Case Report: Making room for radicality: balancing liver reserve and oncologic clearance in hilar cholangiocarcinoma through portal vein embolisation.

Hilar cholangiocarcinoma frequently necessitates extended hepatectomy to achieve oncological clearance, yet the risk of post-hepatectomy liver failure (PHLF) remains a critical concern when the future liver remnant (FLR) is inadequate. Over the last decade, strategies to induce FLR hypertrophy, including Portal Vein Embolization (PVE), Liver Venous Deprivation (LVD), and Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) have redefined the boundaries of resectability in patients with limited FLR. This report discusses a successful extended right hepatectomy enabled by PVE and explores the technical and physiological considerations of modern liver hypertrophy techniques for advanced hilar cholangiocarcinoma, highlighting three key aspects of contemporary hepatobiliary surgery: the physiological role of FLR optimization, the evolving hierarchy of liver hypertrophy strategies, and the intraoperative balance between oncologic radicality and preservation of functional liver reserve. We present a case of a 61-year-old male patient with minimal symptoms who was incidentally diagnosed with Bismuth-Corlette type IIIA hilar cholangiocarcinoma following detection of elevated serum carbohydrate antigen 19-9 (CA19-9) and cholestatic liver dysfunction. Multidisciplinary evaluation identified marginal FLR of 34%, prompting right PVE. Post-PVE volumetric assessment demonstrated robust hypertrophy with FLR increasing to 60.5%. The patient subsequently underwent open extended right hepatectomy with caudate lobectomy, complete bile duct excision, regional lymphadenectomy and Roux-en-Y hepaticojejunostomy reconstruction. The hypertrophied FLR enabled safe completion of extended resection without PHLF. This underscores the importance of preoperative PVE in converting a marginal FLR into an adequate physiological reserve, thereby enabling safe completion of extended hepatectomy for hilar cholangiocarcinoma without PHLF.