Bismuth Classification Research Articles

Outcome in patients with bifurcation tumors who undergo unilateral versus bilateral hepatic duct drainage

Background: There is much controversy as to the importance of establishing drainage of both liver lobes in malignant hilar obstruction. The purpose of the present study was to compare survival data in patients with malignant hilar obstruction, stratified according to the Bismuth classification, who had cholangiography with filling of one or both hepatic ducts and subsequently endoscopic or percutaneous drainage of one or both ducts. Methods: A retrospective review was performed for the time period from July 1990 to July 1995, and 224 patients were identified with a presumed diagnosis of a bifurcation tumor. All x-ray films were reviewed and 150 patients finally diagnosed as hilar tumor were classified according to Bismuth type I, II, or III. Type II and III patients were further subclassified with respect to contrast injection into a single or both hepatic duct systems and whether one or both sides were eventually drained. Results: Data were obtained in 141 patients (4 patients still alive); there were 43 type I, 58 type II, and 40 type III. Type II and III patients were divided into three groups: group A, one lobe opacified with same lobe drained; group B, both lobes opacified with both lobes drained; and group C, both lobes opacified with one lobe drained. Overall median survival for type I, II, and III patients was 160, 131, and 62 days, respectively. Among type II and III patients the median survivals of groups A, B, and C were 145, 225, and 46 days, respectively. Survival was significantly longer in group A vs. group C (p < 0.001), group B vs. group C (p < 0.001, and group A + B (165 days) vs. group C p < 0.001). There was no difference in group A + B versus type I (p = 0.90). In addition, when comparing single drain only (group A + C, 80 days) versus double drains (group B, 225 days), there was a significant survival advantage (p < 0.0001). Conclusion: In bifurcation tumors the best survival was noted in those with bilateral drainage, and the worst survival in those with cholangiographic opacification of both lobes but drainage of only one. (Gastrointest Endosc 1998;47:354-62.)

Long-term survival after resection of proximal bile duct carcinoma (Klatskin tumors)

This retrospective study in 79 surgically treated patients with a proximal bile duct carcinoma, revealed 12 patients [median age (range): 59.5 years (21-73)] who survived for more than 5 years. These 12 patients were analyzed in order to identify specific patient characteristics for long-term survival. Fifteen patients died due to postoperative complications and were excluded from this survival analysis. In relation with preoperative Bismuth classification, there were 3/15 (20%) longterm survivors with type I tumors and 9/26 (35%) long-term survivors with type II tumors. In the group of type III and IV tumors, there were no long-term survivors. Concerning type of resection, 9/51 (18%) patients had long-term survival after local resection and 3/13 (23%) patients after local resection combined with hemi-hepatectomy. Complete tumor free surgical specimen margins were found in only 4/64 cases (6%), of which only one survived for more than 5 years. Negative proximal bile duct margins, absence of multifocality and diploid tumors showed a significant correlation with long-term survival. There was no significant correlation between long-term survival and postoperative radiotherapy Of the 12 long-term survivors, five died after 5 years, of which 2 had developed metastases and one a local recurrence. The other two died of a metastasis of an ovarian adenocarcinoma and of cachexia, respectively. The mean survival of the 64 patients analyzed in this study (in which hospital mortality was excluded) was 33.7 months, with a median survival of 18.8 months. In conclusion, preoperative Bismuth classification of the tumor, absence of multifocality, diploid type tumors, and negative proximal bile duct margins at histopathological examination, were found to be the only significant prognostic factors for long-term survival.

Derivação hepaticojejunal sem sutura: uma alternativa para reconstituição da via biliar

A lesão das vias biliares foi observada em dois pacientes submetidos à colecistectomia videolaparoscópica e convencional. Para reconstituição da via biliar foi aplicada a técnica hepaticojejunostomia em Y-de-Roux com a introdução dao segmento proximal do ducto hepático comum, apoiada por um catéter perdido na luz da alça exclusa, sem sutura. O grau das lesões segundo a classificação de Bismuth tomou a técnica exeqüível. No período de nov/94 a fev/97 os casos evoluíram clinicamente assintomáticos e com exames laboratoriais dentro dos padrões de normalidade. O controle ultra-sonográfico demonstra a presença do catéter simulando o colédoco. A boa evolução dos casos não nos autoriza a conclusões definitivas. A facilidade técnica e a baixa morbidade no pós-operatório nos motivaram a escrever este artigo.

The consequences of a major bile duct injury during laparoscopic cholecystectomy

Bile duct injury is perhaps the most feared complication of laparoscopic cholecystectomy. The focus of this study was on the immediate and short-term outcome of patients who have undergone repair of major bile duct injuries with respect to hospital stay, perioperative interventions, and reoperations. The records of patients who underwent surgery at three academic hospitals in Philadelphia (Hospital of the University of Pennsylvania, Thomas Jefferson University Hospital, and Graduate Hospital) from 1990 to 1995 for repair of a major biliary injury following laparoscopic cholecystectomy were reviewed. A major biliary injury was defined as any disruption (including ligation, avulsion, or resection) of the extrahepatic biliary system. Small biliary leaks not requiring surgery were excluded. Thirty-two patients sustained major bile duct injuries. The injury was recognized immediately in 10 patients. The remaining 22 patients had pain (59%), jaundice (50%), and/or fever (32%) as the symptom heralding the injury. Bismuth classification was as follows: 13% of patients were class I, 63% were class II, 7% were class III, 7% were class IV, and 10% were class V. Biliary reconstruction included a Roux-en-Y hepaticojejunostomy in 30 patients and two were primary repairs. There was one postoperative death from multiorgan system failure. The mean length of hospital stay after repair was 17 ± 8 days. Over a mean follow-up period of 11.5 ± 10.5 months, 11 patients (38%) required 19 emergency readmissions, most commonly for cholangitis. Five patients (17%) required postoperative balloon dilatation for biliary structure. At follow-up 18 patients (62.0%) remain asymptomatic with normal liver function values, eight (28%) are experiencing episodic cholangitis, and three (10%) are asymptomatic with persistently elevated liver function values. The consequences of a major biliary tract injury following laparoscopic cholecystectomy include a complex operative repair resulting in a lengthy postoperative stay with an increased risk of death, an excessive number of perioperative diagnostic and therapeutic studies, frequent readmissions (often as emergencies), and a lifelong risk of restricture. The “cost” to these patients remains enormous.

Malignant tumors of the hepatic bifurcation--results of surgical therapy and prognostic factors

Between 1 January 1986 and 31 December 1994, 45 patients with carcinoma of the hepatic bifurcation underwent operations in the department of surgery. According to Bismuth's classification (1992), there were 7 type I, 4 type II, 22 type III and 12 type IV tumors. 31 of the 45 patients (68.9%) underwent surgical resections with curative intentions: resection of the hepatic bifurcation (n = 9, 29%), resection of the hepatic bifurcation with hilar liver resection (n = 7, 22.6%), resection of the hepatic bifurcation with left hemihepatectomy (n = 10, 32.3%), orthotopic liver transplantation (n = 5, 16.1%). The remaining 14 patients underwent palliative (n = 6) or diagnostic (n = 8) operations. Two of the 45 patients (4.2%) died in hospital. Histological examination demonstrated R0 resection in 17 of 31 (54.8%) of the patients, while in the remaining 14 cases, only a R1/RX resection had been achieved. One-, 2- and 5-year survival rates were 75.4%, 53.9% and 24.5% (median survival: 729 days) in the 31 resected patients, and 30.8%, 10.3% and 0% (median survival: 153 days) in the palliative treatment group. A statistically significant influence on survival could be demonstrated for nodal status (N0/N1) and residual tumor status (R0/R1, R2).

Iatrogenic injury to the bile duct: a working classification for radiologists.

To assess the usefulness of the Bismuth classification method in the preoperative localization of iatrogenic bile duct lesions with cholangiography and to correlate these cholangiographic findings with surgical findings. The records of 33 patients who underwent open or laparoscopic cholecystectomy and who sustained injuries to the biliary tract during the course of these procedures were reviewed retrospectively. The accuracy of the cholangiographic localization of bile duct injury was assessed with the Bismuth classification method, which is based on the localization of the traumatic lesion according to the distance from the biliary confluence. An exact correspondence between cholangiographic and surgical findings was found in 85% of the subjects. A minimal discrepancy was found in the remainder. There was no interobserver variation. The use of the Bismuth classification method appears to be an accurate and practical method for the grading of postoperative bile duct lesions with cholangiography.

Palliation of proximal malignant biliary obstruction by endoscopic endoprosthesis insertion.

For four years up to December 1987, 190 patients (median age 73 years) with proximal malignant biliary obstruction were treated by endoscopic endoprosthesis insertion. Altogether 101 had cholangiocarcinoma, 21 gall bladder carcinoma, 20 local spread of pancreatic carcinoma, and 48 metastatic malignancy. Fifty eight patients had type I, 54 type II, and 78 type III proximal biliary strictures (Bismuth classification). All patients were either unfit or unsuitable for an attempt at curative surgical resection. A single endoprosthesis was placed initially, with a further stent being placed only if relief of cholestasis was insufficient or sepsis developed in undrained segments. The combined percutaneous-endoscopic technique was used to place the endoprosthesis when appropriate, after failed endoscopic endoprosthesis insertion or for second endoprosthesis placement. Full follow up was available in 97%. Thirteen patients were still alive at the time of review and all but one had been treated within the past six months. Initial endoprosthesis insertion succeeded technically at the first attempt in 127 patients, at the second in 30, and at a combined procedure in a further 13 (cumulative total success rate 89% - type I: 93%; type II: 94%; and type III: 84%). There was adequate biliary drainage after single endoprosthesis insertion in 152 of the 170 successful placements, giving an overall successful drainage rate of 80%. Three patients had a second stent placed by combined procedure because of insufficient drainage, giving an overall successful drainage rate of 82% (155 of 190). The final overall drainage success rates were type I: 91%; type II: 83%; and type III: 73%. The early complication rates were type I: 7%; type II: 14%; and type III: 31%. The principle early complication was clinical cholangitis, which occurred in 13 patients (7%) and required second stent placement in five. The 30 day mortality was 22% overall (type I: 14%; type II: 15%; and type III: 32%) but the direct procedure related mortality was only 3%. Median survival overall for types I, II, and III strictures were 21, 12, and 10 weeks respectively but survival was significantly shorter for metastatic than primary malignancy (p<0.05). Endoscopic insertion of a single endoprosthesis will provide good palliation of proximal malignant biliary obstruction caused by unresectable malignancy in 80% of patients. Second stents should be placed only if required. Extensive structuring because of metastatic disease carries a poor prognosis and careful patient selection for treatment is requires.