Obstructive jaundice is a major source of morbidity in patients with cancers
of the hepatic duct confluence. Since the majority have unresectable disease,
palliation is a major goal of therapy. This study was undertaken to evaluate the
effectiveness of intrahepatic biliary-enteric bypass to either the Segment III
duct or the Right sectoral hepatic ducts in patients with unresectable hilar
malignancies. Methods: From 12/91 to 10/96, 51 procedures were performed in
patients with unresectable hilar cholangiocarcinoma or gallbladder cancer. Data
were obtained from a prospective database and retrospective chart review.
Patients were divided into 3 groups based on the primary tumor and the type of
bypass performed: Group 1: Cholangiocarcinoma/Segment III bypass(N=19); Group 2:
Cholangiocarcinoma/Right sectoral hepatic duct bypass(N=14); Group 3:
Gallbladder cancer/segment III bypass(N=18).
Results: Mean hospital stay (14±2 days) and mean blood loss (628±88
ml) were similar among the 3 groups. Peri-operative death occurred in 6 patients
(12%): 0 in Group 1, 3 each in Groups 2 and 3 (p=0.034). Complications in 24
patients (47%) included biliary leak in 12, which significantly prolonged the
hospital stay beyond 10 days (p=0.02). Pre-operative biliary drainage, performed
in 29 patients prior to referral, adversely affected post-operative morbidity:
Drainage No Drainage p
(+) Intra-op Bile Cultures 70% 21% 0.006
Operative Blood Loss 802±182 ml 462±68 ml 0.04
Intervention for Post-op Biliary Leak 39% 0% 0.0001
All survivors had relief of jaundice and symptoms after bypass. Mean
survival in patients with cholangiocarcinoma (Groups 1 and 2) was 64±8
weeks and was unaffected by the type of bypass performed but was significantly
shorter in those who had post-operative biliary leak (30±4 vs. 72±9
weeks, p=0.01). By contrast, mean survival in patients with gallbladder cancer
(Group 3) was 23±6 weeks; all but 3 died within 32 weeks of surgery.
Analysis of long term results was therefore not possible in this group. In
patients with cholangiocarcinoma, the one-year bypass patency was 80% in Group 1
(Segment III bypass) and 60% in Group 2 (Right sectoral hepatic duct bypass).
There were 9 bypass occlusions requiring re-intervention at a mean of 23±6
weeks - 16% in Group 1, 45% in Group 2, p=0.024. Fourteen (31%) patients
required re-admission for biliary sepsis - 28% in Group 1, 55% in Group 2,
p=0.034. Conclusions: 1. Intrahepatic biliary-enteric bypass effectively
relieves symptoms due to malignant hilar obstruction; 2. In patients with
cholangiocarcinoma, Segment III bypass has a superior long term patency and
fewer late complications than Right sectoral hepatic duct bypass; 3. Patients
with gallbladder cancer, because of their poor survival, are probably better
palliated by percutaneous stenting; 4. Pre-operative biliary drainage adds to
post-operative morbidity.
