Transhepatic intubation in benign and malignant lesions of the biliary ducts

Tratamento paliativo da obstrução maligna do hilo hepático pela operação de Soupault-Couinaud

A grande dificuldade, na literatura, para a avaliação dos diferentes métodos utilizados no tratamento paliativo dos tumores irressecáveis do hilo hepático, foi a inexistência de um parâmetro que tornasse uniforme a linguagem dos seus resultados. Este estudo tem por finalidade analisar os resultados da anastomose colangioentérica intraparenquimatosa (ACEI) no dueto do seguimento III, realizada em 17 pacientes consecutivos, portadores de obstrução maligna do hilo hepático. Para tanto, foi avaliado, dentre outras variáveis, um índice de qualidade de vida, denominado índice de Conforto, que permite a comparação numérica dos resultados. Houve regressão importante da icterícia em 88,2% dos casos, e redução estatisticamente significativa dos niveis sericos das bilirrubinas no pos operatorio (p <0 05). A mortalidade hospitalar foi de 11 8% e o índice de Conforto foi equivalente a 81 9% Estcs resulta 45 dos permitem as seguintes conclusões: 1) A técnica proposta representa um método eficiente para resolução da colestase causada por tumores irressecáveis do hilo hepático; 2) O índice de Conforto de 81.9% credencia o método como adequado para o tratamento paliativo desta afecção.

Palliative treatment of extrahepatic bile ducts tumors

Extrahepatic bile duct (EHBD) tumors often become symptomatic in an advanced stage when curative resection is seldom possible. In a group of 111 patients, 7 (6.3%) received no treatment, 32 (28.8%) underwent non-operative biliary drainage (NOD), and 72 (64.8%) underwent surgical exploration. Radical resection was possible in only 25 cases (34.7%); 14 patients (19.4%) underwent a biliary digestive bypass (BDB), 15 (20.8%) received a transtumoral biliary prosthesis (TBP), and 18 (25.0%) an external biliary drainage (EBD). Average survival rates were: 6.5 months after BDB, 4.0 months after TBP, and 2.8 months after EBD. In a second group of 2,066 patients with primary and secondary malignant obstruction of the upper EHBD, treated with the insertion of a Carey-Coons transhepatic transtumoral biliary prosthesis, the average survival was 4.3 months. The early morbidity rate was 0.6%. Obstruction of the prosthesis occurred in 91 patients (4.4%), and the late morbidity rate was 3.6%. Although EHBD tumor treatment results are generally poor, surgical exploration should be performed in all patients with acceptable surgical risk, and without evidence of disseminated disease. When resection of the tumor is not feasible, we favor the use of a BDB or of a biliary prosthesis over that of an external drainage. In poor risk cases or cases with evidence of disseminated disease, we prefer the placement of an internal prosthesis (PTBD or endoscopic.

Biliary reconstruction in benign postoperative stricture with transhepatic tubes

This study reports our experience with 31 patients who underwent biliary reconstructions due to iatrogenic lesions of the main biliary tract. The technique of Hepp and Couinaud, associated with the use of transhepatic Silastic tubes, was utilized in 90% of the patients, and the mucosal graft was employed in only three patients. The recommended time for keeping the transhepatic tube in place was 6 months. In order to prevent subphrenic fluid collection between the tube exit orifice in the hepatic parenchyma and the abdominal wall, the tubes were protected with a Penrose drain over the course of their use. This tactic appeared effective. The immediate postoperative mortality was 9%, and the long-term results, with a mean follow-up period of 44 months, were considered good in 92% of the patients who survived surgery.

Role of radiation after operative palliation in cancer of the proximal bile ducts

Cancer of the proximal bile ducts continues to pose a formidable problem to even the most experienced biliary surgeon. From 1977 through 1985, 51 patients with histologically confirmed proximal bile duct cancers underwent surgical treatment. The lesion was confined to the hilar region in 30 patients; there was extensive hepatic infiltration or distant metastatic disease in 21 patients. One patient underwent resection. Biopsy only was performed in six patients. In the remaining 44 patients, transtumoral dilation and intubation were performed. These 44 patients were further analyzed with regard to how survival was affected by the presence of metastatic disease and by the adjunctive use of radiation therapy. Mean survival in those patients with metastatic disease (n = 16) was 6.1 months, and survival was not improved by the use of postoperative radiation. In the absence of metastatic or advanced local disease, however, the addition of external beam radiation did significantly extend the mean survival from 4.5 to 12.2 months and the median survival from 2.2 to 12.2 months. The operative mortality for the series was 14% and postoperative complications occurred in 18 patients. These findings suggest that the addition of external beam radiation improves survival in patients undergoing palliative treatment of hilar tumors. Further confirmation of the value of radiation awaits prospective investigation.

Thirty years' experience with biliary tract reconstruction by hepaticoenterostomy and transhepatic T tube

This study shows long-term results of biliary tract reconstruction in cases of high stenosis of the hepatic duct. Hepaticoenterostomy was performed with transhepatic insertion of a T tube following an original technique. A portion of the horizontal limb of the T tube is placed in the left hepatic duct, the other portion in the duodenum or jejunum, and the vertical limb extends into the right hepatic duct and the right lobe of the liver and is brought out through the abdominal wall. This tube is irrigated daily and removed after 12 months in order to keep the stent in place for a sufficient duration to prevent stenosis. This technique was used in 45 patients who underwent operations from 1954 to 1984. There were 6 postoperative deaths. Of the 39 patients discharged from the hospital, 37 were followed up. Excellent results were obtained in 30 patients who remained asymptomatic after observation from 1 to 14 years. In three patients, results were good, but there were occasional episodes of fever that subsided with antibiotics; one of these patients was observed for 17 years. Results were poor in four patients who developed a recurrent stenosis; three of them underwent reoperations, with satisfactory results. Long-term observation has shown that the described surgical procedure is useful in cases of high stenosis of the hepatic duct, because a stent can be left in place for a year and usually will prevent stenosis at the biliary intestinal anastomosis.

Treatment of biliary obstruction caused by metastatic cancer

Over an 8-year period, among 41 patients with obstructive jaundice caused by metastases to the liver or lymph nodes adjacent to the porta hepatis, palliative biliary decompression was established surgically in 11, by percutaneous transhepatic biliary drainage (PTBD) in 25, and by both methods in 2. Three patients had no drainage procedure performed. Early mortality after drainage occurred in 6 of 38 patients, and the median survivals (actuarial) for the remaining 32 patients were 4.5 months for the surgical group (range 2 to 21 months) and 4 months for the PTBD group (range 2 to 14 months). Although there were trends toward more frequent hospital readmissions and episodes of cholangitis in the PTBD group, the only statistically significant difference was in the number of catheter manipulations required. We concluded that when patients develop obstructive jaundice as a manifestation of metastatic cancer, useful palliation can be achieved by either surgical or percutaneous decompression.

Proximal stenosis of the bile ducts: results with a new surgical endoprosthesis

A new endoprosthesis designed for surgical intubation of neoplastic strictures of the proximal biliary tract has been developed. The technical aspects of intubation by this endoprosthesis are discussed, and the results in the first 25 patients are given. The results suggest that this device was well tolerated. Mortality and morbidity related to the endoprosthesis were low in comparison to the results given in the literature for intrahepatic cholangioenteric anastomosis. The authors conclude that this procedure could favorably replace intrahepatic cholangioenteric anastomosis as currently used for selected cases of malignant biliary stricture.

Percutaneous cholecystostomy for acute cholecystitis in high-risk patients

Seventeen high-risk critically ill patients with suspected cholecystitis underwent percutaneous transhepatic cholecystostomy between 1981 and 1986 using Hawkins' needle guide system for gallbladder intubation. Acute cholecystitis was documented in 15 patients, including 1 with common bile duct obstruction. Two other patients had common bile duct obstruction secondary to metastatic cancer (one patient) and chronic pancreatic fibrosis (one patient). There was rapid resolution of the signs and symptoms of cholecystitis, sepsis, or both in 16 of the 17 patients. One critically ill patient with positive findings on blood culture and an organism resistant to triple antibiotic therapy died soon after percutaneous cholecystostomy. In the entire group of 17 patients, there was no evidence of bile leaks or other catheter complications. Six patients subsequently underwent successful cholecystectomy and two underwent common bile duct exploration without complications. One patient underwent cholecystojejunostomy, and in three patients, the catheter was removed with no sequelae of cholecystitis. Two remaining patients had the catheter in place and were awaiting operation at last follow-up. Three of four patients who died within 30 days of percutaneous transhepatic cholangiographic cholecystostomy died either from the terminal malignant condition (two patients) or from arrhythmia (one patient with cirrhosis). This review suggests that percutaneous cholecystostomy is a safe and effective procedure for resolving acute cholecystitis in high-risk patients. In addition, the technique of percutaneous transhepatic cholangiographic cholecystostomy appears well suited for percutaneous dissolution of stones, sclerosis of the gallbladder, or both in selected high-risk critically ill patients.