A 55-year-old woman with Klatskin tumour (Bismuth-Corlette type IIIa) has a right portal vein occluded on CT angiography. The future liver remnant (FLR) is estimated at 22%. Which of the following sequential manoeuvres best maximises resectability?
- A Left portal vein embolisation (PVE) to hypertrophy the right lobe
- B Right portal vein embolisation followed by staged right hepatectomy once FLR ≥30–40% ✓
- C ALPPS (Associating Liver Partition and Portal vein ligation for Staged hepatectomy)
- D Proceed directly to extended right hepatectomy as 22% FLR is acceptable in cholestatic liver
Explanation
For a Bismuth IIIa Klatskin tumour (involving right hepatic duct to level of secondary radicles), curative resection requires an extended right hepatectomy (segments 4–8 + caudate), leaving the left lobe as FLR. A pre-operative FLR of 22% is insufficient; the threshold for safe major hepatectomy in a potentially cholestatic/fibrotic liver is ≥40% (vs ≥20–25% for normal liver). Right portal vein embolisation (PVE) induces compensatory left-lobe hypertrophy, and surgery proceeds once FLR reaches ≥30–40%. Left PVE would be wrong as it would hypertrophy the side to be removed. ALPPS carries higher morbidity than standard PVE and is not first-line for Klatskin tumours.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.