The effect of communication between the right and left liver on the outcome of surgical drainage for jaundice due to malignant obstruction at the hilus of the liver

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PUBLISHED VERSION

H. U. Baer, M. Rhyner, S. C. Stain, P. W. Glauser, A. R. Dennison, G. J. Maddern, and L. H. Blumgart The effect of communication between the right and left liver on the outcome of surgical drainage for jaundice due to malignant obstruction at the hilus of the liver

HPB Surgery, 1994; 8(1):27-31

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The Effect of Communication Between

the Right and Left Liver on the Outcome of Surgical Drainage for Jaundice

due to Malignant Obstruction at the Hilus of the Liver

H.

U. BAER,

M.

RHYNER,

S. C.

STAIN,

P. W.

GLAUSER, A. R. DENNISON,

G. J.

MADDERN

and

L. H. BLUMGART

DepartmentofVisceraland TransplantationSurgery,UniversityofBerne,Inselspital, CH-3010Berne,Switzerland

Debate continuesregardingtheoptimal managementof irresectablemalignant proximal biliary obstruction.Controversyexists concerningthe ability ofunilateraldrainagetoprovide adequate biliary decompression with tumors that have occluded the communicationbetweentherightand lefthepatic ductal systems.

Between October 1986 and October 1989, 18 patients with malignant proximal biliary obstructionweretreated byanintrahepatic biliaryentericbypass.Patients were dividedintotwo groups basedonthepresenceorabsenceofacommunicationbeLweenthe right and leftbiliary systems.InGroup I (n 9),therewasfree communication; andinGroup II (n 9)there wasno communication.There were twoperioperative deaths(11%)oneduetopersistent cholangitis and the other to myocardial insufficiency both with one death ineach group. The median survival(excludingperioperativedeaths)was5.6months. Comparison of pre- and postoperative serumlevels of bilirubin and alkalinephosphataseshowed asignificant decreaseineachgroup, butnodifferencebetween thegroupsinthe size of the reduction. Sixteenpatientssurvivedatleast threemonths and thepalliation wasjudgedas excellentineight, fair infive,and unchanged inthree.

These results demonstratethe effectiveness ofbiliaryentericbypass regardlessof communica- tionbetweenthe left andright biliary ductalsystems.

KEY WORDS: Obstructivejaundice hilar obstruction surgical drainage unilateral bilateral

INTRODUCTION

Obstructive jaundice resulting from eitherbenign or malignant biliarystructuremaybe relievedby biliary enteric bypass ^or transtumoral intubational methods

1-6.

When such obstruction involves the conflu- enceof the hepatic ducts^attheliverhilus, the irresectable lesionmay completelyocclude theconfluence,and prevent drainage between the right and left hepatic ductal systems. It has been suggested that adequate reliefof jaundice requires decompression of both ductal systems

17-19.

The aim of thisstudywas to assessthe outcomefor patientswith malignantbiliaryobstruction atthehilus treated by ^a single biliaryenteric anastomosis which drained eitherone orbothductal systems.

PATIENTS

AND

METHODS

Between October 1986and October 1989, 18 patients with obstructivejaundice had abiliaryentericbypass procedure for proven malignant hilar obstruction

[Table 1].

There were 13 males and 5 females with 27

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28 H.U. BAERetal.

amedianage of 56 years (range

42-67).

The cause of obstruction werecholangiocarcinoma

{ 8},

gallbladder carcinoma

{7},

metastatic pancreatic carcinoma

{2}

and hepaticmetastasesfrom colon carcinoma

{

¹

}.

Clinical, biochemical, and radiological assessment wasperformedin all patients includingsonography of the biliarytree, and computed tomography. Delinea- tion of thebiliarytractby percutaneoustranshepatic cholangiographyorendoscopicretrogradecholangio- graphywasemployed toprovidepreciseinformation regardingtheanatomy of thebiliary obstruction.

All patients had aneoplasticprocess involving the proximal

!/3

of the extrahepatic bile ducts with 9 patients having total occlusion at the confluence of the right and left hepatic ducts.

Thesiteof hilar occlusion and thepresenceofacom- munication between the right and leftliver was con- firmed at operation.

An

operative biliary enteric bypass to the segment

III

duct was the treatment of choice using a Roux-en-Y side to side anastomosis.

The segment

III

bypass ^was originally described by Soupault and Couinaud¹⁴and has been modified by several authors

1’2’5’7’15’2’2.

Anastomosistothe seg- mentIIIduct was possible when preoperative studies demonstratedadilatedleft hepatic duct in the absence

of left lobar atrophy and without significant paren- chymalinvolvement ofthe leftliver.Consequently,18 patientshadasegment

III

bypass

22. Two

patients had onlyasegmentV approach

23-25.

The patients^wereretrospectively divided for assess- mentintotwogroupsbasedoncholangiographic evidence of communication between the right and left ductalsystems.

In Group

I

(n 9),

communication was present; and in

Group II (n 9),

^there ^was ^complete obstruction.

The patients were reassessed at threemonths after operationto evaluate clinical symptoms, andby liver function tests.

Assessment

of symptomatic outcome wasdeterminedbyasking whether theircurrentlevelof activity was excellent, fair or poor. Sixteen patients wereavailableforreview

(8

ineachgroup).Theserum bilirubinandalkalinephosphatasewerecomparedto preoperativelevels and between thetwo groups using the Wilcoxon sign ranktestandthestudent’s Ttest.

RESULTS

There were two 30 day postoperative deaths

(11%),

with onedeathfrom each group. The ^{first was}dueto

GroupI-freecommunication

imol/I iJmoi/I

7OO

600

500

400

300

200

100

0

700

600

500

400

300

200

100

Group II-nocommunication

Preoperative Postoperative Preoperative Postoperative

Group Group

I1"

p

>0.1

Figure Comparisonofpreoperativeandpostoperativelevels of serum bilirubin inpatientswith communicationbetween therightand left biliarysystems(Group I) andnocommunication(Group II). Thereisasignificant fallin bilirubin (p 0.01) and there is no difference between thetwogroups(p 0.1 ).

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persistent cholangitisin apatientwith adiffuse multi- centriccholangiocarcinoma withintrahepaticinfiltra- tion. The second patient had gallbladder carcinoma anddiedof progressive heart failure.Sixpatients devel- oped complications

(33%).

^Five patients had a pul- monary infiltrateonchest

X-ray,

andweretreated for pneumonia. One patient required reoperation for an earlypostoperative small bowel obstruction ingroupI.

Theserumbilirubinin

Group I

before surgerywas amedianof 303

mmol/1 (normal

< 25; range

16-545),

andatthree months after operation, the bilirubin was amedianof 101

mmol/1

^(range

9-334).

In

Group II,

the median serumbilirubinpreoperativelywas419

mmol/1

(range

84-560),

and in threemonths,had decreasedto

110mmol/1

^(range 18-253)(Figure

1).

Ineach individ- ualgroup, thereductionofserumbilirubinwasstatis ticallysignificant(p

< 0.05),

but therewasnotasignifi- cantdifference inthedegree of the i’eduction between thegroups.

The fall in the serumlevel of alkaline phosphatase paralleled that of the bilirubin (Figure

2).

There was a significant reduction within each group

(P < 0.05),

and nosignificant difference in the amount of reduc-

tionbetween

Groups

Iand II.In

Group I,

the median preoperative alkalinephosphatase value was 783

U/1

(range 288-1440; normal

< 115),

and decreased to 274

U/1

(range

46-538).

In group

II,

the medianlevel fell from a median of

534U/1

(range

185-1087)

to 316

U/1

(range

74-892).

At

three months after operation, the quality ofpal- liation was assessed by patient interview. The self describedlevel ofactivity bythe patientwasexcellent in eight patients, fair in five, andnoimprovement after operation in three. The median hospital stay for patients discharged from hospital was 25days (range 12-111days).

The median survival for the 18 patients discharged from hospital ^was 5.6 months (range 2-12 months).

Examination of the different pathological subsets showed a particularly poor outcome for the three patients with metastatic disease(median survival 3.4 months; range 2-12

months)

and the seven patients withgallbladdercancer (median^survival ^3.8 ^months:

range 2-8

months).

The median survivalfor

Group

I was4months(range1-14months),while for

Group II

it was9months(range0-39

months).

Group!:freecommunication

pmoll| imolll

1600 1600.

1400

1200

lOOO

800

600

400

200

1400

1200

lOOO

800

600

400

200

GroupI1: nocommunication

Preoperative Postoperative Preoperative Postoperative

Group

^I;

Group

I1"

p

>0.1

Figure 2 Comparisonofpreoperativeandpostoperativelevelsofserumalkalinephosphataseinpatientswith communicationsbetween the right and left biliary systems(GroupI)andnocommunication(GroupIf).Thereis asignificant fallin alkalinephosphatase(p 0.01) and there isnodifferencebetween thetwogroups(p 0. l).

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30 H.U.BAERetal.

DISCUSSION

Thetreatmentof malignant proximal biliary obstruction canbe difficult due to technical operative problems and the hematological and immunological sequelaeof longstanding jaundice

15’26’27’28.

Further- more, the palliative nature of the treatment, and the availability of transhepatic and endoscopic intubational techniques has resulted in considerable debate regarding the best management of these patients

17’18’19’22’23.

Much of the controversy hascen- teredonthe ability ofunilateraldrainage of the rightor left biliary systemtoprovideadequatebiliary decompression and subsequent clinical palliation. Indeed, although there has been well documented surgical experience of

unilateral

drainage, the arguments have persisted, mainly among endoscopists and interven- tionalradiologists,as to whether bilateral drainage^is moreeffectiveormandatory.Contributingtothecon- fusion isthe lack ofdocumentation inthe radiological literatureof thepresenceof lobarliveratrophyin the patients selected forunilateral orbilateral drainage.

The efficacy of palliation by operative biliaryenteric bypasshas been reconfirmedinthecurrentseries. The mortality of 11% ^is comparableto series of patients treatedbyoperative and nonoperative methods3’6’15,22.

Thirteenof the 18 patients had self^describedexcellent orfair palliation.Tworecentseriesby^Choi^etal.

6,

and

Traynor

^etal.⁵ examined the results of intrahepatic bypass procedures for patients ^with hilar obstruc- tion6-

5.

Thetwostudiesreportedsimilarresults with operative mortality of 6% and 13.6% respectively, and resolution of the jaundice in 73% of patients. The median survival times were 8and 9 months.

Treatment of irresectable malignant hilar obstruction is palliative.

Any

efforts to improve the quality of the limitedsurvivalshould have lowmorbid- ity and the necessity ofrepeatedinterventionsreduced to aminimum.Thelessons learned from the results of operativebypasshave relevance for patients treatedby nonoperative transtumoralintubationaltechniques.

Two studies haveconsidered bilateral drainage of the biliary systembyendoscopic orthe percutaneous route³and have failedtoshowanadvantageineither mortalityormorbiditywhencomparedwith unilateral drainage. Thesearein contrast tothe results ofDeviere etal.³ which showed prolonged survival and a low early and late incidence of cholangitis ⁱⁿ bilaterally drained patientscompared withthose in whom only unilateraldrainagewaspossible.Theynote,however, the poor survival and early cholangitis in undrained segments may have been precipitated by the ERCP

itselfintroducing infection intoanundrainedorpoorly drained segment. Problems with non-operativeman- agement of hilarmalignancymaybeashighas 30%³⁰ but allows early discharge from hospital. Operative proceduresof intrahepatic biliarybypass,whileoffer- ing lower mortality 6% to 13.6/o^6-5 carry a pro- longedhospitalization andassociatedcost, butusually lowerthe number of readmissions.

Unilaterallobaratrophywhen present, may be^asso- ciatedwith anipsilateral dilatedhepaticduct

32.

Biliary entericbypass,or stentplacementtothe duct draining an atrophied lobe may seem technically inviting, but caution should be exercised since theparenchyma of the atrophied lobemaynothave thefunctionalcapac- itytorelievejaundice

3’22’33.

Furthermore anastomosis to the duct of a nonfunctional atrophied lobe may resultin anincreased incidence ofearlyand lateinfec- tious complications, and limits the effectiveness of palliation

6.

Comparison between the two groups of patients with drainage ofasingle versus both sides of theliver is illustrative ofwhatcanbeexpectedwithtranstumoral stentplacement.Thereductions in serum bilirubinand alkaline phosphatase weresimilar, and there was no difference in mean survival, ^orⁱⁿ the quality of palliation ifhilarcommunicationispresentorabsent.The demonstrationthatunilateraldrainageproducessimi- lar results to bilateral drainage suggests that an in- creased number of such patients ^can be offered the option of palliative operativebypass. Complete ^hilar obstruction is not a contraindication to unilateral operative biliary decompression.

ACKNOWLEDGEMENTS

WethankMrs. B. Moser-Etterfor hervaluablesecretarial assistance.

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