Ch. 54 – Biliary System

More documents

Recommendations

Info

1586 Section X Abdomen leads to high local recurrence rates due to early involvement of the confl uence of the hepatic ducts and the caudate lobe branches. The addition of a modifi ed hepatic resection has improved resectability rates. However, curative resections are still possible in less than half of patients, and most do not achieve long-term disease control. Surgical treatment depends on the Bismuth-Corlette classifi cation (see Fig. 54-35). For type I and II lesions, the procedure is en bloc resection of the extrahepatic bile ducts and gallbladder with 5- to 10-mm bile duct margins, and regional lymphadenectomy with Roux-en-Y hepaticojejunostomy. In addition to the above operations, type II tumors may require hepatic lobectomy. Because type II and III lesions often involve the ducts of the caudate lobe, many surgeons recommend routine caudate lobectomy. Type III and IV tumors are amenable to potentially curative resection in centers with expertise in these procedures. Aggressive techniques such as hepatectomy and portal vein resection to achieve negative margins are now routine in specialized centers. Substantial progress has been made in curative resection for perihilar cholangiocarcinomas. At least some of this progress has been attributed to the routine use of partial hepatectomy. The rate of margin-negative resections is consistently more than 75% when partial hepatectomy (including resection of the caudate lobe) is added to the bile duct resection. This aggressive approach has resulted in 5-year survival rates above 50% in some series. However, these improvements have been accompanied by higher surgical mortality rates (8%-10% versus 2%-4%). The major prognostic factors are margin status and tumor stage. In addition to location, stage, and status of the resection margins, other factors infl uence outcome after resection. Medical Therapy Numerous reports have suggested that radiation therapy improves survival for patients with cholangiocarcinoma, especially when resection is impossible. External-beam radiotherapy has been delivered using a variety of innovative techniques, including intraoperative radiotherapy and brachytherapy with iridium-192 through percutaneous or endoscopic stents. However, no prospective, randomized trials have been reported, and a well-controlled, but not randomized, trial reported no benefi t for postoperative adjuvant radiation. A survival benefi t for postoperative radiation therapy may be limited to patients with local extension into the liver parenchyma and microscopic residual disease following resection. Chemotherapy has also not been shown to improve survival in patients with either resected or unresected cholangiocarcinoma. Given the potential radiosensitization effect of 5-fl uorouracil or gemcitabine, the combination of radiation and chemotherapy may be more effective than either agent alone. As with gallbladder cancer, the role of adjuvant chemoradiation needs to be tested in patients with cholangiocarcinoma. Finally, photodynamic therapy is emerging as an important palliative option for patients with unresectable cholangiocarcinoma, although it is not widely available. Outcomes Long-term survival in patients with cholangiocarcinoma is highly dependent on the stage of disease at presentation and on whether the patient is treated by a palliative procedure or complete tumor resection. The rate of margin-negative resections has consistently been reported above 75% when partial hepatectomy including resection of the caudate lobe is added to the biliary resection. 49,50 This aggressive approach has increased 5-year survival rates to above 50% in some series. 47,49 However, the perioperative mortality rates accompanying these more extensive resections are slightly higher than those accompanying local excision only (8%-10% versus 2%-4%). 49,51,52 Patients with resectable distal bile duct cancer have the highest rate of resection. Those with resectable distal bile duct cancer have a median survival of 32 to 38 months and a 5-year survival rate of 28% to 45%. Even with multimodality adjuvant therapy, median survival for unresectable intrahepatic tumors has been only 6 to 7 months. Similarly, median survival for patients with unresectable perihilar tumors varies between 5 and 8 months. The use of liver transplantation for the treatment of cholangiocarcinoma is controversial and should be reserved for select patients as a part of research protocols. As more effective adjuvant and neoadjuvant protocols are developed, transplantation may be a more useful treatment for this disease. As indicated previously, this is suggested by early reports from the Mayo Clinic in which survival after neoadjuvant chemoradiation and liver transplantation was signifi cantly improved over resection alone for stage I and II hilar cholangiocarcinoma. 40 Metastatic and Other Tumors Hepatocellular carcinoma and liver metastases can cause obstructive jaundice by direct extension into the perihilar bile ducts. Hepatocellular and metastatic colorectal carcinoma have also both been reported to “embolize” into the biliary tree. This rare phenomenon occurs when tumor cells are shed into the biliary tract and implant distally, leading to biliary obstruction when the tumor embolus increases in size. Hepatic cystadenomas and cystadenocarcinomas arise from the biliary epithelium, and these tumors or the mucin they produce may also cause bile duct obstruction. Primary and secondary hepatic tumors can also produce biliary obstruction by metastasizing to hilar or pericholedochal lymph nodes. Hepatocellular carcinoma, colorectal carcinoma, and pancreatic carcinoma are the most common primary sites associated with biliary tract obstruction from lymph node metastases, although nodal metastases from a number of tumors including breast and ovarian cancer have been reported to cause bile duct obstruction. Lymphoma can also result in biliary obstruc-
tion and mimic either pancreatic cancer or perihilar cholangiocarcinoma. Although commonly extensive, lymphomas usually respond to chemotherapy, leading to resolution of the biliary obstruction. Selected References Anderson CD, Pinson CW, Berlin J, et al: Diagnosis and treatment of cholangiocarcinoma. Oncologist 9:43-57, 2004. Excellent review and summary of the modern treatment of cholangiocarcinoma. Boerma D, Rauws EA, Keulemans YC, et al: Wait-and-see policy or laparoscopic cholecystectomy after endoscopic sphincterotomy for bile-duct stones: A randomised trial. Lancet 360:761- 765, 2002. A randomized, prospective trial comparing observation versus laparoscopic cholecystectomy following endoscopic removal of stones. Recurrent biliary symptoms developed in 47% in the observation arm, and one third of these required cholecystectomy. Cotton PB: Endoscopic management of bile duct stones (apples and oranges). Gut 25:587, 1984. This classic article describes problems and results of the endoscopic management of choledocholithiasis. Dixon E, Vollmer CM Jr, Sahajpal A, et al: An aggressive surgical approach leads to improved survival in patients with gallbladder cancer: A 12-year study at a North American Center. Ann Surg 241:385-394, 2005. A review of the results in a single center over 12 years indicating that an aggressive approach to gallbladder cancer with extensive resection improves long-term survival. Glenn F: Acute cholecystitis. Surg Gynecol Obstet 143:56, 1976. This is a classic review with more than 200 cases by the late master biliary tract surgeon. Serious risk factors and the increased mortality in elderly patients are stressed. Nakeeb A, Comuzzie AG, Martin L, et al: Gallstones: Genetics versus environment. Ann Surg 235:842-849, 2002. An excellent study that examines the contribution of genetics to the pathogenesis of symptomatic gallstones. Rea DJ, Heimbach JK, Rosen CB, et al: Liver transplantation with neoadjuvant chemoradiation is more effective than resection for hilar cholangiocarcinoma. Ann Surg 242:451-458, 2005. Pivotal paper in the renewed interest in liver transplantation in the management of cholangiocarcinoma. Reisner RM: Gallstone ileus: A review of 1001 reported cases. Am Surg 60:441, 1994. An exhaustive review of all cases reported in the English language from 1953 to 1993. It covers all aspects of epidemiology, diagnosis, therapy, and complications. Southern Surgeons Club: A prospective analysis of 1518 laparoscopic cholecystectomies. N Engl J Med 324:1073-1078, 1991. This classic paper is one of the fi rst to identify and report outcomes following laparoscopic cholecystectomy. Chapter 54 Biliary System 1587 Way LW, Stewart L, Gantert W, et al: Causes and prevention of laparoscopic bile duct injuries: Analysis of 252 cases from a human factors and cognitive psychology perspective. Ann Surg 237:460-469, 2003. Intriguing article examining the human factor in the causation of bile duct injury. References 1. Trowbridge RL, Rutkowski NK, Shojania KG: Does this patient have acute cholecystitis? JAMA 289:80-86, 2003. 2. Potter MW, Shah SA, McEnaney P, et al: A critical appraisal of laparoscopic staging in hepatobiliary and pancreatic malignancy. Surg Oncol 9:103-110, 2000. 3. Weber SM, DeMatteo RP, Fong Y, et al: Staging laparoscopy in patients with extrahepatic biliary carcinoma: Analysis of 100 patients. Ann Surg 235:392-399, 2002. 4. Anderson CD, Rice MH, Pinson CW, et al: Fluorodeoxyglucose PET imaging in the evaluation of gallbladder carcinoma and cholangiocarcinoma. J Gastrointest Surg 8:90-97, 2004. 5. Thompson JE Jr, Pitt HA, Doty JE, et al: Broad spectrum penicillin as an adequate therapy for acute cholangitis. Surg Gynecol Obstet 171:275-282, 1990. 6. Thompson JE Jr, Bennion RS, Doty JE, et al: Predictive factors for bactibilia in acute cholecystitis. Arch Surg 125:261-264, 1990. 7. Bellows CF, Berger DH, Crass RA: Management of gallstones. Am Fam Physician 72:637-642, 2005. 8. Nakeeb A, Comuzzie AG, Martin L, et al: Gallstones: Genetics versus environment. Ann Surg 235:842-849, 2002. 9. Stewart L, Oesterle AL, Erdan I, et al: Pathogenesis of pigment gallstones in Western societies: The central role of bacteria. J Gastrointest Surg 6:891-903, 2002. 10. Glasgow RE, Cho M, Hutter MM, et al: The spectrum and cost of complicated gallstone disease in California. Arch Surg 135:1021-1025, 2000. 11. Lo CM, Liu CL, Fan ST, et al: Prospective randomized study of early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Ann Surg 227:461-467, 1998. 12. Lai PB, Kwong KH, Leung KL, et al: Randomized trial of early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Br J Surg 85:764-767, 1998. 13. Kiviluoto T, Siren J, Luukkonen P, et al: Randomised trial of laparoscopic versus open cholecystectomy for acute and gangrenous cholecystitis. Lancet 351:321-325, 1998. 14. Steiner CA, Bass EB, Talamini MA, et al: Surgical rates and operative mortality for open and laparoscopic cholecystectomy in Maryland. N Engl J Med 330:403-408, 1994. 15. Southern Surgeons Club: A prospective analysis of 1518 laparoscopic cholecystectomies. N Engl J Med 324:1073- 1078, 1991. 16. Lau H, Lo CY, Patil NG, et al: Early versus delayed-interval laparoscopic cholecystectomy for acute cholecystitis: A metaanalysis. Surg Endosc 20:82-87, 2006. 17. Willsher PC, Sanabria JR, Gallinger S, et al: Early laparoscopic cholecystectomy for acute cholecystitis: A safe procedure. J Gastrointest Surg 3:50-53, 1999. 18. Liu TH, Consorti ET, Kawashima A, et al: Patient evaluation and management with selective use of magnetic resonance cholangiography and endoscopic retrograde cholangiopancreatography before laparoscopic cholecystectomy. Ann Surg 234:33-40, 2001. 19. Rhodes M, Sussman L, Cohen L, et al: Randomised trial of laparoscopic exploration of common bile duct versus
Page 1 and 2: Biliary System Ravi S. Chari, MD an
Page 3 and 4: Vater, where it empties into the du
Page 5 and 6: Urinary excretion (95% of biliary s
Page 7 and 8: The pain is most commonly triggered
Page 9 and 10: Cholangiography Cholangiography fun
Page 11 and 12: Cholesterol Gallstones The pathogen
Page 13 and 14: tomatic gallstones who fail expecta
Page 15 and 16: A B After endoscopic sphincterotomy
Page 17 and 18: Surgery for Calculous Biliary Disea
Page 19 and 20: Box 54-4 Indications for Intraopera
Page 21 and 22: transduodenal approach may be feasi
Page 23 and 24: is jaundice with or without abdomin
Page 25 and 26: An adequate incision permitting ful
Page 27 and 28: A Recurrent Pyogenic Cholangitis Ch
Page 29 and 30: Management IV antibiotics and aggre
Page 31 and 32: Box 54-6 Todani Modifi cation of Al
Page 33 and 34: Figure 54-31 Operative photography
Page 35 and 36: ant abdominal pain. A heterogeneous
Page 37 and 38: Figure 54-35 Bismuth classifi catio
Page 39: sectable disease; however, intraope

Ch. 54 – Biliary System

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?