Journal of Surgical Oncology 7:319-322 (1975)
By-Pass Anastomosis of lntrahepatic Duct to the Gallbladder .......................................................................................... .......................................................................................... EDWARD F. SCANLON, M.D.,F.A.C.S., and MIGUEL A. OVIEDO, M.D. Obstructiofi of the extrahepatic bile ducts by primary or metastatic carcinoma can sometimes be difficult to relieve. Frequently there is an inadequate length of normal duct proximal to the obstruction to permit an anastomosis. A by-pass anastomosis between a dilated right hepatic biliary radicle and the gallbladder is a simple and satisfactory method of relieving the jaundice. This can be accomplished by using a T-tube as a stent; a vein graft over the T-tube limb in the liver seems to improve the result.
.......................................................................................... .......................................................................................... KEY WORDS: biliary obstruction, biliary bypass, ectrahepatic biliary obstruction
INTRODUCTION The management of jaundice due to malignant obstruction of the hepatic or common ducts is one of the most difficult problems in general surgery (Ross et al., 1973). Since the original work of Longmire and Sanford in 1948 (Longmire and Lippman, 1956), the operation described as intrahepatic cholangiojejunostomy has been in use on patients with malignant obstruction of the extrahepatic biliary ducts (Ragins et al., 1973; Ross et al., 1973; Schutt, 1964). In some poor-risk patients with a patent distal common duct, a lesser procedure would be desirable (Smith, 1969; Smith and Sherlock, 1964). We wish to report on one patient who was treated effectively by draining a dilated right hepatic duct into the gallbladder. We had previously done this with large cholangiolar cysts and felt it might be effective in certain ductal carcinomas. Patient Report A 61-year-old male was admitted to the Evanston Hospital in March 1971, after an adenocarcinoma of the sigmoid colon was found on routine barium enema. A left hemicolectomy was done on March 31, 1971. The pathological diagnosis was carcinoma of the
Edward F. Scanlon, Professor of Surgery, Northwestern University Medical School; Attending Surgeon, Evanston Hospital, Evanston, Illinois. Miguel A. Oviedo, Instructor in Surgery, Northwestern University Medical School; American Cancer Society Training Fellow, Evanston Hospital, Evanston, Illinois. Address reprint requests to Edward F. Scanlon, M.D., 2500 Ridge Avenue, Evanston, Illinois 60201. 319
@Alan R Liss, Inc., 150 Fifth Avenue, New York, N.Y. 10011
320
Scanlon and Oviedo
colon with serosal invasion and no evidence of metastasis in the mesenteric lymph nodes. His postoperative course was uneventful. In February 1972, he was readmitted with a several week history of itching, diarrhea, and upper adbominal pain. He was jaundiced on physical examination. On February 28, 1972, a percutaneous hepatic cholangiogram showed complete obstruction of the proximal common hepatic duct (Fig. 1). The same day an exploratory laparotomy showed metastatic carcinoma of the colon t o the hilum of the liver. It was decided to attempt a biliary anastomosis using the gallbladder and patent cystic duct as the by-pass circuit. After a dilated intrahepatic duct was found in the right lobe of the liver, using a needle for aspiration, one branch of a T-tube was inserted in the bile duct and the other branch was inserted in the gallbladder; the long limb of the T-tube was brought out t o the skin. A postoperative cholangiogram (Fig. 2) shows good filling of the intrahepatic ducts, visualization of the gallbladder, and patent cystic duct with contrast medium in the distal choledoclius and duodenum. The T-tube worked postoperatively, and it also drained bile into the duodenum, bypassing the proximal extrahepatic obstruction. He was then given a course of 5-FU and X-ray therapy to the liver hilum. The patient was readmitted in April 1972, and died two months after the operation. The postmortem examination showed massive replacement of the liver by metastasis from adenocarcinoma of the colon. The biliary by-pass was still patent.
Fig. 1. Preoperative percutaneous transhepatic cholangiogram showing complete obstruction of the proximal common hepatic duct.
32 1
B y-Pass Anastomosis
Fig. 2. Postoperative cholangiogram showing intrahepatic bile ducts, obstruction of the common duct, and patent by-pass with opacification of the gall bladder, cystic duct, and choledochus.
CONCLUSION A patient report with extrahepatic malignant biliary obstruction is presented and a technique of proximal biliary by-pass is described. We consider this procedure indicated in the presence of obstruction of the extrahepatic ducts proximal to the cystic duct, if the gallbladder-cystic duct is patent and if the patient is not a candidate for a radical curative procedure (Terblanche and Louw, 1973; Waddell and Grover, 1973).
322
Scanlon and Oviedo
REFERENCES Longmire, W. P., and Lippman, H. N. (1956). Intrahepatic Cholangiojejunostomy - An operation for biliary obstruction. Surg. Clin. Am. 36:849-863. Ragins, H., Diamond, A., and Meng, C. H. (1973). Intrahepatic Cholangiojejunostomy in the management of malignant biliary obstruction. Surg. Gynecol. Obstet. 136:27-32. Ross, A. P., and Braasch, J. W., and Warren, K. W. (1973). Carcinoma of the proximal bile ducts. Surg. Gynecol. Obstet. 136:923-928. Schutt, R. P. (1964). Bilateral intrahepatic cholangiojejunostomy. Am. 3. Surg. 107:777-780. Smith, R. (1969). Carcinoma of the gallbladder and extrahepatic bile ducts. “Abdominal Operations,” 5th ed., R. Maingot (Ed.). New York: Appleton-Century-Crofts, pp. 876-884. Smith, R., and Sherlock, S. (1964). The short circuit operations in biliary tract surgery. In “Surgery of the Gallbladder and Bile Ducts,” R. Smith and S. Sherlock (Eds.), London: Butterworth, pp. 297-308. Terblanche, J., and Louw, J. H. (1973). U. tube drainage in the palliative therapy of carcinoma of the main hepatic duct junction. Surg. Clin. North Am., 5 3 : 1245-1256. Waddell, W. R., and Grover, F. L. (1973). Gallbladder as conduit between liver and intestine. Surgery 74:524-529.
By-Pass Anastomosis of lntrahepatic Duct to the Gallbladder .......................................................................................... .......................................................................................... EDWARD F. SCANLON, M.D.,F.A.C.S., and MIGUEL A. OVIEDO, M.D. Obstructiofi of the extrahepatic bile ducts by primary or metastatic carcinoma can sometimes be difficult to relieve. Frequently there is an inadequate length of normal duct proximal to the obstruction to permit an anastomosis. A by-pass anastomosis between a dilated right hepatic biliary radicle and the gallbladder is a simple and satisfactory method of relieving the jaundice. This can be accomplished by using a T-tube as a stent; a vein graft over the T-tube limb in the liver seems to improve the result.
.......................................................................................... .......................................................................................... KEY WORDS: biliary obstruction, biliary bypass, ectrahepatic biliary obstruction
INTRODUCTION The management of jaundice due to malignant obstruction of the hepatic or common ducts is one of the most difficult problems in general surgery (Ross et al., 1973). Since the original work of Longmire and Sanford in 1948 (Longmire and Lippman, 1956), the operation described as intrahepatic cholangiojejunostomy has been in use on patients with malignant obstruction of the extrahepatic biliary ducts (Ragins et al., 1973; Ross et al., 1973; Schutt, 1964). In some poor-risk patients with a patent distal common duct, a lesser procedure would be desirable (Smith, 1969; Smith and Sherlock, 1964). We wish to report on one patient who was treated effectively by draining a dilated right hepatic duct into the gallbladder. We had previously done this with large cholangiolar cysts and felt it might be effective in certain ductal carcinomas. Patient Report A 61-year-old male was admitted to the Evanston Hospital in March 1971, after an adenocarcinoma of the sigmoid colon was found on routine barium enema. A left hemicolectomy was done on March 31, 1971. The pathological diagnosis was carcinoma of the
Edward F. Scanlon, Professor of Surgery, Northwestern University Medical School; Attending Surgeon, Evanston Hospital, Evanston, Illinois. Miguel A. Oviedo, Instructor in Surgery, Northwestern University Medical School; American Cancer Society Training Fellow, Evanston Hospital, Evanston, Illinois. Address reprint requests to Edward F. Scanlon, M.D., 2500 Ridge Avenue, Evanston, Illinois 60201. 319
@Alan R Liss, Inc., 150 Fifth Avenue, New York, N.Y. 10011
320
Scanlon and Oviedo
colon with serosal invasion and no evidence of metastasis in the mesenteric lymph nodes. His postoperative course was uneventful. In February 1972, he was readmitted with a several week history of itching, diarrhea, and upper adbominal pain. He was jaundiced on physical examination. On February 28, 1972, a percutaneous hepatic cholangiogram showed complete obstruction of the proximal common hepatic duct (Fig. 1). The same day an exploratory laparotomy showed metastatic carcinoma of the colon t o the hilum of the liver. It was decided to attempt a biliary anastomosis using the gallbladder and patent cystic duct as the by-pass circuit. After a dilated intrahepatic duct was found in the right lobe of the liver, using a needle for aspiration, one branch of a T-tube was inserted in the bile duct and the other branch was inserted in the gallbladder; the long limb of the T-tube was brought out t o the skin. A postoperative cholangiogram (Fig. 2) shows good filling of the intrahepatic ducts, visualization of the gallbladder, and patent cystic duct with contrast medium in the distal choledoclius and duodenum. The T-tube worked postoperatively, and it also drained bile into the duodenum, bypassing the proximal extrahepatic obstruction. He was then given a course of 5-FU and X-ray therapy to the liver hilum. The patient was readmitted in April 1972, and died two months after the operation. The postmortem examination showed massive replacement of the liver by metastasis from adenocarcinoma of the colon. The biliary by-pass was still patent.
Fig. 1. Preoperative percutaneous transhepatic cholangiogram showing complete obstruction of the proximal common hepatic duct.
32 1
B y-Pass Anastomosis
Fig. 2. Postoperative cholangiogram showing intrahepatic bile ducts, obstruction of the common duct, and patent by-pass with opacification of the gall bladder, cystic duct, and choledochus.
CONCLUSION A patient report with extrahepatic malignant biliary obstruction is presented and a technique of proximal biliary by-pass is described. We consider this procedure indicated in the presence of obstruction of the extrahepatic ducts proximal to the cystic duct, if the gallbladder-cystic duct is patent and if the patient is not a candidate for a radical curative procedure (Terblanche and Louw, 1973; Waddell and Grover, 1973).
322
Scanlon and Oviedo
REFERENCES Longmire, W. P., and Lippman, H. N. (1956). Intrahepatic Cholangiojejunostomy - An operation for biliary obstruction. Surg. Clin. Am. 36:849-863. Ragins, H., Diamond, A., and Meng, C. H. (1973). Intrahepatic Cholangiojejunostomy in the management of malignant biliary obstruction. Surg. Gynecol. Obstet. 136:27-32. Ross, A. P., and Braasch, J. W., and Warren, K. W. (1973). Carcinoma of the proximal bile ducts. Surg. Gynecol. Obstet. 136:923-928. Schutt, R. P. (1964). Bilateral intrahepatic cholangiojejunostomy. Am. 3. Surg. 107:777-780. Smith, R. (1969). Carcinoma of the gallbladder and extrahepatic bile ducts. “Abdominal Operations,” 5th ed., R. Maingot (Ed.). New York: Appleton-Century-Crofts, pp. 876-884. Smith, R., and Sherlock, S. (1964). The short circuit operations in biliary tract surgery. In “Surgery of the Gallbladder and Bile Ducts,” R. Smith and S. Sherlock (Eds.), London: Butterworth, pp. 297-308. Terblanche, J., and Louw, J. H. (1973). U. tube drainage in the palliative therapy of carcinoma of the main hepatic duct junction. Surg. Clin. North Am., 5 3 : 1245-1256. Waddell, W. R., and Grover, F. L. (1973). Gallbladder as conduit between liver and intestine. Surgery 74:524-529.
