine + cisplatin + S-1 therapy. CT after chemotherapy still showed RHV thrombosis, along with newly developed peripheral venous shunt formation between the obliterated RHV branches. After 6 months, the same findings were observed, and as the tumor had shrunk, the case was deemed resectable. Left trisectionectomy with bile duct resection was performed. Pathological diagnosis confirmed IPNB (pTisN0M0, pStage 0 according to the Union for International Cancer Control, 8th edition). Following adjuvant chemotherapy, the patient developed pulmonary metastases, which were surgically resected. As of 38 months post-hepatectomy, the patient remains cancer-free.

We encountered a case in which left trisectionectomy with bile duct resection was possible owing to the formation of an RHV shunt, enabling resection of both the primary and recurrent lesions. Continuous imaging is essential for the dynamic assessment of resectability.