Segment III biliary bypass

Background

• Around 80% of the patients with malignant hilar block are candidates for palliative management– Metastases or advanced loco-regional disease– Extensive comorbidity for major surgery

• Aim– Provide long-term relief from

• Pruritis, cholangitis, pain and jaundice.

• Endoscopically placed self-expanding metallic biliary stents

• Low procedure-related complications• Probably the modality of choice

Background

– Percutaneous biliary drainage has comparable results

• An alternative when endoscopic expertise is not available or has failed

• There are multiple isolated undrained segments with cholangitis

– Surgical cholangiojejunostomy provides lasting biliary drainage

• Has limitations of high procedure related morbidity and mortality

Background

• In the absence of high-quality studies, comparing these modalities, the choice of biliary drainage procedure should be guided by the available expertise

• Other modalities of treatment like radiotherapy, chemotherapy and photodynamic therapy currently remain investigational.

Background

• Aims of palliative management– To provide durable relief from symptoms– To improve the quality of life faced with

terminal illness– Besides the patient, it should take into

account the need of the family and caregiver

» National cancer control programme 2002.

Background

Background

• Surgical option– Segment 3 bypass (Ligamentum Teres approach)

– Segment 3 peripheral hepaticojejunostomy

– Longmire & Sandford procedure

– Right duct approach• Right anterior sectoral HJ

• Segment V HJ

• Segment V/VI resection

– Transtumoral intubation

Segment 3 bypass

• History

– Commonly performed operative biliary

drainage procedure for malignant hilar block

– Introduced by Soupalt and Couinaud (1957)

– Popularized by Bismuth and Corlette (1975)

and Blumgart and Kelly (1984).

• Indication– Unresectable malignant hilar obstruction

– Hilar cholangiocarcinoma

– Carcinoma GBAccess to hilum or left duct

not possible

Options

Endoscopic drainage, Percutaneous drainage, Surgical bypass

Segment 3 biliary bypassLigamentum Teres approach

• Rationale• Relative ease to access• Far from the tumor• Segment 3 duct provides drainage ideally

for all the three segments (II, III and IV)» Vellar ID et al Aust Nzl J Surg 1998

• Drains– 30% of the liver parenchyma or at least two

segments – Which translate its success in palliating

symptoms provided remaining segment is sterile» Bismuth H et al Br J Surg 1987

Contraindication

Preoperative work-up

• The aim– Identify candidates for curative

resection and to plan appropriate palliative strategy for the rest• Extent of bile duct involvement• Encasement of common hepatic artery or

main portal vein at the hepatic hilum• Lymph node and distant metastases• Assessment of patient fitness for

undergoing major surgery

• MRCP– For assessment of second-order bile ducts- an

irregular thickening of the bile duct wall (>5 mm) with upstream asymmetric dilatation.

» Manfredi R, et al. Abdom Imaging 2003

– The accuracy • Intra-ductal extension of the tumor (78% to 85%)• Comparable to that of ERCP

– The advantages of MRCP over ERCP• Non-invasive with no consequent complications• Better delineation of the intrahepatic ductal anatomy in

cases of tight strictures» Yeh TS et al Am J Gastroenterol 2000

• Doppler study• MR angiography• CT angiography

AimAssessment of vascular invasion

Locoregional or distant metastasis

Recessus of Rex

Procedure

Modification

An anterior hepatotomy to the left of falciform ligament over the segment III duct-provide adequate length and space for the anastomosis

Criostoir B. O’Suilleabhain et al Am J Surg 2004

Results

O’Suilleabhain CB et al Am J Surg 2004 Jarnagin WR et al Am J Surg 1998

Chaudhary A et al World J Surg 1997, Kapoor VK et al Br J Surg 1996

Garden OJ et al British Journal of Surgery 1994, Bismuth H et al Br J Surg 1987

• Survival – Mean of 9.2 months with median 12 months

» Bismuth H et al Br J Surg 1987

» Jarnagin WR et al Am J Surg 1998

– The patients undergoing surgical bypass are reported to have a longer survival and a superior quality of life as compared to those palliated by other means

» Gazzaniga GM et al Journal of HBP Surg 2000» Figueras J,, et al Liver Transpl 2000

– Surgical bypass however has a higher early morbidity and mortality

– However, these studies need to be interpreted with caution.

– The patient population between the two groups is dissimilar

– Good risk patients undergoing operative palliation and those with advanced disease or co-morbidity being referred for non-operative biliary drainage.

– A cumulative analysis of four studies that compared surgical and non-surgical therapies

• Revealed that median survival between the two groups: 6.8 vs. 5.4 months (NS)

Surgical bypass Endoscopic bypass Percutaneous bypass

Advantage Better quality of life

Better survival (6.8Vs 5.4 m)

Long term patency (80% at 1 year) & low reintervention rate

Intraoperatively non-resectable Ds

Less invasive

Symptomatic palliation (86-90%)

2nd order biliary radical

High therapeutic success

Undrained segments

Disadvantage High early mortality & morbidity

Complexity of procedure

Cholangitis (53% Vs 10% )

Reintervention (85% Vs 30%)

Institutional expertise

Undrained segment

Higher complication rate

External biliary fistula

Singhal D et al Surg Oncol 2005

Conclusion

• Evidence are based largely on retrospective studies

• No recommendations can be made in favour of any one technique.

• The choice is best dictated by the available local expertise

• Endoscopic biliary drainage continues to be the preferred modality for patients detected to have unresectable disease at preoperative evaluation

• Results of PTBD is comparable to EBD and is a viable alternative to endoscopic palliation and when undrained segment is infected

• Segment III cholangiojejunostomy is performed at some centers for patients found to have unresectable disease at exploration. However, in the best of hands it has a mortality ranging between 6–12% and complication rate of 17–51%.