Bile Duct Bifurcation Research Articles

Bile Duct Injuries 12 Years After the Introduction of Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy–associated bile duct injury continues to be an important clinical problem with significant long-term health implications for affected patients. Recent reports suggest that the incidence of this problem may have passed its peak, but the injury rate is still increased compared with the open cholecystectomy era. In addition, there appears to be a subset of patients who present with severe bile duct injury that may include injury to the bile duct bifurcation, the isolated right sectoral duct, and those that occur in conjunction with hepatic arterial ligation. A panel of hepatobiliary surgeons experienced in the management of these difficult surgical problems was convened at the annual meeting of the American Hepato-Pancreato-Biliary Association in Dallas, Texas, to address these unique problems and to suggest methods for injury prevention and management. This report outlines comments made by this panel.

Cholangiocarcinoma of the Hepatic Hilum (Klatskin Tumor).

Since the description by Klatskin in 1965, the management of patients with adenocarcinoma of the hepatic bile duct bifurcation is viewed as a challenging clinical problem with a relatively poor prognosis. Surgery continues to be the mainstay of therapy. Complete resection of the tumor with negative histologic margins offers the best possibility of long-term survival, and hepatic resection is a critical component of the operative approach. Adjuvant chemoradiotherapy has failed to provide a significant survival benefit. Orthotopic liver transplantation for otherwise unresectable lesions remains controversial, as tumor recurrence has been reported in more than 90% of patients. With the shortage of organs, such patients to be selected carefully for transplanation. For patients who present with widespread disease and those with high operative risks, advances in interventional radiology and endoscopy have facilitated nonsurgical management options. Biliary decompression using expandable metallic stents provides superior patency and decreased frequency of hospitalization when compared with plastic stents. Moreover, patients treated with expandable metal stents have survival rates comparable with those who undergo surgical decompression, with fewer early complications. The benefit of external beam radiotherapy for palliation of proximal cholangiocarcinoma is uncertain. Radiotherapy in conjunction with biliary stenting has a survival benefit over stenting alone, but is not without potential toxicity. It should be considered as an adjunct to biliary decompression in all patients with good performance status, because modern conformal CT-based dosimetry can minimize toxicity to normal adjacent tissue. Photodynamic therapy is emerging as a new palliative treatment modality for patients with unresectable tumors in whom stenting has failed. It offers the advantage of an endoscopic delivery system, and unlike radiotherapy, photodynamic therapy may be delivered repeatedly.

Bile Duct Injury following Laparoscopic Cholecystectomy: A Cause for Continued Concern

Previous reports suggest that bile duct injuries sustained during laparoscopic cholecystectomy (lap chole) are frequently severe and related to cautery and high clip ligation. We performed a review of patients who sustained bile duct injury from lap chole since 1990 and assessed time to injury recognition, time to referral, Bismuth classification, initial and subsequent repairs, rate of recurrence, and length of follow-up. Seventy-four patients [median age 44 years, 58 of 74 female (78%)] were referred with a bile duct injury after lap chole. The level of injury was evenly divided between the bile duct bifurcation and the common hepatic duct: Bismuth III, IV, and V (40 of 74, 54%) versus Bismuth I and II (34 of 74, 46%). Concomitant hepatic arterial injury was identified in nine (12%) patients. Patients referred early after bile duct injury and requiring operative intervention underwent hepaticojejunostomy at a median of 2 days after referral. After surgical reconstruction at our center there has been an overall success rate of 89 per cent with no need for reintervention. Six (10%) of these patients have required one additional balloon dilatation at a mean follow-up of >24 months. One (2%) patient underwent biliary-enteric revision in follow-up. In patients with bile duct injury, stricture repair without delay was successful in the majority of patients treated in this series. Only one of 64 patients reconstructed at our center has required reoperation; six others have required a single balloon dilatation with subsequent good or excellent results. The majority of patients treated with operative repair at an experienced center can expect good long-term results with rare need for reintervention.

Reconstructive surgery for ischemic-type lesions at the bile duct bifurcation after liver transplantation.

To assess the feasibility, morbidity, mortality, and clinical success rate of surgical reconstruction of the biliary system in patients with ischemic-type biliary lesions in their liver graft. After liver transplantation, strictures in the biliary tree with secondary sludge formation can occur in the absence of vascular problems. Jaundice, pruritus, and recurrent cholangitis are predominant clinical features leading to considerable morbidity. Interventional measures are the first-line treatment but are frequently only of transient success. Retransplantation is usually considered when interventional treatment is not effective. Surgical exploration and reconstruction was performed in 17 patients with ischemic-type biliary strictures at a median of 2 years after liver transplantation. Findings during surgery, surgical strategies, and postsurgical courses are described. Clinical symptoms and biochemical parameters of cholestasis and liver function were analyzed in the postsurgical course. During surgery, all 17 patients were found to have strictures or sclerotic changes involving the hepatic bifurcation and extrahepatic bile duct. Sludge or stones were present in nine patients. In 14 patients with viable bile ducts proximal to the bifurcation, surgical reconstruction was performed by resection of the bifurcation and hepaticojejunostomy. In three patients with more extensive biliary destruction, portoenterostomy with or without peripheral hepatojejunostomy was performed. The prevalence rate of biliary infection at surgery was 93%; the predominant organisms were Candida and enterococci. The perioperative mortality rate was 0%. Clinical symptoms and biochemical parameters became normal or were considerably improved in 14 of 16 patients (88%). The hepatic bifurcation seems to be a predominant site for ischemic-type biliary changes after liver transplantation. Surgical treatment by resection of the bifurcation and reconstruction by high hepaticojejunostomy is a safe and highly effective approach leading to cure or persistent major improvement in most patients.

What constitutes long term survival after surgery for hilar cholangiocarcinoma?

BACKGROUND Hilar cholangiocarcinomas are rarely considered to be resectable and specific data regarding long term survival are not available. METHODS A retrospective single center experience from 1971 and 1995 details long term survival among 339 patients who underwent surgery for adenocarcinoma of the hepatic duct bifurcation. Tumor removal was accomplished by resection of the bile duct bifurcation either alone (33 patients), in combination with hepatic resection (77 patients), or combined with hepatic and vascular resection (41 patients). Thirty-two patients underwent total hepatectomy and liver transplantation. In 188 patients the tumor was unresectable and palliative internal or external biliary drainage was established. The resectability rate was 49.2% and rose to 54% after inclusion of liver transplantation. The clinicopathologic features of 32 5-year survivors were compared with patients whose survival was less than 5 years. RESULTS Thirty-two patients survived longer than 5 years after surgical treatment of hilar cholangiocarcinoma; 22 of these patients (69%) were still alive at last follow-up. Twenty-six long term survivors had primarily undergone resection; 4 received liver transplants. There was 1 long term survivor beyond 5 years after both exploratory laparotomy and subsequent percutaneous transhepatic drainage, and palliative hepatojejunostomy. Long term survival after resection was significantly associated with less advanced tumor stages. Lymph node involvement and residual tumor were the primary prognostic factors both in a multivariate analysis after resection and in the cohort of long term survivors. Nevertheless, long term survivors were still at a significant risk to die from tumor recurrence. CONCLUSIONS Radical resection offers the best possibility of prolonged survival with a good quality of life for patients with hilar cholangiocarcinoma. Cancer 1997; 79:26-34. © 1997 American Cancer Society.

Resectional surgery of hilar cholangiocarcinoma: a multivariate analysis of prognostic factors.

To define the prognostic factors after surgical resection of bile duct carcinomas at the hepatic bifurcation. The retrospective single-center experience details 151 patients after surgical resection of central bile duct carcinoma performed between 1971 and 1995. Tumor removal was accomplished by resection of the bile duct bifurcation either alone (group I, n = 33), in combination with hepatic resection (group II, n = 77), or combined with hepatic and vascular resection (group III, n = 41). Survival analysis was performed by the Kaplan-Meier method and the relationship between each of the clinicopathologic variables and survival was assessed by the log-rank test. Multivariate results were confirmed using Cox regression. The overall hospital mortality rate was 9.9% and depended on the extent of resection (group 1, 6.1%; group II, 7.8%; group III, 17.1%). After exclusion of hospital deaths, the overall patient survival rate was 28.4% at 5 and 15.5% at 10 years, with a median survival duration of 2.05 +/- 0.23 years. Univariate survival analysis identified tumor size, lymph node metastases, residual tumor stage, and tumor grading as factors with a statistically significant prognostic impact. Survival prognosis was not influenced by the site of the tumor according to the classification of Bismuth and Corlette, extent of resection, International Union Against Cancer (UICC) stage, perineural and vascular invasion, age, or sex. In a multivariate Cox analysis, only lymph node metastases and residual tumor stage proved to be of independent prognostic significance. Resection of central bile duct carcinoma is feasible in many patients and a favorable outcome after resection is mainly determined by curative resection and the absence of lymph node metastases.

What constitutes long term survival after surgery for hilar cholangiocarcinoma?

Hilar cholangiocarcinomas are rarely considered to be resectable and specific data regarding long-term survival are not available. A retrospective single center experience from 1971 and 1995 details long-term survival among 339 patients who underwent surgery for adenocarcinoma of the hepatic duct bifurcation. Tumor removal was accomplished by resection of the bile duct bifurcation either alone (33 patients), in combination with hepatic resection (77 patients), or combined with hepatic and vascular resection (41 patients). Thirty-two patients underwent total hepatectomy and liver transplantation. In 188 patients the tumor was unresectable and palliative internal or external biliary drainage was established. The resectability rate was 49.2% and rose to 54% after inclusion of liver transplantation. The clinicopathologic features of 32 5-year survivors were compared with patients whose survival was less than 5 years. Thirty-two patients survived longer than 5 years after surgical treatment of hilar cholangiocarcinoma; 22 of these patients (69%) were still alive at last follow-up. Twenty-six long-term survivors had primarily undergone resection; 4 received liver transplants. There was 1 long-term survivor beyond 5 years after both exploratory laparotomy and subsequent percutaneous transhepatic drainage, and palliative hepatojejunostomy. Long-term survival after resection was significantly associated with less advanced tumor stages. Lymph node involvement and residual tumor were the primary prognostic factors both in a multivariate analysis after resection and in the cohort of long-term survivors. Nevertheless, long-term survivors were still at a significant risk to die from tumor recurrence. Radical resection offers the best possibility of prolonged survival with a good quality of life for patients with hilar cholangiocarcinoma.

What constitutes long term survival after surgery for hilar cholangiocarcinoma?

BACKGROUND Hilar cholangiocarcinomas are rarely considered to be resectable and specific data regarding long term survival are not available. METHODS A retrospective single center experience from 1971 and 1995 details long term survival among 339 patients who underwent surgery for adenocarcinoma of the hepatic duct bifurcation. Tumor removal was accomplished by resection of the bile duct bifurcation either alone (33 patients), in combination with hepatic resection (77 patients), or combined with hepatic and vascular resection (41 patients). Thirty-two patients underwent total hepatectomy and liver transplantation. In 188 patients the tumor was unresectable and palliative internal or external biliary drainage was established. The resectability rate was 49.2% and rose to 54% after inclusion of liver transplantation. The clinicopathologic features of 32 5-year survivors were compared with patients whose survival was less than 5 years. RESULTS Thirty-two patients survived longer than 5 years after surgical treatment of hilar cholangiocarcinoma; 22 of these patients (69%) were still alive at last follow-up. Twenty-six long term survivors had primarily undergone resection; 4 received liver transplants. There was 1 long term survivor beyond 5 years after both exploratory laparotomy and subsequent percutaneous transhepatic drainage, and palliative hepatojejunostomy. Long term survival after resection was significantly associated with less advanced tumor stages. Lymph node involvement and residual tumor were the primary prognostic factors both in a multivariate analysis after resection and in the cohort of long term survivors. Nevertheless, long term survivors were still at a significant risk to die from tumor recurrence. CONCLUSIONS Radical resection offers the best possibility of prolonged survival with a good quality of life for patients with hilar cholangiocarcinoma. Cancer 1997; 79:26-34. © 1997 American Cancer Society.

Anatomic variants of the biliary tree: diagnosis with MR cholangiopancreatography.

To evaluate the accuracy of magnetic resonance (MR) cholangiopancreatography in the diagnosis of anatomic variants of the biliary tree. In 171 patients, the anatomy of the biliary tree was evaluated with MR cholangiopancreatography. Two independent reviewers evaluated the presence of anatomic variants. Contrast material-enhanced cholangiography that was previously performed opacified the cystic duct in 77 patients and the bile duct bifurcation in 93 patients, and was chosen as the standard of reference in the diagnosis of anatomic variants. MR cholangiopancreatography demonstrated the cystic duct in 126 patients (74%). MR cholangiopancreatography showed a low cystic duct insertion in 11 patients (9%), a medical cystic duct insertion in 22 patients (17%), and a parallel course of the cystic and hepatic ducts in 31 patients (25%). The bile duct bifurcation was demonstrated in 139 patients (81%), and an aberrant right hepatic duct was demonstrated in 12 patients (9%). MR cholangiopancreatography is accurate in the diagnosis of anatomic variants of the biliary tree that may increase the risk of bile duct injury during laparoscopic cholecystectomy.

Transpapillary placement of an endoprosthesis with the aid of the Frimberger Varioguide.

The guide wire, an important requisite for the placement of endoscopic transpapillary biliary prostheses, should combine two, normally incompatible, properties: a high degree of flexibility for atraumatic passage through irregular or "bent" stenoses, and a high degree of stiffness, to prevent sidewise deviation during advancement of the prosthesis. These opposing, formerly incompatible, properties are combined in a new type of guide wire, known as the Varioguide. With the aid of a tension controller, the stiffness of the Varioguide can be varied steplessly. In 88.2% of 68 patients with stenosis of the bile duct we succeeded in placing a transpapillary endoprosthesis with the Varioguide. In 13 cases in which a previous attempt with the conventional guide wire was unsuccessful, placement of the endoprosthesis was successfully accomplished with the Varioguide; the reverse was true in only a single patient. In the case of very narrow, rigid high stenoses, in which placement of a transpapillary endoprosthesis is especially difficult, the Varioguide has proved highly suitable (stenoses of the bile duct bifurcation).

Duodenal atresia with biliary anomalies and unusual gas pattern

This is a case report of a patient with duodenal atresia, with air in distal intestine due to associated bile duct bifurcation, and a bilobed gall bladder.