Obstructive putty-like cast of the biliary tree

A 62-year-old woman was presented at the emergency department with cholangiosepsis. Shehad a history of liver metastases for which she had a left hemihepatectomy and loco regional recurrence atthe liver hilum for which she received chemoradiation therapy MR-imaging of the liver showed multipleintrahepatic fluid collections/abscesses, together with significantly dilated intrahepatic bile ducts. For hersignificant hepatic function impairment she received antibiotic treatment and percutaneous drainage. Thedifferential diagnosis was local tumor recurrence or post radiation fibrosis causing outflow obstructioncentrally in the liver hilum. During the admission the serum bilirubin values kept rising. During surgerysurgeons decided to perform a hepatotomy and connect a loop of the jejunum directly on the liverparenchyma, in order to allow better drainage. Intra operatively, after the hepatotomy, we encountered green-brownisch putty-like material. By traction a ‘cast’ of a large part of the biliary tree was removed.