Abstracts
1997 Digestive Disease Week

Intrahepatic biliary-enteric bypass for malignant hilar obstruction.

WR Jarnagin, E Burke, Y Fong, LH Blumgart. Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY.

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.