Major Intrahepatic Ducts Research Articles

Intraoperative placement of transparietohepatic biliary drainage in remedial hepaticojejunostomy: technique and clinical experience

Remedial biliary surgery most often entails a Roux-en-Y hepaticojejunostomy. Sometimes the duct wall at the porta hepatis has been so damaged by inflammatory changes that the postoperative external drainage of bile away from a biliodigestive suture at risk of dehiscence is advisable. A technique of intraoperative placement of transparietohepatic biliary drainage was devised. The maneuver implies retrograde cannulation of a major intrahepatic duct with a vascular irrigation needle that is pushed to create the transhepatic path. Of 220 remedial hepaticojejunostomies performed in 211 patients (including 151 liver transplant recipients), the technique was applied in 49 (22%) of the most difficult cases in which the preoperative radiologic approach to the biliary tree had failed, was unsafe, or was unfeasible. The only major complication was a parenchymal tear needing perihepatic packing when the maneuver was performed too early after liver transplantation. Postoperative biliary fistula occurred in 2 patients (4%) and access to the biliary tract for percutaneous bilioplasty was provided in the short-term follow-up evaluation of 14 patients (29%).

HEPATOBILIARY IMAGING WITH Tc-99m-HIDA

Availability of the Tc-99m-hepatobiliary agents has permitted an evaluation of the liver-biliary tree-gallbladder-small bowel complex even in the face of elevated bilirubin levels. Although the sequence of events is usually well defined, variations can be found which tend to contribute to diagnostic uncertainties. We wish to point out 2 major variants, which are likely related to increased pressure in the biliary system. 1) Stasis pattern. As long as hepatic ability to extract the radiotracer is still present, the blood level of Tc-99m-HIDA will progressively fall and that within the liver will increase. Once within the liver however, the radiolabel may not progress into the biliary system. This stasis pattern has been recognized in patients with intrahepatic cholestasis. An identical pattern has been noted in 2 males with acute high obstruction of the biliary tree. Hepatic accumulation of tracer occurred, but there was total lack of collection in the larger biliary radicals and no excretion. The diagnosis of high obstruction was confirmed surgically. The presence of acute high obstruction should be considered when a stasis pattern is accompanied by signs and symptoms of cholecystitis (severe pain was present in both cases). 2) Intrahepatic reflux. As the gallbladder contracts, the pressure generated is usually greater than that in the cystic and common bile ducts; hence, the pathway of excretion is from gallbladder toward the small bowel. If this pathway is obstructed, then bile may pass in another direction. A woman was seen with intermittent right upper quadrant pain. The Tc-99m-HIDA study proceeded normally with filling of the gallbladder. Upon administration of a fatty meal, there was prompt emptying of the gallbladder with reflux of activity into the major intrahepatic ducts. At ERCP, there was delayed runoff, and an inferred elevated pressure gradient preventing downward drainage. Hence, increased pressure within the bile excretory pathway can result in unusual distribution of the Tc-99m-HIDA. (Supported by USPHS CA 17802).

Sclerosing carcinoma of the major intrahepatic bile ducts.

Primary carcinoma of the bile ducts may be extrahepatic or intrahepatic in origin. The clinical and diagnostic features of the more prevalent extrahepatic forms are well known, but considerably less information is available for the intrahepatic variety.^1-5Carcinomas arising from the mucosal cells of the finer radicles of the intrahepatic biliary tree are known as cholangiomas and are usually considered to be an uncommon form of primary neoplasm of the liver.⁶There is another unusual type of primary carcinoma of the intrahepatic ducts which is rarer and more difficult to recognize. This form arises from the major intrahepatic ducts near the hilus. Its insidious nature, the ease with which it mimics other biliary tract disorders, and its relative inaccessibility to surgical approach are factors which have made diagnosis very difficult, and frequently impossible until autopsy.^2-4 Since 1950, three patients with primary adenocarcinoma of the intrahepatic bile ducts have