Surgery for hilar cholangiocarcinoma: feasibility and results of parenchyma-conserving liver resection.

BACKGROUND/AIM: Major liver resection has improved the resectability rate of hilar cholangiocarcinomas, but morbidity and mortality may be significant. The aim of this study was to assess the value of parenchyma-conserving liver resection (resection of bile duct with liver segments I and IVb; PCLR) in hilar cholangiocarcinoma. METHODS: Retrospective analysis of prospectively collected data. Factors influencing survival following three types of operations were studied by univariate and multivariate analyses. The three types of operations were: (1) local resection of the bile duct alone (LR); (2) major liver resection (resection of three or more segments, hepatic resection; HR), and (3) PCLR. RESULTS: Forty-six patients (21 males, 25 females; age range 35-77 years, mean age 57, median age 57 years) underwent surgery. There were 11 LR, 12 HR, and 23 PCLR procedures. There were 3 deaths (mortality 6.5%). The mortality was higher following HR (3 out of 12; 25%) than following LR or PCLR (0 out of 34; p = 0.01). Survival was longer following curative resection (median 27 months) than after palliative resection (median 15 months; p = 0.001). Lymph nodal and perineural involvement were adverse factors on univariate, but not on multivariate analysis. PCLR produced better survival (median 29 months) as compared with LR (median 15 months) or HR (median 22.5 months; p < 0.01). CONCLUSIONS: PCLR is applicable to selected patients with Bismuth-Corlette type III disease without major vascular involvement and produces survival rates comparable to those of LR and HR. PCLR may help avoid major liver resections in some patients with hilar cholangiocarcinoma.

Biliary access loops for intrahepatic stones: results of jejunoduodenal anastomosis.

BACKGROUND: Patients with intrahepatic calculi require multiple interventions following successful surgical stone clearance for recurrent stones and cholangitis. The present paper describes the results of a technique of in-continuity side-to-side jejunoduodenal anastomosis (JDA) that provides endoscopic access to the hepaticojejunostomy and intrahepatic ducts. This operation is compared to other techniques in a critical appraisal of various biliary access procedures described for long-term management of intrahepatic -calculi. METHODS: A retrospective analysis of clinical data of 13 patients who underwent biliary drainage procedures with access loops for intrahepatic calculi during the period March 1990 to December 2000 was performed. The postoperative course of patients and the feasibility of postoperative endoscopic access to the hepaticojejunostomy and intrahepatic ductal system in treatment of recurrent cholangitis were assessed. Nine patients underwent JDA, two underwent permanent-access hepaticojejunostomy (PAH) and two others underwent an interposition hepaticojejunoduodenostomy (IHJ). RESULTS: The analysis revealed no major procedure-related complications or mortality. Endoscopic access (using forward-viewing gastroscope) was possible in 100% of cases following JDA, and with difficulty in both cases after PAH. Endoscopic access in the two patients with IHJ failed because of technical reasons. Recurrent cholangitis was seen in seven patients (54%) - two out of two patients in the PAH group, one out of two in the IHJ group and four out of nine in the JDA group. This required 12 endotherapy sessions (mean: 1.5 procedures per patient). CONCLUSION: In-continuity side-to-side JDA allows easy access of conventional gastroduodenoscopes to the biliary tree for removal of recurrent/residual intrahepatic stones. The technique has advantages over other access loop procedures in the long term management of recurrent intrahepatic stones.