A staged approach with initial tumor thrombectomy followed by hepatectomy for icteric-type hepatocellular carcinoma: A case report

Highlights • Obstructive jaundice due to tumor thrombus in the common bile duct with HCC is classified as icteric-type HCC.• Biliary drainage for patients with icteric-type HCC is sometimes difficult.• A staged approach with initial tumor thrombectomy followed by hepatectomy should be considered as one of the options for icteric-type HCC.

* and effective treatment for icteric-type HCC patients. We report a case of icteric-type HCC successfully treated with a staged operation. This work has been reported in line with the SCARE criteria [8].

Presentation of case
A 57-year-old man presented with jaundice. There was no past history of hepatitis or blood transfusion. Blood tests showed high levels of bilirubin, protein induced by vitamin K absence or antagonist-II (PIVKA-II) and carbohydrate antigen 19-9 (CA19-9). The indocyanine green retention test (ICG R 15) could not be evaluated due to obstructive jaundice (Table 1a). 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). An endoscopic nasobiliary drainage (ENBD) tube was inserted in the left liver. ENBD was performed instead of percutaneous transhepatic biliary drainage (PTBD) due to the risk of tumor dissemination and bleeding, and insufficient dilation of the left intrahepatic bile duct. The level of total bilirubin in the bile (LTB) from the left liver as a future remnant liver was calculated at 1 week and 2 weeks after ENBD. LTB was calculated by multiplying bile density and volume obtained by ENBD [9]. One week after ENBD, the total bilirubin density was 16.9 mg/dL and the bile volume was 205 ml. Two weeks after ENBD,

Table 1
Laboratory data and liver function (a). Sequential data of the bilirubin level from the left liver (future remnant liver) (b  the total bilirubin density was 46.0 mg/dL and the bile volume was 235 ml. The LTB from the left liver increased from 34.6 mg to 108.1 mg. However, bleeding from the TT and cholangitis occurred so thatneither the patient's general condition nor the serum level of bilirubin improved. 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). The bilirubin level immediately improved, and he was discharged from the hospital (Fig. 3). However, 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 ICG R 15 was 34% at the second admission. Although the volume of bile could not be measured, the total bilirubin density in the bile from the left liver by ERCP was 40 mg/dL (Table 1b). 99m T-galactosyl human serum albumin ( 99m Tc-GSA) scintigraphy revealed a reduced accumulation of GSA in the right liver. In addition, left liver hypertrophy was observed on GSA scintigraphy (Fig. 4). We judged that right hepatectomy was possible because of the following reasons: (1) decrease in the serum level of total bilirubin, (2) hypertrophy of the left liver similar to portal vein embolization, (3) sufficient future remnant liver function on the basis of the total bilirubin density in the bile from the left liver. The patient underwent right hepatectomy for HCC. The total operation time was 326 min, and the total blood loss was 6264 g. The pathological findings yielded a diagnosis of moderately differentiated HCC with macroscopic portal vein and bile duct TT (Fig. 5).
There was no intrahepatic metastasis, and the surgical margin was negative. The patient's postoperative course was uneventful, and he was discharged on postoperative day 30 and he is well without recurrence 10 years after surgery.

Discussion
TT in the common hepatic bile duct causes obstructive jaundice, and is referred to as icteric-type HCC [1]. According to a recent report, 46.7% of HCC patients with TT in the right or left hepatic duct or the common hepatic bile duct presented with jaundice. Biliary drainage was performed in 83.3% of patients with jaundice and concurrent hemobilia was observed in 26 of 120 (22%) patients with jaundice [6].
Staged hepatectomy is usually performed for patients with unresectable bilobular liver metastasis from colorectal cancer. Portal vein ligation and associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) are performed to increase remnant liver volume. The purposes of the initial operation were the control of hemobilia and effective biliary drainage; therefore, thrombectomy in the bile duct, transection of the right hepatic bile duct and ligation of the right hepatic artery were performed. Transcatheter arterial chemoembolization (TACE) was one of the options instead of ligation of the right hepatic artery; however, Xiangji et al. reported that radical hepatectomy and removal of TT in the bile duct had a better prognosis than TACE alone in 184 patients with icteric-type HCC [10].
There are few reports on staged hepatectomy after thrombectomy in the common hepatic duct. Tsuzuki et al. commented on a staged operation for HCC with jaundice. They performed intrahepatic biliary drainage under local and general anesthesia, and  emphasize that biliary drainage and controlling cholangitis were the keys to successful major hepatectomy [11]. Thrombectomy under choledochotomy and biliary drainage is considered one of the options for patients with icteric-type HCC.
Our patient had TT with hemobilia so that effective drainage was difficult. We could not perform right hepatectomy at the first operation due to high bilirubinemia and cholangitis. The patient's condition improved immediately after the first operation and right hepatectomy could be performed successfully during the second surgery. If major hepatectomy is intended, estimation of the future remnant liver function is very important to avoid postoperative liver failure. However, for icteric-type HCC with high bilirubinemia, accurate estimation is difficult. In this case, ICG R 15 was 34% and Child-Pugh was B after initial surgery with decreased serum level of total bilirubin. 99m Tc-GSA scintigraphy revealed a reduced accumulation of GSA in the right liver compared with preoperative images. In addition, left liver hypertrophy was observed on GSA scintigraphy (Fig. 4). CT showed a rapid increase in the TT in the portal vein from the right branch to the main trunk (Fig. 4), resulting in a situation similar to portal vein embolization. Furthermore, ERCP was preformed and bile juice from the future remnant liver was collected before the first and second surgery. Higuchi et al. reported that the preoperative bile level of total bilirubin in the predicted remnant liver can be used as a predictor for safe hepatectomy with obstructive jaundice [9]. In this case, the volume of bile could not be measured, but the total bilirubin density in the bile from the left liver by ERCP was 40 mg/dL before the second surgery (Table 1b). In addition to these, other liver functions were relatively well maintained (Table 1a).
Bile duct resection for bile duct thrombus of HCC is controversial. A recent article showed that surgical outcomes were better in patients who underwent bile duct resection [6]. However, Yamamoto et al. recommended preserving the bile duct for treatment of recurrences in the remnant liver [12]. Our patient, whose bile duct was preserved, is well 10 years after right hepatectomy. More discussion is required on whether to preserve or resect the bile duct for bile duct thrombus.

Conclusions
Biliary drainage is one of the key points for successful treatment of icteric-type HCC patients. A staged approach with initial tumor thrombectomy followed by hepatectomy should be considered as one of the options for icteric-type HCC.

Funding
This study had no funding.

Ethical approval
This study was not applicable for ethical approval.

Consent
Informed consent was obtained from the patient for the publication of this case report.