SEMINARS IN LIVER DISEASE-VOL.
10, NO. 2 , 1990
Decision-Making in the Treatment of Patients with Malignant Proximal Bile Duct Obstruction M.N. VAN DER HEYDE, M.D., Ph.D., P.C.M. VERBEEK, Ph.D., and N.J. LYGIDAKIS, M.D.
INOPERABLE PATIENTS Patients over 70 years of age and those with associated cardiopulmonary disease or documented widespread tumor dissemination account for approximately 80% of referrals. These patients are usually referred for nonsurgical treatment of jaundice and its direct consequences. Diagnostic procedures should be limited. If possible, an endoprosthesis is inserted endoscopically and occasionally percutaneously. No further procedures aimed at gaining information about the site of origin and characteristics of the tumor are undertaken.
OPERABLE PATIENTS The keynote of decision-making in these patients is that complete drainage of the liver is essential. Jaundice and itching can be controlled by drainage of a part of the liver. An undrained liver lobe, however, puts the patient at risk for cholangitis, sepsis, and death. Thus, the mainstay of the surgical procedure is drainage of the whole liver. This can best be achieved by reestablishing drainage after tumor resection. Complete local tumor control is rarely achieved in these patients, even though this is
From the Department of Surgery. Acudemic Medical Centre, University of Amsterdam. Amsterdam, The Netherlands.
Reprint requests: Dr. Van Der Heyde, Department of Surgery, Academic Medical Centre, University of Amsterdam, Meibergdreef 9 , 1105 AZ. The Netherlands.
the intent of most resections. Keeping this in mind, which preoperative investigations are mandatory before deciding to operate?
Preoperative Investigations Ultrasound Conventional ultrasonography (US) serves to demonstrate the degree of dilation of the intrahepatic bile ducts and may give an indication of the intrahepatic ductal spread of the tumor. Gallbladder cancer infiltrating the hilar ducts can be demonstrated occasionally, but never can be absolutely excluded. In our experience endoscopic ultrasound can be helpful in obtaining more precise information regarding the extension of tumor growth, whereas computed tomography (CT) scan often fails in this respect. Differentiation between vascular invasion and compression is not completely reliable unless complete vascular occlusion is shown. We are increasingly supported by duplex scanning in assessing vascular involvement.
Direct Cholangiography This topic is discussed elsewhere in this issue of Seminars in Liver Diseuse. It should be a general rule that the introduction of radiopaque fluid into an occluded intrahepatic bile duct should always be followed by drainage to avoid septic complications of this diagnostic procedure. Prophylactic antibiotics should be given.
Angiography Vascular involvement, either arterial or venous, indicates that the tumor extends beyond the bile duct proper. It does not necessarily preclude the possibility of obtaining tumor-free margins in the right and left hepatic duct with a local tumor resection. Unilobar vascular involvement does not preclude the possibility of obtaining local tumor control if one proceeds to a lobar liver resection or a vascular reconstruction. In our institution angiography is part of the preoperative evaluation of the patient. However, findings obtained by this investigation have had little if any On the the patient.
Copyright 0 1990 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
14.5
Downloaded by: University of British Columbia. Copyrighted material.
Between January 5 , 1986, and January 7 , 1989, 45 patients with Klatskin tumors were treated surgically in the Amsterdam Medical Centre (AMC). All patients with complicated biliary obstruction are seen, discussed, and treated by a multidisciplinary team of specialized gastroenterologists, surgeons, radiologists, and radiotherapists. Each year, approximately 200 new patients with assumed malignant bile duct obstruction are seen and treated. The large experience thus obtained has resulted in the development of a treatment protocol that will be discussed in this article.
Tissue Diagnosis Images obtained with US or endoscopic retrograde cholangiopancreatography (ERCP) are rarely indicative of the true nature of the obstructing lesion. Brush cytology at ERCP may prove the presence of cancer. The same is true for puncture-aspiration of masses clearly seen at US or CT. Both methods have a high incidence of false-negative findings. Even biopsies taken at operation may give misleading information, the final diagnosis being made only by thorough examination of the resected specimen. Several examples of rare tumors in the liver hilus, such as a breast cancer metastasis, a Hodgkin lymphoma and an oatcell tumor presenting as "typical" Klatskin tumors, and a 9% incidence of benign lesions all presenting as a "typical" Klatskin tumor have been encountered during the years. In view of the fact, however, that all patients involved required the same kind of surgery, that is, resection of the obstructing lesion, these diagnostic failures recognized at or after operation were of no serious consequence. We perform cytodiagnostic punctures only if we abstain from surgical treatment. The fact that we regard bile as a source of implantation metastases has played a decisive role in our considerations, as discussed by Verbeek and colleagues elsewhere in this issue of Seminars.
Preoperative Decision-Making In the majority of our patients the preoperative studies strongly suggest extensive tumor growth precluding curative surgery, unless the patient is fit enough to undergo a lobar liver resection, possibly combined with one or more vascular reconstructions. Usually, we try to decide preoperatively whether or not the patient is a candidate for such an extended operation, weighing factors such as age, general condition, and residual liver function. In case of a negative decision in this regard, the only aim of the subsequent operation is complete drainage of both liver lobes.
Perioperative Decision-Making Patients Eligible for Liver Resection Presence of extrahepatic tumor growth or hepatic metastasis is looked for as a first step in the operation. It is rarely encountered unexpectedly and does not necessarily mean that a palliative procedure should not be carried out. One of our 45 patients had peritoneal spread of tumor. This patient had been successfully drained by endoprosthesis and, although feasible, for this reason no tumor resection was carried out. In the 44 remaining patients the tumor was explored. It should be stressed that in the majority of cases exploration means dissection. The resectability of these tumors cannot be evaluated by palpation (or perioperative US). Careful dissection of the liver hilus, cholecystectomy and a transection of the common bile duct have to be carried out to enable the surgeon to make the most pertinent decision: should a
10, NUMBER 2, 1990
local resection of the confluence and the tumor mass be performed or an additional hepatic resection be carried out? Lobar liver resection may be done for two reasons: ( I ) The possibility of complete local tumor control, which cannot otherwise be achieved; and (2) the impracticability of adequate drainage of both liver lobes in patients with type 111' tumors extending into the segmental ducts of one liver lobe. If a partial liver resection is carried out with the aim of complete local tumor control, the increased risk of extending the operation should be carefully weighed against the chance of achieving cure. Predominance of tumor extension and infiltration to one side is found in most patients. In patients with predominance of the right side it is tempting to perform an extended right hepatectomy. In accordance with Mizumot0 et a],' a resection of the caudate lobe is added to the hepatectomy in most cases. This is most easily done if segment IV is removed in continuity with the right lobe. A prerequisite is that a tumor-free margin be obtained at the segemental confluence of the ducts of segments I1 and 111. It should, however, be kept in mind that a tumor-free margin in the duct does not imply absence of perineural or perivascular infiltration at the resection margin. Adding a lobar hepatectomy to a local tumor resection may increase the number of operations with intended cure. So far, it has not shown that it increases long-term survival significantly.'-' Our personal experience supports this.
AMC Experience Forty-five patients with histologically proved cholangiocarcinoma in the liver hilus were surgically explored. In 42 of these, tumor resection was performed (Table 1). Twenty-two patients underwent a local resection (group A) and 20 patients had a lobar hepatic resection in continuity (extended) with the resection of the biliary confluence (group B) (9 right- and 11 left-sided hepatectomies). In group A two patients died during the first postoperative month. In group B, eight patients died. Liver insufficiency (two cases), bleeding (two cases), and sepsis (six cases) were the predominant causes of death. Thus, 32 patients could be followed up: 20 in group B and 12 in group A. The mean survival time was 25 months in group A and 27 months in group B. As shown in Figure 1 , there was no significant difference in survival between the two groups, among pa-
TABLE l . AMC Experience
Local resection alone Local t liver resection
No.
Hosl>irtrl Mortulity
Meuir Survivul" (inonth)
5-Yetrr Survivul
22
2
25
I
20
8
27
2
"Of 20 patients with local resection and o f 12 patients with local and liver resection.
Downloaded by: University of British Columbia. Copyrighted material.
SEMINARS IN LIVER DISEASE-VOLUME
146
Cumulative proportion surviving %
loo
0J 0
10
20
30
50
40
60
DER HEYDE, VERBEEK, LYGIDAKIS
141
in untreated patients and the dangers of invasive investigations in this regard. We share the opinion of others4 that a patient having had his dilated bile duct filled with contrast medium is at high risk for unmanageable cholangitis if the relevant duct is not adequately drained. In these patients we are willing to perform a lobar resection, even if this is done only with the aim of leaving no undrained liver tissue behind. The decision is easy to make in the presence of overt atrophy of one liver lobe and in the rare cases in which the left lobe cannot be adequately drained. The decision to perform an extended right hepatectomy is difficult. We abstained from liver resection in this situation in two patients. Both patients died, even though the left lobe was satisfactorily drained, within 2 and 6 weeks postoperatively, of uncontrollable sepsis. In weighing pros and cons, it should be kept in mind that an extended right hepatectomy allows the fashioning of a safe anastomosis on segments I1 and 111. This is of importance, since it increases the chance of a smooth postoperative course. Even extensive liver resections are usually well tolerated by these patients in the absence of septic postoperative complications.
Time (months) local resection - - - - - - local resectlon*hepatectomy (11-20) (11.12)
FIG. 1. Comparison of the survival of 20 patients in whom local resection was performed and 12 patients in whom local resection plus hepatectomy was performed.
Patients Not Eligible for Liver Resection In patients with types 1 and 11 tumors and in the majority of patients deemed eligible for surgical exploration with type I11 tumors, at least macroscopically tumor-free margins can be obtained in the bile ducts of both liver lobes. In some of these patients preoperative studies may have shown vascular invasion or even occlusion. This is not a contraindication for surgery, although we are aware of the fact that tumor will be left behind during the dissection of the confluence. In our experience the early postoperative course of these patients is not influenced by the presence of tumor as long as the anastomoses are not compromised. It could be argued that these patients should be treated by internal or external tube drainage. In those cases in which the segmental ducts in both lobes still communicate this might be an alternative, as described. elsewhere in this issue of Seminars. In our experience, however, the quality of life is enhanced by surgical drainage. &
tients who survived the initial month postsurgery. At present, three of the 8 patients surviving more than 5 years have no evidence of disease; two had a liver resection, one had a local resection. Similarly, 2 of 5 patients surviving 4 years appear disease-free; both had a liver resection. Finally, two of 8 patients surviving 3 years are also disease-free having had a liver resection and one, a local resection. All patients surviving more than 3 years had type 111 Klatskin tumors. Complete microscopic tumor control was not achieved in any of these seven currently disease-free patients. All had postoperative external irradiation. All except one had poorly differentiated cancers. In conclusion, in our patient group the addition of hepatectomy significantly increased the postoperative mortality, but it did not increase the number of curative resections and it did not significantly increase survival. These findings have influenced our perioperative decision-making. We now perform a liver resection in addition to local resection only if the local situation shows that there is a reasonable possibility of achieving local tumor control by doing so. The perioperative decision to extend the operation and proceed to a liver resection is even more difficult if the local findings preclude complete macroscopic tumor removal. In patients with type 111 tumor and extension of tumor into the segmental duct on one side and extensive hilar infiltration, we are faced with a dilemma: should the undrained lobe be removed'? Klatskin,' in his original publication, pointed out the relative rarity of cholangitis
.
DISCUSSION Although cholangiocarcinomas in the porta hepatis most often "tend to be small and to remain sharply localized" (Klatskin,'), their location and growth pattern rarely make complete local tumor control by surgery attainable at the time of presentation. This has been our experience in Amsterdam. Mean survival times of patients reported by other groups3."' show that they share our experience, even if the resection is deemed "radical." Tumor-free margins are rarely obtained, especially in type 111 patients. In the present series only 2 of 42 patients had resection margins deemed tumor-free by the pathologist. Even in these rare patients, the distance between the tumor and the plane of resection is minimal
Downloaded by: University of British Columbia. Copyrighted material.
DECISION-MAKING IN BILE DUCT OBSTRUCTION-VAN
SEMINARS IN LIVER DISEASE-VOLUME
and would never have been acceptable for the surgeon in the treatment of any other gastrointestinal carcinoma. This fact has serious consequences. As proposed by Kopelson et al,' these patients require additive treatment postoperatively. As mentioned by Gonzalez et a1 in this issue of Seminars, postoperative radiotherapy is an essential part of our treatment protocol. Since 1986, we have been inserting the distal end of the jejunal loop used for the cholangioenterostomies in the abdominal wall as a stoma to be used for the introduction of iridium wires. A second consequence is that, in making decisions about the treatment of these patients, one should be realistic and aim for a result that meets the requirements of any palliative treatment: low mortality, acceptable morbidity, and prolongation of survival with an optimal quality of life. The use of catheters placed either percutaneously or endoscopically is discussed in this issue of Seminars by Van Leeuwen et al. The role of tubes introduced at operation has recently been reviewed by Terblanche et al.' This method was popular in the years before 1910 when the possibility of resection was hardly ever considered. In a recently reported French collective study,4 describing results in 88 patients, the 30-day mortality was 27.3% and the median survival was 9 months. The authors have abandoned the use of U-tubes mainly because of the low quality of life of patients surviving more than a few months: a high incidence of cholangitis and intolerance of the tube by the patient. Intrahepatic biliodigestive anastomoses were described and widely used by French surgeons.'.' The socalled round ligament approach to the duct of segment 111 can be carried out with a low mortality even in elderly patients. Although the anastomosis is relatively distant from the main hepatic duct confluence, its use is limited by tumor extension into the segmental duct^.'^ It is the operation of choice for patients with a gallbladder carcinoma obstructing the common hepatic duct. The technique is only rarely an alternative to resection. Longterm palliation can be expected in patients with type I and some with type I1 tumors. In these patients a local resection is possible in most cases. For our group, the main dilemma is the matter of adding lobar hepatectomy to local resection of tumor. There is no doubt that the addition of hepatic resection increases the postoperative mortality. This was clearly demonstrated in our series. Eight of 20 patients died in the hospital after major liver resections. Bleeding and infection were the main causes of death. The high risk of a liver resection in these severely compromised pa-
10, NUMBER 2, 1990
tients is demonstrated by the fact that there has been no operative mortality since 1986 in our group of patients having had a liver resection for primary or secondary liver tumors. We have not been able to show a difference in survival between patients with and without hepatectomy. The collective French series described by Launois and Cubertafond4 shows the same: a median survival of 24 months without and 23 months with liver resection. It might be argued that these were not randomized studies and that only the bad cases had a liver resection. This was definitively not the case in our material: the majority of liver resections were done in patients in whom complete local tumor control seemed attainable. Nowadays, we are reluctant to do a liver resection, especially if this leaves less than 30% of liver tissue, as in extended right hepatectomies. A palliative operation should have the lowest possible mortality.
REFERENCES Bismuth H, Corlette MB: lntrahepatic cholangioenteric anastomosis In carcinoma of the hilus of the liver. Surg Gynecol Obstet 140:170-178, 1975. Mizumoto R, Kawarada Y, Suzuki H: Surgical treatment of hilar carcinoma of the bile duct. Surg Gynecol Obstet 162:153-156, 1986. Beazly RM, Hadjis N. Benjamin IS. Blumgart LH: Clinico pathological aspects of high bile duct cancer. Ann Surg 199:623-634, 1984. Launois B, Cubertafond P (Eds): Les cancers des voies biliaires extrahipatiques. Paris, Masson, 1988. Klatskin G: Adenocarcinoma of the hepatic duct at its bifurcation within the porta hepatis. Am J Med 38:241-256, 1965. Evander A, Fredlund P, Hoevels J, et al: Evaluation of aggressive surgery for carcinoma of the extrahepatic bile ducts. Ann Surg 191:23-29, 1980. Kopelson G , Harisiades L, Tretter P, Chu H Chang: The role of radiation therapy in cancer of the extra-hepatic biliary system. Int J Radiat Oncol Biol Phys 2:883-894, 1977. Terblanche J, Kahn D, Bornman PC, Werner D: The role of U tube palliative treatment in high bile duct carcinoma. Surgery 103:624-632, 1988. Hepp J. Moreaux J , Lechaux JP: Les anastomoses biliodigestives intra-hepatiques dans les cancers de voies biliaires. Nouv Presse Med 2: 1829-1832, 1973. Choi TK, Tan ST, Lai ECS, Wong J: Malignant hilar biliary obstruction treated by segmental bilioenteric anastomosis. Surgery 104:525-529, 1988.
Downloaded by: University of British Columbia. Copyrighted material.
148
10, NO. 2 , 1990
Decision-Making in the Treatment of Patients with Malignant Proximal Bile Duct Obstruction M.N. VAN DER HEYDE, M.D., Ph.D., P.C.M. VERBEEK, Ph.D., and N.J. LYGIDAKIS, M.D.
INOPERABLE PATIENTS Patients over 70 years of age and those with associated cardiopulmonary disease or documented widespread tumor dissemination account for approximately 80% of referrals. These patients are usually referred for nonsurgical treatment of jaundice and its direct consequences. Diagnostic procedures should be limited. If possible, an endoprosthesis is inserted endoscopically and occasionally percutaneously. No further procedures aimed at gaining information about the site of origin and characteristics of the tumor are undertaken.
OPERABLE PATIENTS The keynote of decision-making in these patients is that complete drainage of the liver is essential. Jaundice and itching can be controlled by drainage of a part of the liver. An undrained liver lobe, however, puts the patient at risk for cholangitis, sepsis, and death. Thus, the mainstay of the surgical procedure is drainage of the whole liver. This can best be achieved by reestablishing drainage after tumor resection. Complete local tumor control is rarely achieved in these patients, even though this is
From the Department of Surgery. Acudemic Medical Centre, University of Amsterdam. Amsterdam, The Netherlands.
Reprint requests: Dr. Van Der Heyde, Department of Surgery, Academic Medical Centre, University of Amsterdam, Meibergdreef 9 , 1105 AZ. The Netherlands.
the intent of most resections. Keeping this in mind, which preoperative investigations are mandatory before deciding to operate?
Preoperative Investigations Ultrasound Conventional ultrasonography (US) serves to demonstrate the degree of dilation of the intrahepatic bile ducts and may give an indication of the intrahepatic ductal spread of the tumor. Gallbladder cancer infiltrating the hilar ducts can be demonstrated occasionally, but never can be absolutely excluded. In our experience endoscopic ultrasound can be helpful in obtaining more precise information regarding the extension of tumor growth, whereas computed tomography (CT) scan often fails in this respect. Differentiation between vascular invasion and compression is not completely reliable unless complete vascular occlusion is shown. We are increasingly supported by duplex scanning in assessing vascular involvement.
Direct Cholangiography This topic is discussed elsewhere in this issue of Seminars in Liver Diseuse. It should be a general rule that the introduction of radiopaque fluid into an occluded intrahepatic bile duct should always be followed by drainage to avoid septic complications of this diagnostic procedure. Prophylactic antibiotics should be given.
Angiography Vascular involvement, either arterial or venous, indicates that the tumor extends beyond the bile duct proper. It does not necessarily preclude the possibility of obtaining tumor-free margins in the right and left hepatic duct with a local tumor resection. Unilobar vascular involvement does not preclude the possibility of obtaining local tumor control if one proceeds to a lobar liver resection or a vascular reconstruction. In our institution angiography is part of the preoperative evaluation of the patient. However, findings obtained by this investigation have had little if any On the the patient.
Copyright 0 1990 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
14.5
Downloaded by: University of British Columbia. Copyrighted material.
Between January 5 , 1986, and January 7 , 1989, 45 patients with Klatskin tumors were treated surgically in the Amsterdam Medical Centre (AMC). All patients with complicated biliary obstruction are seen, discussed, and treated by a multidisciplinary team of specialized gastroenterologists, surgeons, radiologists, and radiotherapists. Each year, approximately 200 new patients with assumed malignant bile duct obstruction are seen and treated. The large experience thus obtained has resulted in the development of a treatment protocol that will be discussed in this article.
Tissue Diagnosis Images obtained with US or endoscopic retrograde cholangiopancreatography (ERCP) are rarely indicative of the true nature of the obstructing lesion. Brush cytology at ERCP may prove the presence of cancer. The same is true for puncture-aspiration of masses clearly seen at US or CT. Both methods have a high incidence of false-negative findings. Even biopsies taken at operation may give misleading information, the final diagnosis being made only by thorough examination of the resected specimen. Several examples of rare tumors in the liver hilus, such as a breast cancer metastasis, a Hodgkin lymphoma and an oatcell tumor presenting as "typical" Klatskin tumors, and a 9% incidence of benign lesions all presenting as a "typical" Klatskin tumor have been encountered during the years. In view of the fact, however, that all patients involved required the same kind of surgery, that is, resection of the obstructing lesion, these diagnostic failures recognized at or after operation were of no serious consequence. We perform cytodiagnostic punctures only if we abstain from surgical treatment. The fact that we regard bile as a source of implantation metastases has played a decisive role in our considerations, as discussed by Verbeek and colleagues elsewhere in this issue of Seminars.
Preoperative Decision-Making In the majority of our patients the preoperative studies strongly suggest extensive tumor growth precluding curative surgery, unless the patient is fit enough to undergo a lobar liver resection, possibly combined with one or more vascular reconstructions. Usually, we try to decide preoperatively whether or not the patient is a candidate for such an extended operation, weighing factors such as age, general condition, and residual liver function. In case of a negative decision in this regard, the only aim of the subsequent operation is complete drainage of both liver lobes.
Perioperative Decision-Making Patients Eligible for Liver Resection Presence of extrahepatic tumor growth or hepatic metastasis is looked for as a first step in the operation. It is rarely encountered unexpectedly and does not necessarily mean that a palliative procedure should not be carried out. One of our 45 patients had peritoneal spread of tumor. This patient had been successfully drained by endoprosthesis and, although feasible, for this reason no tumor resection was carried out. In the 44 remaining patients the tumor was explored. It should be stressed that in the majority of cases exploration means dissection. The resectability of these tumors cannot be evaluated by palpation (or perioperative US). Careful dissection of the liver hilus, cholecystectomy and a transection of the common bile duct have to be carried out to enable the surgeon to make the most pertinent decision: should a
10, NUMBER 2, 1990
local resection of the confluence and the tumor mass be performed or an additional hepatic resection be carried out? Lobar liver resection may be done for two reasons: ( I ) The possibility of complete local tumor control, which cannot otherwise be achieved; and (2) the impracticability of adequate drainage of both liver lobes in patients with type 111' tumors extending into the segmental ducts of one liver lobe. If a partial liver resection is carried out with the aim of complete local tumor control, the increased risk of extending the operation should be carefully weighed against the chance of achieving cure. Predominance of tumor extension and infiltration to one side is found in most patients. In patients with predominance of the right side it is tempting to perform an extended right hepatectomy. In accordance with Mizumot0 et a],' a resection of the caudate lobe is added to the hepatectomy in most cases. This is most easily done if segment IV is removed in continuity with the right lobe. A prerequisite is that a tumor-free margin be obtained at the segemental confluence of the ducts of segments I1 and 111. It should, however, be kept in mind that a tumor-free margin in the duct does not imply absence of perineural or perivascular infiltration at the resection margin. Adding a lobar hepatectomy to a local tumor resection may increase the number of operations with intended cure. So far, it has not shown that it increases long-term survival significantly.'-' Our personal experience supports this.
AMC Experience Forty-five patients with histologically proved cholangiocarcinoma in the liver hilus were surgically explored. In 42 of these, tumor resection was performed (Table 1). Twenty-two patients underwent a local resection (group A) and 20 patients had a lobar hepatic resection in continuity (extended) with the resection of the biliary confluence (group B) (9 right- and 11 left-sided hepatectomies). In group A two patients died during the first postoperative month. In group B, eight patients died. Liver insufficiency (two cases), bleeding (two cases), and sepsis (six cases) were the predominant causes of death. Thus, 32 patients could be followed up: 20 in group B and 12 in group A. The mean survival time was 25 months in group A and 27 months in group B. As shown in Figure 1 , there was no significant difference in survival between the two groups, among pa-
TABLE l . AMC Experience
Local resection alone Local t liver resection
No.
Hosl>irtrl Mortulity
Meuir Survivul" (inonth)
5-Yetrr Survivul
22
2
25
I
20
8
27
2
"Of 20 patients with local resection and o f 12 patients with local and liver resection.
Downloaded by: University of British Columbia. Copyrighted material.
SEMINARS IN LIVER DISEASE-VOLUME
146
Cumulative proportion surviving %
loo
0J 0
10
20
30
50
40
60
DER HEYDE, VERBEEK, LYGIDAKIS
141
in untreated patients and the dangers of invasive investigations in this regard. We share the opinion of others4 that a patient having had his dilated bile duct filled with contrast medium is at high risk for unmanageable cholangitis if the relevant duct is not adequately drained. In these patients we are willing to perform a lobar resection, even if this is done only with the aim of leaving no undrained liver tissue behind. The decision is easy to make in the presence of overt atrophy of one liver lobe and in the rare cases in which the left lobe cannot be adequately drained. The decision to perform an extended right hepatectomy is difficult. We abstained from liver resection in this situation in two patients. Both patients died, even though the left lobe was satisfactorily drained, within 2 and 6 weeks postoperatively, of uncontrollable sepsis. In weighing pros and cons, it should be kept in mind that an extended right hepatectomy allows the fashioning of a safe anastomosis on segments I1 and 111. This is of importance, since it increases the chance of a smooth postoperative course. Even extensive liver resections are usually well tolerated by these patients in the absence of septic postoperative complications.
Time (months) local resection - - - - - - local resectlon*hepatectomy (11-20) (11.12)
FIG. 1. Comparison of the survival of 20 patients in whom local resection was performed and 12 patients in whom local resection plus hepatectomy was performed.
Patients Not Eligible for Liver Resection In patients with types 1 and 11 tumors and in the majority of patients deemed eligible for surgical exploration with type I11 tumors, at least macroscopically tumor-free margins can be obtained in the bile ducts of both liver lobes. In some of these patients preoperative studies may have shown vascular invasion or even occlusion. This is not a contraindication for surgery, although we are aware of the fact that tumor will be left behind during the dissection of the confluence. In our experience the early postoperative course of these patients is not influenced by the presence of tumor as long as the anastomoses are not compromised. It could be argued that these patients should be treated by internal or external tube drainage. In those cases in which the segmental ducts in both lobes still communicate this might be an alternative, as described. elsewhere in this issue of Seminars. In our experience, however, the quality of life is enhanced by surgical drainage. &
tients who survived the initial month postsurgery. At present, three of the 8 patients surviving more than 5 years have no evidence of disease; two had a liver resection, one had a local resection. Similarly, 2 of 5 patients surviving 4 years appear disease-free; both had a liver resection. Finally, two of 8 patients surviving 3 years are also disease-free having had a liver resection and one, a local resection. All patients surviving more than 3 years had type 111 Klatskin tumors. Complete microscopic tumor control was not achieved in any of these seven currently disease-free patients. All had postoperative external irradiation. All except one had poorly differentiated cancers. In conclusion, in our patient group the addition of hepatectomy significantly increased the postoperative mortality, but it did not increase the number of curative resections and it did not significantly increase survival. These findings have influenced our perioperative decision-making. We now perform a liver resection in addition to local resection only if the local situation shows that there is a reasonable possibility of achieving local tumor control by doing so. The perioperative decision to extend the operation and proceed to a liver resection is even more difficult if the local findings preclude complete macroscopic tumor removal. In patients with type 111 tumor and extension of tumor into the segmental duct on one side and extensive hilar infiltration, we are faced with a dilemma: should the undrained lobe be removed'? Klatskin,' in his original publication, pointed out the relative rarity of cholangitis
.
DISCUSSION Although cholangiocarcinomas in the porta hepatis most often "tend to be small and to remain sharply localized" (Klatskin,'), their location and growth pattern rarely make complete local tumor control by surgery attainable at the time of presentation. This has been our experience in Amsterdam. Mean survival times of patients reported by other groups3."' show that they share our experience, even if the resection is deemed "radical." Tumor-free margins are rarely obtained, especially in type 111 patients. In the present series only 2 of 42 patients had resection margins deemed tumor-free by the pathologist. Even in these rare patients, the distance between the tumor and the plane of resection is minimal
Downloaded by: University of British Columbia. Copyrighted material.
DECISION-MAKING IN BILE DUCT OBSTRUCTION-VAN
SEMINARS IN LIVER DISEASE-VOLUME
and would never have been acceptable for the surgeon in the treatment of any other gastrointestinal carcinoma. This fact has serious consequences. As proposed by Kopelson et al,' these patients require additive treatment postoperatively. As mentioned by Gonzalez et a1 in this issue of Seminars, postoperative radiotherapy is an essential part of our treatment protocol. Since 1986, we have been inserting the distal end of the jejunal loop used for the cholangioenterostomies in the abdominal wall as a stoma to be used for the introduction of iridium wires. A second consequence is that, in making decisions about the treatment of these patients, one should be realistic and aim for a result that meets the requirements of any palliative treatment: low mortality, acceptable morbidity, and prolongation of survival with an optimal quality of life. The use of catheters placed either percutaneously or endoscopically is discussed in this issue of Seminars by Van Leeuwen et al. The role of tubes introduced at operation has recently been reviewed by Terblanche et al.' This method was popular in the years before 1910 when the possibility of resection was hardly ever considered. In a recently reported French collective study,4 describing results in 88 patients, the 30-day mortality was 27.3% and the median survival was 9 months. The authors have abandoned the use of U-tubes mainly because of the low quality of life of patients surviving more than a few months: a high incidence of cholangitis and intolerance of the tube by the patient. Intrahepatic biliodigestive anastomoses were described and widely used by French surgeons.'.' The socalled round ligament approach to the duct of segment 111 can be carried out with a low mortality even in elderly patients. Although the anastomosis is relatively distant from the main hepatic duct confluence, its use is limited by tumor extension into the segmental duct^.'^ It is the operation of choice for patients with a gallbladder carcinoma obstructing the common hepatic duct. The technique is only rarely an alternative to resection. Longterm palliation can be expected in patients with type I and some with type I1 tumors. In these patients a local resection is possible in most cases. For our group, the main dilemma is the matter of adding lobar hepatectomy to local resection of tumor. There is no doubt that the addition of hepatic resection increases the postoperative mortality. This was clearly demonstrated in our series. Eight of 20 patients died in the hospital after major liver resections. Bleeding and infection were the main causes of death. The high risk of a liver resection in these severely compromised pa-
10, NUMBER 2, 1990
tients is demonstrated by the fact that there has been no operative mortality since 1986 in our group of patients having had a liver resection for primary or secondary liver tumors. We have not been able to show a difference in survival between patients with and without hepatectomy. The collective French series described by Launois and Cubertafond4 shows the same: a median survival of 24 months without and 23 months with liver resection. It might be argued that these were not randomized studies and that only the bad cases had a liver resection. This was definitively not the case in our material: the majority of liver resections were done in patients in whom complete local tumor control seemed attainable. Nowadays, we are reluctant to do a liver resection, especially if this leaves less than 30% of liver tissue, as in extended right hepatectomies. A palliative operation should have the lowest possible mortality.
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