Biliary obstruction from hepatic regeneration following extended right hepatectomy for tumor

Two patients, aged 2 and 6 months, underwent extended right hepatectomy for hepatoblastoma. Tumor resection was complete in both and postoperative chemotherapy was begun. One patient became markedly jaundiced 4 months postoperatively. Imaging evaluation showed marked nodular liver enlargement and intrahepatic ductal dilatation. At laparotomy an obstructed distal common duct was draped over a huge regenerating liver nodule. A high Roux-En-Y choledochojejunostomy was followed by a decrease in bilirubin to normal within 4 days. Chemotherapy was restarted and the patient remains anicteric and healthy. No evidence of tumor recurrence was found. A second patient became jaundiced 2 weeks after resection. Imaging evaluation suggested tumor recurrence. At laparotomy biopsy failed to confirm recurrent tumor but the area of the porta was not explored. Jaundice persisted and the patient died of liver failure thought secondary to tumor recurrence 4 months postoperation. Postmortem examination showed a completely obstructed common duct draped over a liver nodule and no evidence of tumor. These two patients illustrate the heretofore unrecorded entity of biliary obstruction from regenerating liver following resection for tumor. The sudden appearance of jaundice following a successful liver resection for tumor should raise the suspicion of benign repairable biliary obstruction rather than unresectable tumor recurrence. The definitive evaluation is reexploration rather than various imaging modalities, which may not only be misleading, but may delay life-saving intervention.