Segment III biliary bypass

Background

• Around 80% of the patients with malignant hilar block are

candidates for palliative management
– Metastases or advanced loco-regional disease
– Extensive comorbidity for major surgery
• Aim
– Provide long-term relief from
• Pruritis, cholangitis, pain and jaundice.
• Endoscopically placed self-expanding metallic biliary stents
• Low procedure-related complications
• Probably the modality of choice
 Background

– Percutaneous biliary drainage has comparable results

• An alternative when endoscopic expertise is not available or
has failed
• There are multiple isolated undrained segments with
cholangitis

– Surgical cholangiojejunostomy provides lasting biliary

drainage
• Has limitations of high procedure related morbidity and
mortality
 Background

• In the absence of high-quality studies, comparing

these modalities, the choice of biliary drainage
procedure should be guided by the available
expertise

• Other modalities of treatment like radiotherapy,

chemotherapy and photodynamic therapy
currently remain investigational.
 Background

• Aims of palliative management

– To provide durable relief from symptoms
– To improve the quality of life faced with
terminal illness
– Besides the patient, it should take into
account the need of the family and caregiver
» National cancer control programme 2002.
Background
 Background

• Surgical option
– Segment 3 bypass (Ligamentum Teres approach)
– Segment 3 peripheral hepaticojejunostomy
– Longmire & Sandford procedure
– Right duct approach
• Right anterior sectoral HJ
• Segment V HJ
• Segment V/VI resection
– Transtumoral intubation
 Segment 3 bypass
• History
– Commonly performed operative biliary
drainage procedure for malignant hilar block
– Introduced by Soupalt and Couinaud (1957)
– Popularized by Bismuth and Corlette (1975)
and Blumgart and Kelly (1984).
• Indication
– Unresectable malignant hilar obstruction

– Hilar cholangiocarcinoma Access to hilum or left duct

– Carcinoma GB not possible

Options

Endoscopic drainage, Percutaneous drainage, Surgical bypass

 Segment 3 biliary bypass
Ligamentum Teres approach
• Rationale
• Relative ease to access
• Far from the tumor
• Segment 3 duct provides drainage ideally for all
the three segments (II, III and IV)
» Vellar ID et al Aust Nzl J Surg 1998
• Drains
– 30% of the liver parenchyma or at least two segments
– Which translate its success in palliating symptoms
provided remaining segment is sterile
» Bismuth H et al Br J Surg 1987
Contraindication
 Preoperative work-up

• The aim
– Identify candidates for curative resection and to
plan appropriate palliative strategy for the rest
• Extent of bile duct involvement
• Encasement of common hepatic artery or main portal
vein at the hepatic hilum
• Lymph node and distant metastases
• Assessment of patient fitness for undergoing major
surgery
• MRCP
– For assessment of second-order bile ducts- an irregular thickening
of the bile duct wall (>5 mm) with upstream asymmetric
dilatation.
» Manfredi R, et al. Abdom Imaging 2003
– The accuracy
• Intra-ductal extension of the tumor (78% to 85%)
• Comparable to that of ERCP
– The advantages of MRCP over ERCP
• Non-invasive with no consequent complications
• Better delineation of the intrahepatic ductal anatomy in cases of tight
strictures
» Yeh TS et al Am J Gastroenterol 2000
• Doppler study
Aim
• MR angiography Assessment of vascular invasion
Locoregional or distant metastasis
• CT angiography
Procedure

Recessus of Rex
 Modification

An anterior hepatotomy to the left of falciform ligament over the segment III duct-
provide adequate length and space for the anastomosis

Criostoir B. O’Suilleabhain et al Am J Surg 2004

Results

O’Suilleabhain CB et al Am J Surg 2004

Jarnagin WR et al Am J Surg 1998
Chaudhary A et al World J Surg 1997
, Kapoor VK et al Br J Surg 1996
Garden OJ et al British Journal of Surgery 1994,
Bismuth H et al Br J Surg 1987
• Survival
– Mean of 9.2 months with median 12 months
» Bismuth H et al Br J Surg 1987
» Jarnagin WR et al Am J Surg 1998
– The patients undergoing surgical bypass are reported to
have a longer survival and a superior quality of life as
compared to those palliated by other means
» Gazzaniga GM et al Journal of HBP Surg 2000
» Figueras J,, et al Liver Transpl 2000

– Surgical bypass however has a higher early morbidity

and mortality
– However, these studies need to be interpreted with caution.
– The patient population between the two groups is dissimilar
– Good risk patients undergoing operative palliation and those with
advanced disease or co-morbidity being referred for non-operative
biliary drainage.
– A cumulative analysis of four studies that compared surgical and
non-surgical therapies
• Revealed that median survival between the two groups: 6.8 vs. 5.4 months
(NS)
 Surgical bypass Endoscopic bypass Percutaneous bypass

Advantage Better quality of life Less invasive 2nd order biliary radical
Better survival (6.8Vs Symptomatic palliation High therapeutic success
5.4 m) (86-90%) Undrained segments
Long term patency (80%
at 1 year) & low
reintervention rate
Intraoperatively non-
resectable Ds

Disadvantage High early mortality & Cholangitis (53% Vs Higher complication rate
morbidity 10% ) External biliary fistula
Complexity of procedure Reintervention (85% Vs
30%)
Institutional expertise
Undrained segment

Singhal D et al Surg Oncol 2005

 Conclusion
• Evidence are based largely on retrospective studies
• No recommendations can be made in favour of any one technique.
• The choice is best dictated by the available local expertise
• Endoscopic biliary drainage continues to be the preferred modality for patients
detected to have unresectable disease at preoperative evaluation
• Results of PTBD is comparable to EBD and is a viable alternative to endoscopic
palliation and when undrained segment is infected
• Segment III cholangiojejunostomy is performed at some centers for patients
found to have unresectable disease at exploration. However, in the best of hands
it has a mortality ranging between 6–12% and complication rate of 17–51%.