The Use of Silastic Transhepatic Stents in Benign and Malignant Biliary Strictures JOHN L. CAMERON, M.D., BOB W. GAYLER, M.D., GEORGE D. ZUIDEMA, M.D.
Between 1969 and 1978, 45 patients with biliary strictures have been managed surgically utilizing silastic transhepatic stents. In 25 patients the strictures were benign. After resection or dilatation of the benign stricture, an hepaticojejunostomy was performed to a Roux-en-Y loop. The anastomosis was stented with a large bore silastic tube with multiple side holes passed through the biliary tree, out the anterior surface of the liver, and then out through the abdominal wall. There was one hospital death. Most stents were left in place for one year. Of the 15 patients with long-term follow-up, all have had excellent results. In 20 patients the strictures were malignant and involved the common hepatic duct in 10 patients or its bifurcation in 10 patients. In 14 patients the tumor was thought to be primary in the biliary tree, and in six patients the tumor was felt to represent a metastasis or direct extension from another site. In three patients the tumors were resected, and in the remaining they were dilated or bypassed. After positioning a silastic transhepatic stent, a hepaticojejunostomy was carried out. There were two hospital deaths. Serum bilirubin on admission averaged 17.1 mg%, and after decompression 1.8 mg%. Five patients have survived over one year, and two over two years. Postoperative radiotherapy and a primary biliary tumor favored longer survival.
ENIGN AND MALIGNANT strictures of the biliary D tree present difficult problems in management. Benign strictures are usually high in the hilum of the liver and difficult to expose, a mucosa-to-mucosa anastomosis hard to achieve, and late recurrences disappointingly frequent. With malignant biliary strictures involving the common hepatic duct or bifurcation, resection is usually not possible. Such patients die, not from the slow growing biliary tumor, but from hepatic failure due to biliary obstruction which is difficult to adequately and permanently decompress.5 A technique used over the past nine years to manage such patients utilizes a silastic transhepatic biliary stent. Despite the different problems that benign and malignant strictures present, the use of this technique of transhepatic intubation with a silastic stent has markedly improved the management of both groups
of patients. Presented at the Annual Meeting of the American Surgical Association April 26-28, 1978, Dallas, Texas.
From the Departments of Surgery and Radiology, The Johns Hopkins Medical Institutions, Baltimore Maryland
Clinical Material Forty-five patients with biliary strictures have been managed with silastic transhepatic biliary stents at The Johns Hopkins Medical Institutions between 1969 and 1978. In 25 patients the stricture was benign and in the remaining 20 patients it was malignant.
Benign Strictures The ages of these 25 patients ranged from 18 to 75 years and averaged 42 years. Twenty were females and five were males. The etiology of the benign stricture was surgical trauma in 21 patients, a gun shot wound to the porta hepatis in one patient, congenital cystic dilatation of the biliary tree in one, a benign cystadenoma in one, and an idiopathic inflammatory process in one. The stricture involved the common hepatic duct in 21 patients and the bifurcation of the hepatic duct in four. For 13 patients the current procedure was the first attempt at repair of their benign stricture. Seven patients had undergone one prior repair, four had two prior repairs, and one patient had undergone four prior repairs. Serum bilirubin at the time of admission ranged from 0.4 mg% to 19.3 mg%, and averaged 7.4 mg% (Table 1). Malignant Strictures The ages of these 20 patients ranged from 43 to 82 years and averaged 61 years. Thirteen were males and 7 were females. In ten patients the malignant stricture involved primarily the common hepatic duct. In the remaining ten patients the tumor occurred at the bifurcation. In 14 patients the tumor was felt to be primary in the biliary tree. However, this was often difficult to determine and in some instances the tumor could have originated in the pancreas or elsewhere. In
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TABLE 1. Biliary Strictures in 45 Patients
Stricture Site
Biliary Stricture
Patients
Age (Yrs.)
Sex (M, F)
Benign Malignant
25 20
42 61
20F, SM 7F, 13M
BifurCHD cation 21 10
4 10
Serum Bilirubin (mg%) 7.4 17.1
the remaining six patients the malignant biliary stricture was felt to represent direct extension or metastatic spread from a tumor in the colon (three patients), stomach (one patient), gallbladder (one patient), or pancreas (one patient). One of the patients who had a primary biliary tract tumor involving his bifurcation had a long history of ulcerative colitis. Serum bilirubin at admission in these 20 patients with malignant biliary strictures ranged from 4.9 to 36.9 mg%, and averaged 17.1 mg% (Table 1).
Operative Management Most patients prior to surgery had their biliary tract anatomy defined by transhepatic, endoscopic retrograde, T tube, or sinus tract cholangiography. All patients were started on Penicillin and Gentamycin the night prior to operation. Benign Strictures Twenty-four of the 25 patients with benign strictures had their repair performed in the hilum of the liver. In 16 patients the stricture was resected. In eight instances the stricture was so high in the hilum or the parenchyma of the liver that it was not resectable, and was dilated with Bake's dilators. The final patient had an intrahepatic cholangiojejunostomy (Longmire Procedure) performed at the periphery of the left lobe of the liver. After the stricture was resected or dilated, a curved stone forceps was introduced into the biliary tree and advanced either through the right or left intrahepatic duct until it could be brought within a centimeter or two of Glisson's capsule on the anterior superior (diaphragmatic) surface. The forceps were then forcibly advanced out through the liver parenchyma. A silastic biliary stent was sutured to the end of the forceps and drawn back down through the liver parenchyma, intrahepatic biliary tree, and out the hilum of the liver (Fig. 1). The silastic biliary stents are 60 cm in length and come in three outside diameters: 10 mm, 8 mm, and 6 mm. Forty per cent of the length of the silastic stent contains multiple side holes.* The largest stent that will be accommodated by the dilated *
Dow Coming
553
biliary tree is used. Generally it is one of the two larger sizes. In 15 patients with benign strictures the stent was placed in the right hepatic duct. In eight patients, including the one undergoing a Longmire Procedure, the stent was placed in the left hepatic duct. In two of the patients with strictures involving the bifurcation of the hepatic duct, stents were placed in both the right and left hepatic ducts (Table 2). Once the stent is in place, a Roux-en-Y loop is fashioned and placed in the hilum. The end of the loop is closed and an end-to-side hepaticojejunostomy performed. In most instances a mucosa-to-mucosa anastomosis cannot be fashioned. After the biliary stent is placed into the jejunum through a stab wound, the Roux-en-Y loop is sutured to the hepatic duct, liver capsule, and other hilar structures surrounding the biliary stent. A large mattress suture is then placed around the exit site of the stent on the anterior surface of the liver. This end of the tube is brought out through a stab wound in the upper abdomen and connected to bile bag drainage (Fig. 2). Penrose drains are left to drain the exit site of the stent on the anterior surface of the liver, and the anastomosis. Postoperatively, the biliary stent is left to gravity drainage until a cholangiogram demonstrates that the anastomosis and exit site on the liver have sealed. The Penrose drains are then removed and the stent clamped. Thereafter, the patient irrigates the transhepatic stent twice a day for as long as it remains in. Malignant Strictures Operative management of the 20 patients with malignant strictures was very similar to those with benign strictures. In three patients, two with tumors at the bifurcation and one with a tumor in the common hepatic duct, resection was performed. In all three patients positive tumor margins in both ducts were left on the liver side. In 16 patients the tumor was dilated by passing instruments up from normal duct below the tumor, or else the biliary tree was entered via the left or right hepatic duct above the tumor (Fig. 3). One patient had an intrahepatic cholangiojejunostomy (Longmire Procedure) performed away from the tumor and hilum of the liver. After access to the intrahepatic biliary tree was achieved by resection, dilatation, or entering above the tumor, a TABLE 2. Silastic Transhepatic Tube Placement No. Stents
Biliary
Location of Stents
Stricture
Patients
1
2
3
R Duct
L Duct
Both
3 Ducts
Benign Malignant
25 20
23 14
2
0 1
15 6
8 8
2 5
0 1
5
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Ann. Surg. m October 1978
........ ..
FIG. 1. Stone forceps have been passed into the common hepatic duct at the hilum, advanced through the intrahepatic biliary tree, and forced out through the parenchyma on the anterior surface of the liver. A silastic biliary stent is then sutured to the end of the forceps so that it can be drawn back into the intrahepatic biliary tree and out the hilum.
transhepatic biliary stent was inserted in a fashion identical to that for benign strictures. In 14 patients one transhepatic stent was placed. In eight instances the single stent was placed in the left hepatic duct and in six patients it was placed in the right hepatic duct. Five patients had biliary stents placed in both the left and right hepatic ducts. The final patient, after tumor resection, was left with three large open ducts, and transhepatic stents were placed in all three (Table 2). In four patients, once the silastic stent was inserted, it was passed into the duodenum through the common duct, after performing a sphincteroplasty. In the remaining 16 patients a Roux-en-Y loop was constructed and a hepaticojejunostomy performed. In many instances the jejunum was sutured to tumor surrounding the egress site of the silastic stent in the liver hilum. The tumor margins were marked with hemoclips for possible radiotherapy (Fig. 4). The stent exit site on the liver and the anastomosis were drained and the stent managed in a fashion identical to that described for benign strictures. Clinical Course
Benign Strictures One patient died following repair of a benign stricture. She was a 67-year-old-woman with a biliary stricture of 20 years duration and biliary cirrhosis. She had
undergone two prior attempts at repair. She tolerated the operative procedure but died in the hospital 65 days later of liver failure. Hospitalization in the remaining 24 patients ranged from eight to 70 days, and averaged 31 days. All patients developed biliary-cutaneous fistulas at the exit site of the biliary stent from the liver and/or from the anastomosis. All fistulas closed spontaneously but often took two or three weeks and resulted in the long average hospitalization. Four patients developed wound infections following surgery. Three patients required drainage of an intra-abdominal abscess. Two patients developed sepsis during the first week after surgery, presumably from bile leaks. There have been two late deaths. Both patients died of sepsis during sodium cholate infusion into their transhepatic stent. Both patients had tolerated their operative procedures well and were asymptomatic. At eight months following their repair both were readmitted for sodium cholate infusion because of retained intrahepatic biliary sludge that had not been successfully cleared from the biliary tree at the time of repair. Shortly after the infusions were started both became hypotensive and died. Positive blood cultures were obtained in one. The remaining 22 patients are alive and well. In most patients the silastic transhepatic stent was left in for 12 months and then removed. Initially the tubes were changed during this 12 month period only if they
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SILASTIC TRANSHEPATIC STENTS
FIG. 2. A Roux-en-Yjejunal loop is sutured to hepatic duct, liver capsule and other structures at the egress site of the silastic stent in the hilum of the liver. That portion of the stent that passes through the liver and into the jejunum contains multiple side holes. N
Tuvdior
R. and L.hepatic ducts
FIG. 3. When dealing with malignant biliary strictures, the lesion is either resected (A), dilated from below (B), or bypassed (C) by entering the right or left hepatic duct above the tumor. Silastic stents are then placed in a fashion identical to that for benign strictures.
..hepatic duct
ol
c
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CAMERON, GAYLER AND ZUIDEMA
Ann. Surg. * October 1978
FIG. 4. Postoperative cholangiogram of a patient who underwent dilatation of a malignant stricture with the placement of a silastic stent into the left hepatic duct. Hemoclips mark the tumor for the radiotherapist.
became partially occluded. Recently we have been routinely changing all stents every three months to avoid partial occlusion with leakage around the stent cutaneous exit site and/or fever. These tube changes can easily be performed under fluoroscopy as an outpatient procedure. A guide wire is threaded through the silastic stent into the Roux-en-Y loop. The stent is then removed leaving the guide wire in place. The new silastic transhepatic stent is then easily threaded back in place over the guide wire, which is then removed.2 Twelve patients have had their tubes removed permanently and have been followed an average of four years and 11 months (12-108 months). All 12 are classified as excellent results. Eleven have remained asymptomatic and with a normal serum bilirubin. The twelfth patient became jaundiced from a stricture recurrence six years and ten months following his initial repair. He was reoperated upon and a silastic stent reinserted after dilitation of the stricture. The transhepatic stent was left in for 16 months. He has now been followed for two years and two months since his second repair and remains asymptomatic. In three additional patients followed for an average of two years and two months (15-42 months) the silastic stents remain in place. Because of the difficulty of the repair, it is not anticipated that the stents will be removed. They are changed in outpatient radiology every three to six months. All three patients
are asymptomatic. Two patients have normal serum bilirubins, and the third has a mild elevation. All three are classified as excellent results. The final seven patients have all been operated upon during the last 12 months. The stents remain in place. It is anticipated that they will be removed in all seven patients at 12 months. All are asymptomatic (Table 3).
Malignant Strictures Two patients died following surgery for a malignant stricture. One patient, a 66-year-old male with a biliary tumor at the bifurcation, died of sepsis 30 days after surgery. A stent was placed in his right hepatic duct, but because of tumor his left duct could not be decompressed. Cholangitis in his occluded left duct could not be controlled with antibiotics. The second death occurred in a 62-year-old man with a tumor at his bifurcation. Ten days after surgery he suddenly became septic and died. Subphrenic and subhepatic abscesses were found. Hospitalization in the remaining 18 patients ranged from seven to 77 days and averaged 30 days. Two patients required drainage of an intraabdominal abscess. One developed postoperative sepsis and one patient developed a wound infection. After biliary decompression the average serum bilirubin dropped from an admission value of 17.1 mg% to 1.8 mg%.
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TABLE 4. Effect of Radiotherapy and Site of Origin on Survival in 12 Patients Dying with Malignant Biliary Strictures
TABLE 3. Surgical Results of Patients with Benign Strictures
Results < 12 Months
Patients
Operative Deaths
Late Deaths
Excellent
Poor
25
1
2*
7
0
557
Results > 12 Months
Patients
Average Survival (Mos.)
12
11
7 5
12 7
6 6
15 7
Excellent Poor 15
0
* Secondary to sodium cholate infusion.
Twelve of the 18 patients who were discharged from the hospital have died. Two lived for over two years, one lived for over one year, three died between seven and 12 months following surgery, and six died within the first 6 months of surgery. Average length of survival in these 12 patients was 11 months. In the seven patients who received radiotherapy survival averaged 13 months as compared to 7 months in those five patients who received no radiotheapy. Six of the 12 patients who died were felt to have primary biliary tract tumors, and survival in this group averaged 15 months. In the six patients with secondary malignant biliary obstruction, survival averaged 7 months (Table 4). Of these 12 patients who survived the operation and were discharged from the hospital, eight died as a result of their tumor, and not from biliary obstruction. Two patients were not adequately decompressed and one died of sepsis at three months, and the second of hepatic failure at six months. The cause of death in the remaining two patients is not known. Six patients remain alive. Two have survived more than one year, two are alive seven to 12 months following surgery, and two have been operated upon during the past six months (Fig. 5).
Late Deaths Radiotherapy Yes No Malignant Strictures Primary Secondary
preferable to one using the duodenum or distal bile duct.616 Whether or not to use a biliary stent is somewhat more controversial but many surgeons advocate their use in difficult repairs.6'16 However, even with these techniques utilized in the most prominent clinics, longterm success is generally achieved in only 65% to 80% of patients.3 16-'8 Most benign strictures occur high in the hilum of the liver and are close to or involve the bifurcation of the common hepatic duct. An anatomical repair with good mucosa-to-mucosa approximation is always preferable, but often impossible. The technique of repair for benign strictures described here does not depend upon mucosa-to-mucosa approximation. After placing a biliary silastic stent transhepatically the jejunal loop is positioned around the egress site of the tube high in the hilum of the liver. During the ensuing weeks and months the gap that may exist between the mucosal surfaces will be bridged with epithelium. The scar that also forms will do so in the environment of the relatively nonreactive silastic stent with a minimum of
Discussion
The technique of transhepatic intubation was described by Goetze4 in 1951 and by Praderi in 1961.10.11 Subsequently, Smith popularized this technique of biliary stenting,'3 and reported his experience with benign strictures in 1975,18 Saypol and Kurian'2 in 1969 introduced the modification of a U tube transhepatic stent, and in 1972 Terblanche, Saunders, and Louw15 extended this to malignant strictures. The technique of transhepatic intubation using a silastic stent has been utilized in our clinic since 1969. An initial report on this technique in ten patients was reported in 1976.2 The silastic stent has distinct advantages in the management of both benign and malignant biliary strictures, and we feel is responsible for improvement in longterm results. Over the past decade the surgical management of benign strictures has become fairly standardized. Most surgeons feel an anastomosis between the proximal hepatic segment and a Roux-en-Y jejunal loop is
PATIENTS
MP JS F B -4 M K -4 DH AJ 0 t MH RS t WV HR C E __ -_ RR GH CM CK JS GP IU -
PRI MARY SECON DARY -. RADI AT ION THERAPY
DEAD
0 __
6 12 18 24 30 MONTHS FIG. 5. Clinical course of the 18 patients with malignant biliary strictures who survived surgery.
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CAMERON, GAYLER AND ZUIDEMA
foreign body reaction. As scar contracture occurs the anastomosis will be maintained widely patent by the large bore stent. At the end of a 12-month period, with the tract well epithelialized and a stable scar, the stent can be removed. In the interim the biliary tree and anstomosis can be kept free of biliary sludge by daily irrigations. Changing the tube every three months further insures against sludge collection and partial obstruction. Tube changes can be performed in ten minutes as an outpatient procedure.2 The tube also provides access for cholangiography. Utilizing this technique of repair, virtually all patients with benign strictures have been managed successfull. The only two late deaths were probably related to sodium cholate infusions. Even though bile salt infusion into the biliary tree is effective and tolerated well through a T-tube, its use with a transhepatic stent infusing the solution directly into the liver is dangerous and should be avoided.9 All 12 patients who have had their stents removed have had excellent results. The one recurrence (six years and ten months after the initial repair) was successfully treated by a second intubation. Smith has advocated a "mucosal graft technique" pulling the Roux-en-Y loop up into the liver with the transhepatic tube.'8 He has not used silastic and generally leaves the stent in place for only three to four months. His success rate has been 65%. We feel the use of a silastic stent left in for one year is important. If the repair is particularly tenuous, and a major duct has not been intubated, the stent may be left in permanently. We have recognized no adverse consequences of leaving the stent in over long periods in the three patients so managed (15, 21, 42 months). This technique of stenting can also be extended for use in the Longmire Procedure, when the hilum of the liver is no longer safe to dissect. ' Malignant biliary strictures present a different set of problems. If the tumor is primary in the biliary tree it often will be slow growing and slow to metastasize. Recognition of these tumors, first well described by Klatskin,5 is often delayed. When the diagnosis is finally confirmed deep jaundice may be present and the patient often dies of hepatic failure. Ideally, such tumors should be recognized early and resected. However, because of the close proximity to the hepatic artery and portal vein, and the right and left intrahepatic ducts, local extension usually makes the tumor unresectable. Extended operative procedures including partial liver resection have been advocated and performed,7 as has liver resection and allotransplantation. 14 However, currently, these procedures carry operative and late mortalities that argue against their routine use. Thus, for most patients with biliary tract tumors, effective biliary decompression is what is
needed. The large bore thick walled silastic stents are very effective in this task. The average serum bilirubin on admission of 17.1 mg% dropped to 1.8 mg% after decompression. This allows effective palliation so that the patient's subsequent course will be determined by the malignant tumor, and not by the biliary obstruction. As adjuvant therapy improves, the palliation achievable should also improve. In our series the addition of radiotherapy to transhepatic intubation doubled survival time. Because of the small numbers, however, this difference was not statistically significant. Of the 12 patients felt to have primary biliary tract tumors who left the hospital, four lived or are still alive one year after surgery, and two lived over two years. Average survival of the patients with primary biliary tract tumors who have died was 15 months. Secondary malignant biliary strictures, with the tumor arising outside of the bile ducts, is often a more rapid process. The colon, pancreas, or gall bladder malignancies from the biliary obstruction arises is often rapid growing, and death occurs from the tumor before hepatic failure is a problem. Occasionally, however, such a patient will remain relatively healthy despite disseminated tumor, and will be a suitable candidate for biliary decompression. The use of a silastic transheptic stent affords a relatively simple, rapid means of effecting this decompression. Palliation is usually somewhat shorter, however, because of tumor growth elsewhere. Our data suggest that survival after successful transhepatic stenting is only half as long with a secondary malignant stricture (7 months) as with a primary malignant stricture (15 months). Silastic transhepatic stents were placed in only one duct in 14 patients with malignant strictures. In the remaining six patients both major ductal systems were drained. Ideally, both ducts should be intubated to avoid obstruction and sepsis. Drainage from both ducts is not needed to control the serum bilirubin. Longmire8 has pointed out that decompression of one lobe is sufficient to maintain normal liver function. However, if infection occurs in the undrained duct it will not be controllable with antibiotics. One hospital death and one late death in our series were attributable to sepsis in an undrained duct. References 1. Cameron, J. L., Gayler, B. W. and Harrington, D. P.: Modification of the Longmire Procedure. Ann. Surg. 187:379, 1978. 2. Cameron, J. L., Skinner, D. B. and Zuidema, G. D.: Long-
Term Transhepatic Intubation for Hilar Hepatic Duct Strictures. Ann. Surg., 183:488, 1976. 3. Glen, F.: latrogenic Injuries to the Biliary Ductal System. Surg. Gynecol. Obstet., 146:430, 1978. 4. Goetze, O.: Die Tranchepatische Dauerdrainage bei der Hoken Gallengangsstenose. Arch. Klin. Chir. 270:97, 1951. 5. Klatskin, G.: Adenocarcinoma of the Hepatic Duct at Its Bifurcation Within the Porta Hepatis. Am. J. Med., 38:241, 1965.
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6. Longmire, W. P.: The Diverse Causes of Biliary Obstruction and Their Remedies. Curr. Probl. Surg., Vol. XIV, June, 1977. 7. Longmire, W. P., McArthur, M. S., Bastounis, E. A. and Hiatt, J.: Carcinoma of the Extrahepatic Biliary Tree. Ann. Surg., 178:333, 1973. 8. Longmire, W. P. and Tompkins, R. K.: Lesions of the Segmental and Lobar Hepatic Ducts. Ann. Surg., 182:478, 1975. 9. Pitt, H. A. and Cameron, J. L.: Sodium Cholate Dissolution of Retained Biliary Stones: Mortality Following Intrahepatic Infusion. In Press. 10. Praderi, R. C.: CholedocostomiaTranshepatico. Boll. Soc. Circ. [Uraguay], 32:237, 1961. 11. Praderi, R. C.: Twelve Years Experience with Transhepatic Intubation. Ann. Surg., 179:937, 1974. 12. Saypol, G. M. and Kurian, G.: A Technique of Repair of Stricture of the Bile Duct. Surg. Gynecol. Obstet., 128: 1071, 1969.
13. Smith, R.: Hepaticojejunostomy with Transhepatic Intubation. Brit. J. Surg., 51:186, 1964. 14. Starzl, T. E., Porter, K. A., Putnam, C. W., et al.: Orthotopic Liver Transplantation in Ninety-Three Patients. Surg. Gynecol. Obstet., 142:487, 1976. 15. Terblanche, J., Saunders, S. J. and Louw, J. H.: Prolonged Palliation in Carcinoma of the Main Hepatic Duct Junction. Surgery, 71:720, 1972. 16. Warren, K. W., Mountain, J. C. and Midell, A. I.: Management of Strictures of the Biliary Tract. Surg. Clin. North Am., 51:711, 1971. 17. Way, L. W. and Dunphy, J. E.: Biliary Stricture. Am. J. Surg.. 124:287, 1972. 18. Wexler, M. J., Smith, R.: Jejunal Mucosal Graft: A Sutureless Technique for Repair of High Bile Duct Strictures. Am. J. Surg., 129:204, 1975.
DISCUSSION
meier, of this society, in 1957. Transhepatic intubation was first described in the Uruguayan literature by Praderi in 1961. and he reported it in the English literature in 1974. The U-tube procedure, as I have described it here today. was developed as a result of a problem in a patient in 1968, and used in two patients in 1969. In addition. Praderi and Uraguay described a similar technique in 1971. (Slide) I want to update the published results from Groote Schuur Hospital, Cape Town. We had 26 cases of bile duct junction carcinoma between 1961 and 1972. The last 15 of these have been followed up to the present time. You will see that ten of these 15 patients survived for longer than one year. Two of them are alive and well at 61/2 years, having had the U-tube procedure, together with 6000 rads of radiotherapy to the localized area of the tumor. Four patients had radiotherapy and the U-tube procedure and a total of eight of this group had the U-tube procedure. We subsequently had an inexplicable gap of three years without any patients, but in recent patients we have used a combination of the U-tube and radiotherapy to the localized area. With this type of long-term survival, one just begins to wonder whether we aren't perhaps approaching cure by a very simple technique.
DR. JOHN TERBLANCHE (Cape Town, South Africa): I'm going to address myself mainly to the second half of this excellent paper which I enjoyed very much indeed. (Slide) In doing so, I wish to make a plea to the members of the Association for the use of the U-tube, as depicted here. There are some technical differences since the last publication from our group of the use of this tube. We now use a long Argyle "Levine" type nasogastric tube. This is longer than the tube originally described and leaves you with long ends, which makes it easy to w ork with. We believe a firm tube is important. We have actually had a tumor constrict a Silastic tube and had to replace it for that reason. You will notice that we use only one hole above and one hole below the lesion. Bile drains through the tube and on into the duodenum. The U-tube does not produce an external biliary fistula. (Slide) The tube is firmly fixed with a cross-piece, and I believe this is important and an advantage. We've actually had the problem of transhepatic tubes falling out, and this cross piece certainly holds the U-tube in place. In addition, when a transhepatic tube does fall out, if one doesn't replace it early, in our experience, it can be difficult to replace. This, I think, is a particular advantage of the U-tube procedure. Recently, we have converted the U-tube to a circle 0-tube, as soon as the patient is stable postoperatively. In other words, the two external limbs are joined together, and one has a completely closed system whereby the bile from either side will flow back into the patient without problems. I would like to put the history of intubation of both benign and malignant strictures into perspective, as I believe this has not always been clearly defined. (The references will be published in Surgery Annual, Volume XI.) With regard to benign strictures, transhepatic intubation was first described by the two Mexican surgeons, Quijano and Munoz, in 1957 and 1959. Rodney Smith's classic paper in 1964, which was the first in the English literature, really started people using this technique for strictures. As far as the U-tube's use in strictures is concerned, the first reports were in 1951 and 1959 by Goetze, the German surgeon, in the German literature. The most widely quoted paper is that of Saypol and Kurian in the American literature in 1969. However, Heydenrych, of South Africa, in a largely ignored paper, also described the use of the U-tube in biliary strictures in the same year in the American literature. Unlike Saypol, he had, in fact, already changed one of these tubes in a patient. I personally believe that a combination of the U-tube with Rodney Smith's mucosal graft procedure, as originally described by Goetze in 1951, has revolutionized our management of really high strictures. This makes the lesion very easy to handle technically. With regard to bile duct carcinoma, the pioneering paper on dilatation and local intubation was, of course, published by Dr. Alte-
DR. WILLIAM P. LONGMIRE (Los Angeles. California): I would first like to compliment Drs. Cameron, Gayler, and Zuidema for the excellence of their presentation. They, more than anyone in this country, have emphasized the technique of transhepatic intubation in the management of strictures of the common bile duct. and all of us are indebted to Dr. Terblanche for clarifying the use of this transhepatic tube in malignant strictures. I wish to speak primarily about the benign strictures. (Slide) The techniques that have to be employed in the repair will vary depending upon the location of injury. In cases where there is a significant segment of dilated common bile duct, such as that seen in this slide, a mucosa-to-mucosa anastomosis with a T-tube stent. generally for one to three months, will suffice. On the other hand, when the stricture lies high in the hepatic duct, as is so often the case, the mucosa of the intestine is frequently just approximated to the orifices of the ducts. In this circumstance, longterm stenting, as advocated by the authors, is certainly essential. Dr. Cameron indicated that in their series most of the repairs were of this variety. Many of these injuries occur when there is a confusing anamolous condition of the extrahepatic ducts, that leads the surgeon not only to put a clip across the duct or to traumatize it, but to actually excise a large segment of the extrahepatic system. The principle of longterm stenting in difficult biliary anastomosis (and here I, too would like to digress a moment to mention some historical aspects, like those Dr. Terblanche has brought before us) was really first illuminated by Magoon and Claggett in 1958. They reported 12 cases from the Mayo Clinic in which Vitallium tubes had been inserted to stent a biliary-enteric anastomosis and had been in
Between 1969 and 1978, 45 patients with biliary strictures have been managed surgically utilizing silastic transhepatic stents. In 25 patients the strictures were benign. After resection or dilatation of the benign stricture, an hepaticojejunostomy was performed to a Roux-en-Y loop. The anastomosis was stented with a large bore silastic tube with multiple side holes passed through the biliary tree, out the anterior surface of the liver, and then out through the abdominal wall. There was one hospital death. Most stents were left in place for one year. Of the 15 patients with long-term follow-up, all have had excellent results. In 20 patients the strictures were malignant and involved the common hepatic duct in 10 patients or its bifurcation in 10 patients. In 14 patients the tumor was thought to be primary in the biliary tree, and in six patients the tumor was felt to represent a metastasis or direct extension from another site. In three patients the tumors were resected, and in the remaining they were dilated or bypassed. After positioning a silastic transhepatic stent, a hepaticojejunostomy was carried out. There were two hospital deaths. Serum bilirubin on admission averaged 17.1 mg%, and after decompression 1.8 mg%. Five patients have survived over one year, and two over two years. Postoperative radiotherapy and a primary biliary tumor favored longer survival.
ENIGN AND MALIGNANT strictures of the biliary D tree present difficult problems in management. Benign strictures are usually high in the hilum of the liver and difficult to expose, a mucosa-to-mucosa anastomosis hard to achieve, and late recurrences disappointingly frequent. With malignant biliary strictures involving the common hepatic duct or bifurcation, resection is usually not possible. Such patients die, not from the slow growing biliary tumor, but from hepatic failure due to biliary obstruction which is difficult to adequately and permanently decompress.5 A technique used over the past nine years to manage such patients utilizes a silastic transhepatic biliary stent. Despite the different problems that benign and malignant strictures present, the use of this technique of transhepatic intubation with a silastic stent has markedly improved the management of both groups
of patients. Presented at the Annual Meeting of the American Surgical Association April 26-28, 1978, Dallas, Texas.
From the Departments of Surgery and Radiology, The Johns Hopkins Medical Institutions, Baltimore Maryland
Clinical Material Forty-five patients with biliary strictures have been managed with silastic transhepatic biliary stents at The Johns Hopkins Medical Institutions between 1969 and 1978. In 25 patients the stricture was benign and in the remaining 20 patients it was malignant.
Benign Strictures The ages of these 25 patients ranged from 18 to 75 years and averaged 42 years. Twenty were females and five were males. The etiology of the benign stricture was surgical trauma in 21 patients, a gun shot wound to the porta hepatis in one patient, congenital cystic dilatation of the biliary tree in one, a benign cystadenoma in one, and an idiopathic inflammatory process in one. The stricture involved the common hepatic duct in 21 patients and the bifurcation of the hepatic duct in four. For 13 patients the current procedure was the first attempt at repair of their benign stricture. Seven patients had undergone one prior repair, four had two prior repairs, and one patient had undergone four prior repairs. Serum bilirubin at the time of admission ranged from 0.4 mg% to 19.3 mg%, and averaged 7.4 mg% (Table 1). Malignant Strictures The ages of these 20 patients ranged from 43 to 82 years and averaged 61 years. Thirteen were males and 7 were females. In ten patients the malignant stricture involved primarily the common hepatic duct. In the remaining ten patients the tumor occurred at the bifurcation. In 14 patients the tumor was felt to be primary in the biliary tree. However, this was often difficult to determine and in some instances the tumor could have originated in the pancreas or elsewhere. In
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TABLE 1. Biliary Strictures in 45 Patients
Stricture Site
Biliary Stricture
Patients
Age (Yrs.)
Sex (M, F)
Benign Malignant
25 20
42 61
20F, SM 7F, 13M
BifurCHD cation 21 10
4 10
Serum Bilirubin (mg%) 7.4 17.1
the remaining six patients the malignant biliary stricture was felt to represent direct extension or metastatic spread from a tumor in the colon (three patients), stomach (one patient), gallbladder (one patient), or pancreas (one patient). One of the patients who had a primary biliary tract tumor involving his bifurcation had a long history of ulcerative colitis. Serum bilirubin at admission in these 20 patients with malignant biliary strictures ranged from 4.9 to 36.9 mg%, and averaged 17.1 mg% (Table 1).
Operative Management Most patients prior to surgery had their biliary tract anatomy defined by transhepatic, endoscopic retrograde, T tube, or sinus tract cholangiography. All patients were started on Penicillin and Gentamycin the night prior to operation. Benign Strictures Twenty-four of the 25 patients with benign strictures had their repair performed in the hilum of the liver. In 16 patients the stricture was resected. In eight instances the stricture was so high in the hilum or the parenchyma of the liver that it was not resectable, and was dilated with Bake's dilators. The final patient had an intrahepatic cholangiojejunostomy (Longmire Procedure) performed at the periphery of the left lobe of the liver. After the stricture was resected or dilated, a curved stone forceps was introduced into the biliary tree and advanced either through the right or left intrahepatic duct until it could be brought within a centimeter or two of Glisson's capsule on the anterior superior (diaphragmatic) surface. The forceps were then forcibly advanced out through the liver parenchyma. A silastic biliary stent was sutured to the end of the forceps and drawn back down through the liver parenchyma, intrahepatic biliary tree, and out the hilum of the liver (Fig. 1). The silastic biliary stents are 60 cm in length and come in three outside diameters: 10 mm, 8 mm, and 6 mm. Forty per cent of the length of the silastic stent contains multiple side holes.* The largest stent that will be accommodated by the dilated *
Dow Coming
553
biliary tree is used. Generally it is one of the two larger sizes. In 15 patients with benign strictures the stent was placed in the right hepatic duct. In eight patients, including the one undergoing a Longmire Procedure, the stent was placed in the left hepatic duct. In two of the patients with strictures involving the bifurcation of the hepatic duct, stents were placed in both the right and left hepatic ducts (Table 2). Once the stent is in place, a Roux-en-Y loop is fashioned and placed in the hilum. The end of the loop is closed and an end-to-side hepaticojejunostomy performed. In most instances a mucosa-to-mucosa anastomosis cannot be fashioned. After the biliary stent is placed into the jejunum through a stab wound, the Roux-en-Y loop is sutured to the hepatic duct, liver capsule, and other hilar structures surrounding the biliary stent. A large mattress suture is then placed around the exit site of the stent on the anterior surface of the liver. This end of the tube is brought out through a stab wound in the upper abdomen and connected to bile bag drainage (Fig. 2). Penrose drains are left to drain the exit site of the stent on the anterior surface of the liver, and the anastomosis. Postoperatively, the biliary stent is left to gravity drainage until a cholangiogram demonstrates that the anastomosis and exit site on the liver have sealed. The Penrose drains are then removed and the stent clamped. Thereafter, the patient irrigates the transhepatic stent twice a day for as long as it remains in. Malignant Strictures Operative management of the 20 patients with malignant strictures was very similar to those with benign strictures. In three patients, two with tumors at the bifurcation and one with a tumor in the common hepatic duct, resection was performed. In all three patients positive tumor margins in both ducts were left on the liver side. In 16 patients the tumor was dilated by passing instruments up from normal duct below the tumor, or else the biliary tree was entered via the left or right hepatic duct above the tumor (Fig. 3). One patient had an intrahepatic cholangiojejunostomy (Longmire Procedure) performed away from the tumor and hilum of the liver. After access to the intrahepatic biliary tree was achieved by resection, dilatation, or entering above the tumor, a TABLE 2. Silastic Transhepatic Tube Placement No. Stents
Biliary
Location of Stents
Stricture
Patients
1
2
3
R Duct
L Duct
Both
3 Ducts
Benign Malignant
25 20
23 14
2
0 1
15 6
8 8
2 5
0 1
5
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CAMERON, GAYLER AND ZUIDEMA
Ann. Surg. m October 1978
........ ..
FIG. 1. Stone forceps have been passed into the common hepatic duct at the hilum, advanced through the intrahepatic biliary tree, and forced out through the parenchyma on the anterior surface of the liver. A silastic biliary stent is then sutured to the end of the forceps so that it can be drawn back into the intrahepatic biliary tree and out the hilum.
transhepatic biliary stent was inserted in a fashion identical to that for benign strictures. In 14 patients one transhepatic stent was placed. In eight instances the single stent was placed in the left hepatic duct and in six patients it was placed in the right hepatic duct. Five patients had biliary stents placed in both the left and right hepatic ducts. The final patient, after tumor resection, was left with three large open ducts, and transhepatic stents were placed in all three (Table 2). In four patients, once the silastic stent was inserted, it was passed into the duodenum through the common duct, after performing a sphincteroplasty. In the remaining 16 patients a Roux-en-Y loop was constructed and a hepaticojejunostomy performed. In many instances the jejunum was sutured to tumor surrounding the egress site of the silastic stent in the liver hilum. The tumor margins were marked with hemoclips for possible radiotherapy (Fig. 4). The stent exit site on the liver and the anastomosis were drained and the stent managed in a fashion identical to that described for benign strictures. Clinical Course
Benign Strictures One patient died following repair of a benign stricture. She was a 67-year-old-woman with a biliary stricture of 20 years duration and biliary cirrhosis. She had
undergone two prior attempts at repair. She tolerated the operative procedure but died in the hospital 65 days later of liver failure. Hospitalization in the remaining 24 patients ranged from eight to 70 days, and averaged 31 days. All patients developed biliary-cutaneous fistulas at the exit site of the biliary stent from the liver and/or from the anastomosis. All fistulas closed spontaneously but often took two or three weeks and resulted in the long average hospitalization. Four patients developed wound infections following surgery. Three patients required drainage of an intra-abdominal abscess. Two patients developed sepsis during the first week after surgery, presumably from bile leaks. There have been two late deaths. Both patients died of sepsis during sodium cholate infusion into their transhepatic stent. Both patients had tolerated their operative procedures well and were asymptomatic. At eight months following their repair both were readmitted for sodium cholate infusion because of retained intrahepatic biliary sludge that had not been successfully cleared from the biliary tree at the time of repair. Shortly after the infusions were started both became hypotensive and died. Positive blood cultures were obtained in one. The remaining 22 patients are alive and well. In most patients the silastic transhepatic stent was left in for 12 months and then removed. Initially the tubes were changed during this 12 month period only if they
-lSi :.,lt8,-:2 . .~ ~ ~ ~ . . :. . u
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SILASTIC TRANSHEPATIC STENTS
FIG. 2. A Roux-en-Yjejunal loop is sutured to hepatic duct, liver capsule and other structures at the egress site of the silastic stent in the hilum of the liver. That portion of the stent that passes through the liver and into the jejunum contains multiple side holes. N
Tuvdior
R. and L.hepatic ducts
FIG. 3. When dealing with malignant biliary strictures, the lesion is either resected (A), dilated from below (B), or bypassed (C) by entering the right or left hepatic duct above the tumor. Silastic stents are then placed in a fashion identical to that for benign strictures.
..hepatic duct
ol
c
556
CAMERON, GAYLER AND ZUIDEMA
Ann. Surg. * October 1978
FIG. 4. Postoperative cholangiogram of a patient who underwent dilatation of a malignant stricture with the placement of a silastic stent into the left hepatic duct. Hemoclips mark the tumor for the radiotherapist.
became partially occluded. Recently we have been routinely changing all stents every three months to avoid partial occlusion with leakage around the stent cutaneous exit site and/or fever. These tube changes can easily be performed under fluoroscopy as an outpatient procedure. A guide wire is threaded through the silastic stent into the Roux-en-Y loop. The stent is then removed leaving the guide wire in place. The new silastic transhepatic stent is then easily threaded back in place over the guide wire, which is then removed.2 Twelve patients have had their tubes removed permanently and have been followed an average of four years and 11 months (12-108 months). All 12 are classified as excellent results. Eleven have remained asymptomatic and with a normal serum bilirubin. The twelfth patient became jaundiced from a stricture recurrence six years and ten months following his initial repair. He was reoperated upon and a silastic stent reinserted after dilitation of the stricture. The transhepatic stent was left in for 16 months. He has now been followed for two years and two months since his second repair and remains asymptomatic. In three additional patients followed for an average of two years and two months (15-42 months) the silastic stents remain in place. Because of the difficulty of the repair, it is not anticipated that the stents will be removed. They are changed in outpatient radiology every three to six months. All three patients
are asymptomatic. Two patients have normal serum bilirubins, and the third has a mild elevation. All three are classified as excellent results. The final seven patients have all been operated upon during the last 12 months. The stents remain in place. It is anticipated that they will be removed in all seven patients at 12 months. All are asymptomatic (Table 3).
Malignant Strictures Two patients died following surgery for a malignant stricture. One patient, a 66-year-old male with a biliary tumor at the bifurcation, died of sepsis 30 days after surgery. A stent was placed in his right hepatic duct, but because of tumor his left duct could not be decompressed. Cholangitis in his occluded left duct could not be controlled with antibiotics. The second death occurred in a 62-year-old man with a tumor at his bifurcation. Ten days after surgery he suddenly became septic and died. Subphrenic and subhepatic abscesses were found. Hospitalization in the remaining 18 patients ranged from seven to 77 days and averaged 30 days. Two patients required drainage of an intraabdominal abscess. One developed postoperative sepsis and one patient developed a wound infection. After biliary decompression the average serum bilirubin dropped from an admission value of 17.1 mg% to 1.8 mg%.
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TABLE 4. Effect of Radiotherapy and Site of Origin on Survival in 12 Patients Dying with Malignant Biliary Strictures
TABLE 3. Surgical Results of Patients with Benign Strictures
Results < 12 Months
Patients
Operative Deaths
Late Deaths
Excellent
Poor
25
1
2*
7
0
557
Results > 12 Months
Patients
Average Survival (Mos.)
12
11
7 5
12 7
6 6
15 7
Excellent Poor 15
0
* Secondary to sodium cholate infusion.
Twelve of the 18 patients who were discharged from the hospital have died. Two lived for over two years, one lived for over one year, three died between seven and 12 months following surgery, and six died within the first 6 months of surgery. Average length of survival in these 12 patients was 11 months. In the seven patients who received radiotherapy survival averaged 13 months as compared to 7 months in those five patients who received no radiotheapy. Six of the 12 patients who died were felt to have primary biliary tract tumors, and survival in this group averaged 15 months. In the six patients with secondary malignant biliary obstruction, survival averaged 7 months (Table 4). Of these 12 patients who survived the operation and were discharged from the hospital, eight died as a result of their tumor, and not from biliary obstruction. Two patients were not adequately decompressed and one died of sepsis at three months, and the second of hepatic failure at six months. The cause of death in the remaining two patients is not known. Six patients remain alive. Two have survived more than one year, two are alive seven to 12 months following surgery, and two have been operated upon during the past six months (Fig. 5).
Late Deaths Radiotherapy Yes No Malignant Strictures Primary Secondary
preferable to one using the duodenum or distal bile duct.616 Whether or not to use a biliary stent is somewhat more controversial but many surgeons advocate their use in difficult repairs.6'16 However, even with these techniques utilized in the most prominent clinics, longterm success is generally achieved in only 65% to 80% of patients.3 16-'8 Most benign strictures occur high in the hilum of the liver and are close to or involve the bifurcation of the common hepatic duct. An anatomical repair with good mucosa-to-mucosa approximation is always preferable, but often impossible. The technique of repair for benign strictures described here does not depend upon mucosa-to-mucosa approximation. After placing a biliary silastic stent transhepatically the jejunal loop is positioned around the egress site of the tube high in the hilum of the liver. During the ensuing weeks and months the gap that may exist between the mucosal surfaces will be bridged with epithelium. The scar that also forms will do so in the environment of the relatively nonreactive silastic stent with a minimum of
Discussion
The technique of transhepatic intubation was described by Goetze4 in 1951 and by Praderi in 1961.10.11 Subsequently, Smith popularized this technique of biliary stenting,'3 and reported his experience with benign strictures in 1975,18 Saypol and Kurian'2 in 1969 introduced the modification of a U tube transhepatic stent, and in 1972 Terblanche, Saunders, and Louw15 extended this to malignant strictures. The technique of transhepatic intubation using a silastic stent has been utilized in our clinic since 1969. An initial report on this technique in ten patients was reported in 1976.2 The silastic stent has distinct advantages in the management of both benign and malignant biliary strictures, and we feel is responsible for improvement in longterm results. Over the past decade the surgical management of benign strictures has become fairly standardized. Most surgeons feel an anastomosis between the proximal hepatic segment and a Roux-en-Y jejunal loop is
PATIENTS
MP JS F B -4 M K -4 DH AJ 0 t MH RS t WV HR C E __ -_ RR GH CM CK JS GP IU -
PRI MARY SECON DARY -. RADI AT ION THERAPY
DEAD
0 __
6 12 18 24 30 MONTHS FIG. 5. Clinical course of the 18 patients with malignant biliary strictures who survived surgery.
558
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CAMERON, GAYLER AND ZUIDEMA
foreign body reaction. As scar contracture occurs the anastomosis will be maintained widely patent by the large bore stent. At the end of a 12-month period, with the tract well epithelialized and a stable scar, the stent can be removed. In the interim the biliary tree and anstomosis can be kept free of biliary sludge by daily irrigations. Changing the tube every three months further insures against sludge collection and partial obstruction. Tube changes can be performed in ten minutes as an outpatient procedure.2 The tube also provides access for cholangiography. Utilizing this technique of repair, virtually all patients with benign strictures have been managed successfull. The only two late deaths were probably related to sodium cholate infusions. Even though bile salt infusion into the biliary tree is effective and tolerated well through a T-tube, its use with a transhepatic stent infusing the solution directly into the liver is dangerous and should be avoided.9 All 12 patients who have had their stents removed have had excellent results. The one recurrence (six years and ten months after the initial repair) was successfully treated by a second intubation. Smith has advocated a "mucosal graft technique" pulling the Roux-en-Y loop up into the liver with the transhepatic tube.'8 He has not used silastic and generally leaves the stent in place for only three to four months. His success rate has been 65%. We feel the use of a silastic stent left in for one year is important. If the repair is particularly tenuous, and a major duct has not been intubated, the stent may be left in permanently. We have recognized no adverse consequences of leaving the stent in over long periods in the three patients so managed (15, 21, 42 months). This technique of stenting can also be extended for use in the Longmire Procedure, when the hilum of the liver is no longer safe to dissect. ' Malignant biliary strictures present a different set of problems. If the tumor is primary in the biliary tree it often will be slow growing and slow to metastasize. Recognition of these tumors, first well described by Klatskin,5 is often delayed. When the diagnosis is finally confirmed deep jaundice may be present and the patient often dies of hepatic failure. Ideally, such tumors should be recognized early and resected. However, because of the close proximity to the hepatic artery and portal vein, and the right and left intrahepatic ducts, local extension usually makes the tumor unresectable. Extended operative procedures including partial liver resection have been advocated and performed,7 as has liver resection and allotransplantation. 14 However, currently, these procedures carry operative and late mortalities that argue against their routine use. Thus, for most patients with biliary tract tumors, effective biliary decompression is what is
needed. The large bore thick walled silastic stents are very effective in this task. The average serum bilirubin on admission of 17.1 mg% dropped to 1.8 mg% after decompression. This allows effective palliation so that the patient's subsequent course will be determined by the malignant tumor, and not by the biliary obstruction. As adjuvant therapy improves, the palliation achievable should also improve. In our series the addition of radiotherapy to transhepatic intubation doubled survival time. Because of the small numbers, however, this difference was not statistically significant. Of the 12 patients felt to have primary biliary tract tumors who left the hospital, four lived or are still alive one year after surgery, and two lived over two years. Average survival of the patients with primary biliary tract tumors who have died was 15 months. Secondary malignant biliary strictures, with the tumor arising outside of the bile ducts, is often a more rapid process. The colon, pancreas, or gall bladder malignancies from the biliary obstruction arises is often rapid growing, and death occurs from the tumor before hepatic failure is a problem. Occasionally, however, such a patient will remain relatively healthy despite disseminated tumor, and will be a suitable candidate for biliary decompression. The use of a silastic transheptic stent affords a relatively simple, rapid means of effecting this decompression. Palliation is usually somewhat shorter, however, because of tumor growth elsewhere. Our data suggest that survival after successful transhepatic stenting is only half as long with a secondary malignant stricture (7 months) as with a primary malignant stricture (15 months). Silastic transhepatic stents were placed in only one duct in 14 patients with malignant strictures. In the remaining six patients both major ductal systems were drained. Ideally, both ducts should be intubated to avoid obstruction and sepsis. Drainage from both ducts is not needed to control the serum bilirubin. Longmire8 has pointed out that decompression of one lobe is sufficient to maintain normal liver function. However, if infection occurs in the undrained duct it will not be controllable with antibiotics. One hospital death and one late death in our series were attributable to sepsis in an undrained duct. References 1. Cameron, J. L., Gayler, B. W. and Harrington, D. P.: Modification of the Longmire Procedure. Ann. Surg. 187:379, 1978. 2. Cameron, J. L., Skinner, D. B. and Zuidema, G. D.: Long-
Term Transhepatic Intubation for Hilar Hepatic Duct Strictures. Ann. Surg., 183:488, 1976. 3. Glen, F.: latrogenic Injuries to the Biliary Ductal System. Surg. Gynecol. Obstet., 146:430, 1978. 4. Goetze, O.: Die Tranchepatische Dauerdrainage bei der Hoken Gallengangsstenose. Arch. Klin. Chir. 270:97, 1951. 5. Klatskin, G.: Adenocarcinoma of the Hepatic Duct at Its Bifurcation Within the Porta Hepatis. Am. J. Med., 38:241, 1965.
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6. Longmire, W. P.: The Diverse Causes of Biliary Obstruction and Their Remedies. Curr. Probl. Surg., Vol. XIV, June, 1977. 7. Longmire, W. P., McArthur, M. S., Bastounis, E. A. and Hiatt, J.: Carcinoma of the Extrahepatic Biliary Tree. Ann. Surg., 178:333, 1973. 8. Longmire, W. P. and Tompkins, R. K.: Lesions of the Segmental and Lobar Hepatic Ducts. Ann. Surg., 182:478, 1975. 9. Pitt, H. A. and Cameron, J. L.: Sodium Cholate Dissolution of Retained Biliary Stones: Mortality Following Intrahepatic Infusion. In Press. 10. Praderi, R. C.: CholedocostomiaTranshepatico. Boll. Soc. Circ. [Uraguay], 32:237, 1961. 11. Praderi, R. C.: Twelve Years Experience with Transhepatic Intubation. Ann. Surg., 179:937, 1974. 12. Saypol, G. M. and Kurian, G.: A Technique of Repair of Stricture of the Bile Duct. Surg. Gynecol. Obstet., 128: 1071, 1969.
13. Smith, R.: Hepaticojejunostomy with Transhepatic Intubation. Brit. J. Surg., 51:186, 1964. 14. Starzl, T. E., Porter, K. A., Putnam, C. W., et al.: Orthotopic Liver Transplantation in Ninety-Three Patients. Surg. Gynecol. Obstet., 142:487, 1976. 15. Terblanche, J., Saunders, S. J. and Louw, J. H.: Prolonged Palliation in Carcinoma of the Main Hepatic Duct Junction. Surgery, 71:720, 1972. 16. Warren, K. W., Mountain, J. C. and Midell, A. I.: Management of Strictures of the Biliary Tract. Surg. Clin. North Am., 51:711, 1971. 17. Way, L. W. and Dunphy, J. E.: Biliary Stricture. Am. J. Surg.. 124:287, 1972. 18. Wexler, M. J., Smith, R.: Jejunal Mucosal Graft: A Sutureless Technique for Repair of High Bile Duct Strictures. Am. J. Surg., 129:204, 1975.
DISCUSSION
meier, of this society, in 1957. Transhepatic intubation was first described in the Uruguayan literature by Praderi in 1961. and he reported it in the English literature in 1974. The U-tube procedure, as I have described it here today. was developed as a result of a problem in a patient in 1968, and used in two patients in 1969. In addition. Praderi and Uraguay described a similar technique in 1971. (Slide) I want to update the published results from Groote Schuur Hospital, Cape Town. We had 26 cases of bile duct junction carcinoma between 1961 and 1972. The last 15 of these have been followed up to the present time. You will see that ten of these 15 patients survived for longer than one year. Two of them are alive and well at 61/2 years, having had the U-tube procedure, together with 6000 rads of radiotherapy to the localized area of the tumor. Four patients had radiotherapy and the U-tube procedure and a total of eight of this group had the U-tube procedure. We subsequently had an inexplicable gap of three years without any patients, but in recent patients we have used a combination of the U-tube and radiotherapy to the localized area. With this type of long-term survival, one just begins to wonder whether we aren't perhaps approaching cure by a very simple technique.
DR. JOHN TERBLANCHE (Cape Town, South Africa): I'm going to address myself mainly to the second half of this excellent paper which I enjoyed very much indeed. (Slide) In doing so, I wish to make a plea to the members of the Association for the use of the U-tube, as depicted here. There are some technical differences since the last publication from our group of the use of this tube. We now use a long Argyle "Levine" type nasogastric tube. This is longer than the tube originally described and leaves you with long ends, which makes it easy to w ork with. We believe a firm tube is important. We have actually had a tumor constrict a Silastic tube and had to replace it for that reason. You will notice that we use only one hole above and one hole below the lesion. Bile drains through the tube and on into the duodenum. The U-tube does not produce an external biliary fistula. (Slide) The tube is firmly fixed with a cross-piece, and I believe this is important and an advantage. We've actually had the problem of transhepatic tubes falling out, and this cross piece certainly holds the U-tube in place. In addition, when a transhepatic tube does fall out, if one doesn't replace it early, in our experience, it can be difficult to replace. This, I think, is a particular advantage of the U-tube procedure. Recently, we have converted the U-tube to a circle 0-tube, as soon as the patient is stable postoperatively. In other words, the two external limbs are joined together, and one has a completely closed system whereby the bile from either side will flow back into the patient without problems. I would like to put the history of intubation of both benign and malignant strictures into perspective, as I believe this has not always been clearly defined. (The references will be published in Surgery Annual, Volume XI.) With regard to benign strictures, transhepatic intubation was first described by the two Mexican surgeons, Quijano and Munoz, in 1957 and 1959. Rodney Smith's classic paper in 1964, which was the first in the English literature, really started people using this technique for strictures. As far as the U-tube's use in strictures is concerned, the first reports were in 1951 and 1959 by Goetze, the German surgeon, in the German literature. The most widely quoted paper is that of Saypol and Kurian in the American literature in 1969. However, Heydenrych, of South Africa, in a largely ignored paper, also described the use of the U-tube in biliary strictures in the same year in the American literature. Unlike Saypol, he had, in fact, already changed one of these tubes in a patient. I personally believe that a combination of the U-tube with Rodney Smith's mucosal graft procedure, as originally described by Goetze in 1951, has revolutionized our management of really high strictures. This makes the lesion very easy to handle technically. With regard to bile duct carcinoma, the pioneering paper on dilatation and local intubation was, of course, published by Dr. Alte-
DR. WILLIAM P. LONGMIRE (Los Angeles. California): I would first like to compliment Drs. Cameron, Gayler, and Zuidema for the excellence of their presentation. They, more than anyone in this country, have emphasized the technique of transhepatic intubation in the management of strictures of the common bile duct. and all of us are indebted to Dr. Terblanche for clarifying the use of this transhepatic tube in malignant strictures. I wish to speak primarily about the benign strictures. (Slide) The techniques that have to be employed in the repair will vary depending upon the location of injury. In cases where there is a significant segment of dilated common bile duct, such as that seen in this slide, a mucosa-to-mucosa anastomosis with a T-tube stent. generally for one to three months, will suffice. On the other hand, when the stricture lies high in the hepatic duct, as is so often the case, the mucosa of the intestine is frequently just approximated to the orifices of the ducts. In this circumstance, longterm stenting, as advocated by the authors, is certainly essential. Dr. Cameron indicated that in their series most of the repairs were of this variety. Many of these injuries occur when there is a confusing anamolous condition of the extrahepatic ducts, that leads the surgeon not only to put a clip across the duct or to traumatize it, but to actually excise a large segment of the extrahepatic system. The principle of longterm stenting in difficult biliary anastomosis (and here I, too would like to digress a moment to mention some historical aspects, like those Dr. Terblanche has brought before us) was really first illuminated by Magoon and Claggett in 1958. They reported 12 cases from the Mayo Clinic in which Vitallium tubes had been inserted to stent a biliary-enteric anastomosis and had been in
