Segment Iii Bypass 18 407

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 GB

Access to hilum or left duct not possible

Options Endoscopic drainage, Percutaneous drainage, Surgical bypass

Segment 3 biliary bypass Ligamentum 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

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• 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

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– 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

Aim Assessment of vascular invasion Locoregional or distant metastasis

Procedure Recessus of Rex

Modification

An anterior hepatotomy to the left of falciform ligament over the segment III ductprovide 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 Less invasive 2nd order biliary radical Better survival (6.8Vs Symptomatic palliation High therapeutic success 5.4 m) (86-90%) Undrained segments Long term patency (80% at 1 year) & low reintervention rate Intraoperatively nonresectable Ds

Disadvantage

High early mortality & Cholangitis (53% Vs Higher complication rate morbidity 10% ) External biliary fistula Complexity of procedure Reintervention (85% Vs 30%) Institutional expertise Undrained segment

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%. • • • •