Palliation of malignant hilar obstruction at a single centre--review of operative and non-operative techniques.
Introduction. Jaundice secondary to a malignant hilar obstruction can be relieved by operative bypass or percutaneous stenting. Comparative trials involving these techniques are scarce. We reviewed our experience with these competing techniques in the palliation of malignant hilar obstruction.
Patients and methods. All patients with malignant hilar obstruction managed at our institution during the period 1992 - 2002 were identified for review.
Results. A total of 36 deeply jaundiced patients with hilar obstruction were identified. Twenty-two patients underwent exploration with the intention of performing an operative bypass and 14 patients underwent percutaneous transhepatic cholangiography (PTC) with intention to stent. Procedure-related mortality was similar in both groups. Morbidity was much higher in the operative group. Effective symptom relief was achieved with both techniques. In the PTC group recurrent biliary obstruction in 2 patients necessitated salvage non-operative procedures. Although survival rates were slightly longer in the operative group, this was not significant. There were no long-term survivors.
Conclusion. Operative bypass provides better sustained relief of jaundice than PTC. However long-term survival in both groups is poor and operative bypass is best reserved for younger patients with no technical contraindications. Despite early and late procedural failures PTC is the method of choice for patients with advanced-stage disease and those with significant co-morbidities.
Only a small subset of patients with malignant hilar obstruction may be candidates for resectional surgery and for the majority palliation of jaundice is the therapeutic objective. (1-6) The gold standard in palliation is a widely patent biliary enteric anastomosis, above the level of obstruction. For patients with a proximal obstruction, this involves the fashioning of an intrahepatic biliary-enteric anastomosis. (7-19) However, in patients with advanced malignancy and jaundice major abdominal surgery carries risk. (20-23) The endoscopic or percutaneous deployment of stents across the obstruction has increasingly been used as an alternative to operative bypass. (24-27) The first stents were plastic and narrow-gauge and recurrent occlusion necessitated further procedures, thus impacting negatively on the quality of palliation. (23) Modern self-expanding metal wall stents provide more durable relief of jaundice. (4,23,24,26) We reviewed our experience with the management of malignant hilar obstruction over the period 1992 - 2002 in an attempt to clarify the roles of operative and non-operative bypass. This period encompassed the era of operative bypass and the advent of the percutaneous metal wallstent insertion at our institution.
Patients and methods
We reviewed all patients who had presented to us with malignant hilar obstruction between 1992 and 2002 and who were treated with either a biliary enteric bypass or a wallstent. Notes were retrieved from the hospital records and proformas were filled out documenting routine demographic details, modality of treatment complications and survival.
We used the technique initially described by Soupault and Couinaud (7) in 1957 which involves the anastomosis of a jejunal loop to the segment III duct on the left side of the liver. The operation relies on the anatomical understanding that the obliterated umbilical vein which runs in the ligamentum teres joins the segment III branch of the portal vein. The accompanying bile duct lies above and behind this corresponding portal venous radical. Downward traction to the right on the divided ligamentum teres allows for finger and diathermy fracture of the parenchyma between segments III and IV (Fig. 1). This creates a wedge-shaped space leading down to the segment III duct (Fig. 2). The bile duct is located by needle aspiration and is exposed for 2 cm. It is opened longitudinally for at least 1 cm and a Roux-en-Y loop is anastomosed end-to-side or side-to-side depending on the best fit in the confined space using a fine interrupted absorbable suture material (Fig. 3). A transanastomotic stent is left in place depending on the operator's discretion. This allows for postoperative cholangiography and is removed 2 weeks after the operation.
[FIGURES 1-3 OMITTED]
Percutaneous transhepatic cholangiography (PTC)
With the patient cleaned and draped, a puncture site is fluoroscopically selected below the costophrenic angle in the mid-axillary line. A 22-gauge Chiba needle is advanced towards a marker placed on the xiphisternum, and contrast is injected as the cannula is withdrawn. Once ductal entry is confirmed the biliary tree is opacified and a definite point of entry identified. The system is re-cannulated and a guide-wire is passed into the system and manipulated across the stricture into the duodenum. The tract is dilated prior to the self-expanding metal stent being delivered, with the distal end in the duodenum and the proximal end sitting in a peripheral biliary radicle. Once the position is confirmed, the stent is deployed.
A total of 36 deeply jaundiced patients with hilar obstruction were treated at our institution during the period under review. Their age range was 46 - 89 years and the average serum bilirubin level was 251 [micro]mol/l (range 105 - 407 [micro]mol/l). During the period 1992 - 1998, 22 patients underwent exploration with the intention of performing a segment III duct cholangioenteric anastomosis. Since 1998 no patient has undergone an operative segment III bypass. One patient had undergone a prior attempt at endoscopic stenting. Two patients (9%) died peri-operatively. One patient with liver cirrhosis died from coagulopathic bleeding and 1 from a myocardial infarction. Three patients (14%) developed biliary fistula, 1 of which persisted until the patient's death. Twenty patients were discharged home. The bilirubin level fell significantly from 243 [micro]mol/l ([+ or -] 114) to 95 ([+ or -] 47) [micro]mol/l 2 weeks after surgery (p < 0.0003) in all patients. Pruritus was relieved in all patients. Eight patients (36%) remained jaundice free until death at 1, 3, 6, 6, 8, 9, 9 and 11 months following surgery. Twelve patients were still alive after a year. Ten (83%) of these were anicteric after a year. Only 4 returned for review after 1 year. All of this group have subsequently died. The longest survivor lived for 28 months.
Between 1995 and 2002 14 patients (age range 53 - 78 years) underwent PTC with the intention to stent. Their diagnosis included cholangiocarcinoma (N = 10), hepatoma (N = 1), and gallbladder carcinoma (N = 3). Non-therapeutic exploration (N = 2), unsuccessful cholecystjejunostomy (N = 1) and failed endoscopic stent placement (N = 1) were performed before referral. Three were in established renal failure at presentation. PTC was successful at a single sitting in 9 patients, and at multiple sittings in 3. In 2 PTC was unsuccessful. These patients were left with external biliary fistulas (14%). In all patients who had undergone successful PTC, serum bilirubin levels dropped significantly by 1 week (84 [micro]mmol, p < 0.003). All these patients experienced relief of pruritus. Renal failure resolved in the 3 patients who had presented with this established complication. Two patients (14%) died during the index hospital admission. Recurrent biliary obstruction in 2 patients (14%) necessitated salvage endoscopic retrograde cholangiopancreatography (ERCP) and PTC respectively. Three were transferred back to their referral hospital. Four patients survived more than a year. The remaining patients died as outpatients, with a median survival of 7 months. Figs 4 and 5 show the PTC of a patient demonstrating short hilar stricture with a failed endoscopic stent in situ. An overlapping stent was deployed percutaneously to alleviate the obstruction.
[FIGURES 4-5 OMITTED]
The literature reporting on the operative palliation of malignant hilar obstruction is summarised in Table I and that reporting on the non-operative palliation is summarised in Table II. There are several consistent features in these series. As in our study, the numbers are generally small, the long-term survivors are few, and there is a paucity of quality-of-life data. Histological data are similarly vague as it is often difficult to obtain decent histological specimens in the setting of biliary malignancy. Most series include a number of diverse pathologies such as Klatskin tumours, gallbladder carcinomas and external compression from malignant hilar lymph nodes.
Our results with operative bypass are in keeping with the literature and confirm that the operation is technically feasible and successful in providing symptom relief until death, although it is associated with a not inconsiderable mortality and morbidity. (9,11,15,28,29) Survival is limited to less than a year in all series including our own.
In our non-operative group significant numbers presented with established renal failure (N = 3) and prior intervention (N = 4). We feel that this has contributed to our relatively high morbidity and mortality and technical failure rate with this procedure. We would expect a much higher primary success rate in patients who did not have an established complication of obstructive jaundice and who had not undergone unsuccessful invasive interventions before referral.
Decision-making in this group of patients is difficult. They have advanced malignancy, limited life expectancy and are at risk of developing several life-threatening complications. It is essential that the treatment modality has negligible morbidity and mortality and provides sustained relief of jaundice until death. Choosing the most appropriate palliative approach for an individual patient must take into account the patient's expected remaining life expectancy and systemic fitness. (3,5,6,22,25-27,30) The objection to non-operative palliation advanced by Myburgh (18) was that it was not as durable a procedure as operative bypass. He felt that the operation spared the patient any further interventions during what short time was left. Plastic stents are prone to early occlusion, (31) and series using self-expanding metal stents report long-term occlusion rates ranging from 23% to 27%. (32-34) His concerns are real, as confirmed by our re-intervention rate of 14%. However, radiological or endoscopic re-intervention does not necessarily equate to less than satisfactory palliation. In Lai et al.'s comparative historical series, (35) although the non-operative group required more frequent readmissions to deal with stent occlusion, there was no demonstrable difference in quality of life between the 2 groups. Most stent occlusions can be dealt with radiologically or endoscopically as we did in 2 of our patients. If follow-up is good and the development of jaundice is recognised early, then appropriate intervention can be elective with minimal inconvenience to the patient. There has never been a double-blind randomised trial comparing stenting with operative bypass, and results are further confounded by the tendency to select patients for stenting on the basis of co-morbidity and advanced malignancy. Neo-adjuvant therapy has been advocated by some units for hilar lesions, however reported numbers remain small and benefits marginal. (36,37) If adjuvant therapy were to become an established part of treatment of this disease and to prolong survival the choice of palliative technique may be further complicated.
In general, fitter patients with reasonable life expectancy are selected for operative biliary bypass, while frail patients are selected for non-operative palliation. Consequently the development of prognostic scoring systems in these patients has received attention. (30,38) The difficulty in obtaining statistically significant numbers has necessitated multi-centre pooling of data, thus compounding selection bias. A number of mathematical models have been derived from pooled data to predict poor outcome in patients with malignant hilar obstruction and thus select patients for non-operative palliation. (30,38) However these scoring systems remain cumbersome and their universal applicability is unclear.
Ultimately local bias, referral patterns and available expertise influence the choice of therapy. We feel that PTC can be performed with minimal morbidity and can provide sustained relief of jaundice. If the event of occlusion salvage is usually possible, either endoscopically or percutaneously. Operative bypass is a major abdominal operation, which carries a definite mortality rate. We have moved away from operative bypass for all but the fittest of patients, or for patients who undergo laparotomy with intention to resect.
The assistance of M. Dinanath, research assistant, is acknowledged.
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DAMIAN L. CLARKE, F.C.S. (S.A.) SANDIE R. THOMSON, CH.M., F.R.C.S. (ENG. & ED.) FRANK ANDERSON, F.C.S. (S.A.) MATHAVEN MOODLEY, F.C.S. (S.A.) INES BUCCIMAZZA, F.C.S. (S.A.)
Department of general surgery, Nelson r. Mandela school of Medicine, university of KwaZulu-Natal, Durban
VIJEN V. MOODLEY, F.C.R. (S.A.)
Department of radiology, Nelson r. Mandela school of Medicine, university of KwaZulu-Natal, Durban
TABLE I. SERIES OF INTRAHEPATIC-CHOLANGIOENTERIC ANASTOMOSIS FOR HILAR OBSTRUCTION Pre-operative bilirubin Period No.of average Series Date (years) patients ([micro]mol/l) Traynor 1987 25 48 331 et al. (17) Jagannath 1992 NS 17 323 et al. (10) Lai et al. (35) 1992 6 34 220 Myburg (18) 1995 NS 65 NS Guthrie 1994 8 26 350 et al. (9) Jarnagin 1998 5 55 NS et al. (11) Vellar et 1998 NS 10 NS al. (19) Suzuki et 2001 NS 15 NS al. (15) Clarke 2004 10 18 243 (this study) Average 10 293 Hospital average Operative Morbidty Jaundice stay Series mortality (%) relief (%) (days) Traynor 6 17 73 NS et al. (17) Jagannath 6 30 76 NS et al. (10) Lai et al. (35) 18 50 NS 35 Myburg (18) 2 NS NS NS Guthrie 11 23 78 5 - 44 et al. (9) Jarnagin 11 45 100 14 et al. (11) Vellar et 10 NS 66 NS al. (19) Suzuki et 0 13 77 NS al. (15) Clarke 9 14 100 14 (this study) Average 9 27 81 21 Late failure Median rate survival Series (%) (months) Traynor NS 9.2 et al. (17) Jagannath NS NS et al. (10) Lai et al. (35) 1.4/month 3 Myburg (18) 1 6 Guthrie 25 7.5 et al. (9) Jarnagin 18 3 et al. (11) Vellar et NS NS al. (19) Suzuki et 44 9 al. (15) Clarke 20 7 (this study) Average 22 7 NS = not stated TABLE II. SERIES OF STENTS FOR HILAR OBSTRUCTION Approach Period stent No. of Series Date (years) type patients Wagner et 1992 2 PTC/PS 9 al. (34) Wagner et 1992 2 PTC/MWS 11 al. (34) Lai et 1992 6 ENDO & 16 al. (15) PTC/PS Schima et 1997 NS PTC/MWS 41 al. (32) Gerhards 2001 7 ENDO & 41 et PTC/PS al. (31) Cheng et 2002 10 ENDO/MWS 36 al. (33) Clarke 2004 10 PTC/MWS 14 (this study) Average 6 24 Pre-operative Technical Re- bilirubin Jaundice tailure intervention Series average reliet (%) rate (%) Wagner et 152 Value NS 12 22 al. (34) SD Wagner et 204 Value NS 0 18 al. (34) SD Lai et 273 Value NS 0 3.5/month al. (15) SD Schima et NS SP 0 NS al. (32) 96 days Gerhards 162 Value NS 0 78 et SD al. (31) Cheng et NS NS 3 31 al. (33) Clarke 251 SD 14 14 (this 84 [micro]mol/l study) by 7 days Average 208 9 32 Early Hospital Median mortality Morbidity stay survival Series (%) (%) (days) (months) Wagner et 0 NS NS NS al. (34) Wagner et 0 NS NS NS al. (34) Lai et 38 50 34 1.4 al. (15) Schima et 39 0 NS 6 al. (32) Gerhards 3 12 7 9 et al. (31) Cheng et 6 8 NS 5 al. (33) Clarke 14 14 6 7 (this study) Average 14 21 16 5 NS = not stated; PTC = percutaneous transhepatic cholangiography; ENDO = endoscopic; PS = plastic stent; MWS = metal wall stent; SD = significant drop; SP = stent patency.
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|Title Annotation:||General Surgery|
|Author:||Clarke, Damian L.; Thomson, Sandie R.; Anderson, Frank; Moodley, Mathaven; Buccimazza, Ines; Moodley|
|Publication:||South African Journal of Surgery|
|Article Type:||Clinical report|
|Date:||Feb 1, 2007|
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