Reprint requests: John L. Cameron, M.D., Department of Surgery,. The Johns Hopkins ..... Cameron JL, Skinner DB, Zuidema GD. Long-term transhepatic.
Proximal Bile Duct Tumors Surgical Management with Silastic Transhepatic Biliary Stents JOHN L. CAMERON, M.D., PATRICK BROE, M.B., GEORGE D. ZUIDEMA, M.D.
Over a nine-year period, 27 patients with proximal biliary tumors were operated upon. In ten of the 27 patients (37%) tumor resection including the hepatic bifurcation was possible, and bilateral hepaticojejunostomies were performed using silastic transhepatic biliary stents. In the remaining 17 patients the tumor was partially resected, dilated, or bypassed, and reconstruction to a Roux-en-Y jejunal loop was carried out using silastic transhepatic biliary stents. Hospital mortality for those patients undergoing resection was zero, and for the entire group 4% (1/27). The mean bilirubin on admission was 13.2 mg/dl and after discharge fell to a mean of 1.5 mg/dl. Mean survival for the entire group is 18 months with 11 patients still alive. Mean survival for the first nine patients undergoing resection is 21 months with seven patients still alive (one for over 5 years). The 15 patients dying following discharge survived for a mean of 14 months.
1
CARCINOMAS MAY ARISE anywhere in the biliary tree. The most difficult to diagnose and to manage sur-
gically are the proximal lesions arising at the common hepatic duct bifurcation, or in the common hepatic duct and extending proximally to involve the bifurcation. These tumors are often small, slow growing, and slow to metastasize. They usually cause death not from tumor spread, but from hepatic failure and/or sepsis from highgrade biliary obstruction. In recent years the more frequent use of the newer techniques for obtaining cholangiography in the jaundiced patient has made diagnosis of these small lesions possible at an earlier stage. This has allowed surgical intervention at a time when curative resection may be possible, or at least palliative decompression carried out. Over a nine-year period we have operated upon 27 patients with proximal biliary tumors. Our results using silastic transhepatic biliary stents are reported. Clinical Material Between October 1973 and March 1982, 27 patients with proximal biliary tract tumors were operated upon Presented at the Annual Meeting of the American Surgical Asso-
ciation, Boston, Massachusetts, April 21-23, 1982. Reprint requests: John L. Cameron, M.D., Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland 21205.
From the Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland
at The Johns Hopkins Medical Institutions and managed with silastic transhepatic biliary stents. Nineteen of the patients were men and eight were women. Twenty-one of the patients were white and six were black. Ages ranged from 24 to 76 years and averaged 60 years. Two ofthe patients also had chronic ulcerative colitis. Thirteen ofthe 27 patients had undergone biliary tract surgery within the 24 months prior to referral. All underwent cholecystectomy and/or common duct exploration. The diagnosis of a biliary malignancy was confirmed or suspected in only six patients. During this same time interval four additional patients were seen who on the basis of cholangiography or prior surgery were also felt to have proximal biliary malignancies. They were managed by percutaneous transhepatic internal drainage and were not operated upon either because of (1) acute illness that precluded safe operative intervention, (2) advanced age and/or systemic disease, or (3) cholangiographic evidence of unresectability. Five additional patients with proximal biliary tumors were managed by the modified Longmire procedure' and are not included. Twenty-five of the 27 patients operated upon presented with jaundice. One patient presented with mild abdominal pain and an elevated alkaline phosphatase. The diagnosis of a biliary tumor blocking only one lobar hepatic duct was made by endoscopic retrograde cholangiography. Another patient presented with recurrent episodes of cholangitis. Weight loss was present in ten patients, and seven had mild abdominal pain. Two patients were febrile at the time of presentation. On admission to Hopkins the serum bilirubin of these 27 patients ranged from 0.8 mg/dl to 36.5 mg/dl and averaged 13.2 mg/dl. The mean serum alkaline phosphatase was markedly elevated, the mean serum transaminases mildly elevated, and the mean serum albumin was normal (Table 1).
0003-4932/82/1000/0412 $01.20 © J. B. Lippincott Company
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The diagnosis of a proximal biliary tumor was made in all instances by cholangiography. In 20 patients the cholangiography was performed percutaneously, in three by the endoscopic retrograde route, and in four patients via a T tube that had been placed in the distal common duct operatively before referral to Hopkins. Six patients at the time of percutaneous cholangiography had Ring catheters2 inserted into one or both ductal systems and passed through the tumor into the duodenum. Internal drainage prior to surgery was maintained for three to 13 days with a mean of seven days. The interval between the initial symptoms and surgical intervention at Hopkins ranged from two weeks to two years, and averaged eight months.
Operative Management The cholangiographic diagnosis of a proximal biliary cancer is considered secure enough that resection is attempted without tissue confirmation. If cholecystectomy has not previously been performed, the gall bladder is mobilized to improve access to the hepatic duct bifurcation. In addition, the common bile duct is divided early in the dissection (Fig. 1). This allows one to reflect the proximal common duct and common hepatic duct in a cephalad direction, separating the biliary tract from the portal vein. The hepatic bifurcation can then be dissected from in front and behind, with the portal vein bifurcation safely separated from the biliary structures. Having Ring catheters in both the right and left ductal systems allows easy palpation of these structures above the bifurcation in the areolar tissue prior to their entering the hepatic parenchyma. Even at this stage a tumor mass may not be evident, although the bifurcation is always thickened and firm suggesting cancer. If normal ducts can be palpated above the tumor at the bifurcation, the ducts are divided and the tumor removed. Silastic transhepatic biliary stents are inserted by passing a Bakes dilator or Randall Stone forceps up the right and left ductal systems and out through parenchyma onto the diaphragmatic surface of the liver. The silastic stent is then secured to the instrument and pulled back down through hepatic parenchyma, the biliary system, and out the porta hepatis (Fig. 2). These stents are generally 6 mm in outside diameter, and 60 cm in length. Forty per cent of the length contains multiple side holes. The portion of the stent remaining in the ductal system and Roux-en-Y loop contains side holes. That portion of the stent passing out through the superior surface of the liver is brought out through a stab wound in the upper abdomen, and contains no side holes. A Roux-en-Y loop 60 cm in length is then constructed and brought up in a retrocolic fashion into the right upper quadrant. Bilateral hepaticojejunostomies are performed (Fig. 3). In
TABLE 1. Liver Function Tests at the Time of Admission and at the Lowest Level Following Discharge from the Hospital
Bilirubin (mg/dl) Alkaline Phosphatase
(IU/L) SGOT (IU/L) SGPT (IU/L) Albumin (g/dl)
Normal
Pre Op
Post Op
.6.
|
SURVIVAL CURVE OF PATIENTS TREATED WITH BILATERAL (solid line) vs UNILATERAL (inlerrupled line) |SILASTIC TRANSHEPATIC STENTS
E
.5 z 0
a:4. 0 ---
0.
0
.3.
I
0.
IL
VA-
_,
.2-
0
6
12
I8
24 30 TIME (months)
36
42
''
66
FIG. 5. Comparison of survival curve of patients stented with two (or three) silastic transhepatic tubes to that of patients stented with only one tube. All patients undergoing resection were reconstructed with two stents and are in the upper curve, whereas most patients in the lower curve were merely palliated with one stent after tumor dilatation.
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sample and because of the fibrotic nature of many of these lesions. The mean interval between the first symptom and surgical management at Hopkins was eight months. Diagnosis before operation by cholangiography, however, can be made with a high degree of accuracy. In the absence of prior biliary surgery, a narrowing or obstruction at or near the hepatic bifurcation, with a dilated intrahepatic biliary tree and a normal or collapsed common duct and gall bladder, virtually can be nothing else but a biliary tract malignancy. All 27 of these patients were correctly diagnosed before operation by cholangiography. The percutaneous transhepatic route will most often be the most appropriate, but endoscopic retrograde and even T-tube cholangiography, if the patient has recently undergone surgery, can serve just as well. The other diagnoses that one might confuse with a proximal biliary tumor are sclerosing cholangitis, a benign stricture, a benign biliary tumor and metastatic disease. Combining the clinical presentation with the above radiographic criteria will allow easy and accurate differentiation in the great majority of patients. The appropriate surgical management of proximal biliary tumors is still not firmly established. Some surgeons have advocated only palliative procedures, such as stenting, and feel few or none of the lesions are resectable.' Others have suggested that intrahepatic cholangioenteric anastomoses are of benefit in palliating these patients.5 The authors' experience, however, with the Longmire procedure for malignant disease has been poor, and its use has been abandoned. Most surgeons now recommend an attempt at tumor resection, with or without hepatic lobectomy. Resectability rates from recent series have varied widely. Wheeler and colleagues4 reported 41 consecutive patients with proximal biliary tumors in which none were resected. The Mayo Clinic6 and Lahey Clinic7 have reported resectability rates of 11% and 12%, respectively. Five of 32 patients ( 16%) with proximal biliary tract malignancies in the series of Chitwood et al.8 were resected. Combining tumor resection with hepatic lobectomy where necessary allowed Thompkins et al.9 to report a resectability rate of 47% (22/47), and Launois et al.'0 a rate of 61% (11/18). When hepatic resection is combined with tumor excision, operative mortality increases. Hospital mortality for resection in the series of Thompkins et al. was 23%, and in the series of Launois et al. 18%. In the present series 10 of 27 tumors were resected (37%). There were no hospital deaths among the ten patients undergoing resection. Hepatic resection was not performed in any patient. By mobilizing or removing the gallbladder and dividing the distal common bile duct early in the dissection (Fig. 1), one can markedly improve access to the porta hepatis. The hepatic bifurcation rests upon the portal vein bifurcation, and dissection of the biliary
Ann. Surg. - October 1982
structures high in the porta hepatis without reflection of the biliary tree in a cephalad direction leaves the portal venous bifurcation at risk. Positioning Ring catheters in the right and left hepatic ducts before operation aids in identifying these structures above the bifurcation at the time of surgery. With these few technical aids, many of these proximal tumors can be removed without hepatic resection. The hospital mortality has been so low in our series, and palliation so acceptable, that we have been unwilling to incur the additional mortality that hepatic resection carries, with uncertain benefit. Although the authors have used preoperative percutaneous biliary decompression in six patients, it is not felt to be essential. Most of these patients are in good health at the time of presentation (mean serum albumin 3.9 g/dl), and in none of the 27 patients was metastatic disease present. These patients, with a minimum of selection, tolerate surgery well. The authors do feel, however, that Ring catheters are of benefit technically at the time of surgery. In occasional patients one may decide to use percutaneous decompression with Ring catheters as the primary therapy. Because of advanced age, systemic disease, acute illness, or cholangiographic evidence of tumor extension well up into the hepatic parenchyma, one might decide that operative intervention is unwise. In these patients percutaneous decompression with a Ring catheter, with or without radiotherapy, may be the treatment of choice. The benefit of radiotherapy in managing patients with proximal biliary tumors is unproven. Because the natural history of bile duct cancer is often one of slow growth, and because no controlled trials of radiotherapy have been performed, it is difficult to evaluate its effect. Radiotherapy, nevertheless, has generally been adopted as standard therapy. Survival with proximal biliary tumors is clearly dependent upon what procedure is performed at the time of surgery. In a recent literature review of over 400 patients,"' laparotomy alone was associated with a mean survival of 5.6 months. Stenting with a Y or T tube was followed by a mean survival of9.9 months. Transhepatic stenting was followed by a survival of 18.6 months, and tumor resection with a survival of 22.2 months. All 27 patients in this series were stented transhepatically with large-bore, thick-walled, silastic tubes. These stents, if properly positioned, should decompress the entire biliary tree. Because of their large bore and thick wall, occlusion and/or compression by tumor is not apt to occur. The biliary stents are therefore capable of maintaining enough biliary drainage to allow adequate hepatic function even in the face of significant local tumor growth. This should allow patients who have only been palliated, or who recur after resection, to survive until they die from disseminated tumor rather than from hepatic failure and sepsis. Mean survival in the entire group is 18
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months with 11 patients still alive. Life-table survival demonstrates a two-year survival of 40%. Among the first nine patients undergoing resection (the tenth patient is only one-month postsurgery and is excluded), mean survival is 21 months with seven of the patients still alive. Fifteen of the 26 patients discharged from the hospital have died. Only seven of these 15 patients discharged from the hospital died from tumor dissemination, however, with five dying from hepatic failure and two from biliary sepsis (one patient died from gastrointestinal bleeding). The seven patients dying from tumor survived a mean of 17 months, whereas the seven patients dying from inadequate liver decompression survived 11 months. Life-table survival curves (Fig. 5) suggest that patients decompressed with two (or three) silastic transhepatic biliary stents survive longer than do patients decompressed with only one stent. The authors now routinely attempt to decompress both the right and left hepatic ducts with silastic stents, whether or not resection is performed. Another possible reason for the prolongation of survival in those patients stented with two tubes in comparison with those treated with one tube is that the former group contains all patients who were resected. The combination of tumor resection and external and internal irradiation may well lead to cure in some of these patients. The authors have one patient who has survived over five years. However, the biologic behavior of these tumors is so unpredictable that ten-year followups probably will be necessary. Since predicting outcome is difficult, the authors have chosen to leave the silastic stents in indefinitely. With benign stricture repairs, the stents have been routinely removed at one year.12 For patients with malignant strictures, however, they are considered permanent. The authors routinely
change the stents every three to six months during an outpatient visit. U tubes have not been used.'3 Since stents are now routinely placed in both ductal systems, using U tubes would mean the patient would have four tube ends exiting on the abdominal wall.
DISCUSSION
followers, and easily dilate the duct up to a diameter in excess of 7 mm. The Ochsner-Fenger probe has one disadvantage. On pronounced bending, the steel spiral tends to gap open, and to produce a rough surface. We took this problem to V. Mueller, and they covered the dilator with a plastic shield. We also asked them to construct a female thread at the proximal end, (slide) to accommodate standard urethral dilators, and it is this modified probe that we use today. I wish to show a short film strip to demonstrate the use of it-the motion picture, please? [A film was started.] I would like to say, too, that Dr. A. G. Ochsner and Dr. Christian Fenger, prominent surgeons of Chicago, were also prominent members ofthis society, and it was Dr. Ochsner who recommended the sweeping social reforms consisting of emasculation of degenerates and others to which our President, President Roblo Hanlon, referred yesterday. The tumor in this instance had extended down from the hilum of the liver, and involved the superior surface of the pancreas and duodenum. We are cutting away a little part of the tumor here, and the biopsy disclosed carcinoma. It is possible to guide the coated dilator
DR. ROBERT S. SPARKMAN (Dallas, Texas): I shall confine my remarks to some technical considerations in the placement of transhepatic tubes. (slide) This antique flexible biliary probe, seldom used today, can still be found in most operating suites, and continues to be listed in the catalogs of the major instrument suppliers. Pilling refers to it as the Ochsner flexible probe. (slide) V. Mueller lists it as the Fenger gall duct probe, (slide) while A--ean Hospital calls it the Ochsner-Fenger probe. This probe, by reason of n> flexibility and variable curvature, usually can be guided up the major hepatic ducts. (slide) I have discovered by chance that with only moderate pressure, it will traverse the entire major hepatic duct, and emerge bloodlessly from the liver surface. (slide) This permitted us to attach tubes to it and then to pull them back through the liver, to emerge at the hilum. (slide) We also found that if we could draw an ordinary urethral filiform through this tract, we could then insert graduated urethral
References 1. Cameron JL, Gayler BW, Harrington DP. Modification of the Longmire procedure. Ann Surg 1978; 187:379-382. 2. Pollock TW, Ring ER, Oleaga JA, et al. Percutaneous decompression of benign and malignant biliary obstruction. Arch Surg 1979; 114:148-151. 3. Cameron JL, Skinner DB, Zuidema GD. Long-term transhepatic intubation for hilar hepatic duct structures. Ann Surg 1976;
183:488-495. 4. Wheeler PG, Dawson JL, Nunnerley H, et al. Newer techniques in the diagnosis and treatment of proximal bile duct carcinoma-an analysis of 41 consecutive patients. Q J Med 1981; 1:247-258. 5. Bismuth H, Corlette MB. Intrahepatic cholangioenteric anastomosis in carcinoma of the hilus of the liver. Surg Gynecol Obstet 1975; 140:170-178. 6. Akwari OE, Kelly KA. Surgical treatment of adenocarcinoma location: junction of the right, left and common hepatic biliary ducts. Arch Surg 1979; 114:22-25. 7. Ross AP, Braasch JW, Warren KW. Carcinoma of the proximal bile ducts. Surg Gynecol Obstet 1973; 136:923-928. 8. Chitwood WR, Meyers WC, Heaston DK, et al. Diagnosis and treatment of primary extrahepatic bile duct tumors. Am J Surg 1982; 143:99-106. 9. Thompkins RK, Thomas D, Wile A, Longmire WP. Prognostic factors in bile duct carcinoma: analysis of 96 cases. Ann Surg 1981; 194:447-457. 10. Launois B, Campion JP, Brissot P, Gosselin M. Carcinoma of the hepatic hilus. Surgical management and the case for resection. Ann Surg 1979; 190:151-157. 11. Broe PJ, Cameron JL. The management of proximal biliary tract tumors. Adv Surg 1981; 15:47-91. 12. Cameron JL, Gayler BW, Zuidema GD. The use of silastic transhepatic stents in benign and malignant biliary strictures. Ann Surg 1978; 188:552-561. 13. Terblanche J, Louw JH. U-tube drainage in the palliative therapy of carcinoma of the main hepatic duct junction. Surg Clin North Am 1973; 53:1245.
