Outcome in patients with bifurcation tumors who undergo unilateral versus bilateral hepatic duct drainage☆,☆☆,★,★★

Presented as a poster at the annual meeting of the American Society for Gastrointestinal Endoscopy, May 1996, San Francisco, California.
https://doi.org/10.1016/S0016-5107(98)70218-4Get rights and content

Abstract

Background: There is much controversy as to the importance of establishing drainage of both liver lobes in malignant hilar obstruction. The purpose of the present study was to compare survival data in patients with malignant hilar obstruction, stratified according to the Bismuth classification, who had cholangiography with filling of one or both hepatic ducts and subsequently endoscopic or percutaneous drainage of one or both ducts. Methods: A retrospective review was performed for the time period from July 1990 to July 1995, and 224 patients were identified with a presumed diagnosis of a bifurcation tumor. All x-ray films were reviewed and 150 patients finally diagnosed as hilar tumor were classified according to Bismuth type I, II, or III. Type II and III patients were further subclassified with respect to contrast injection into a single or both hepatic duct systems and whether one or both sides were eventually drained. Results: Data were obtained in 141 patients (4 patients still alive); there were 43 type I, 58 type II, and 40 type III. Type II and III patients were divided into three groups: group A, one lobe opacified with same lobe drained; group B, both lobes opacified with both lobes drained; and group C, both lobes opacified with one lobe drained. Overall median survival for type I, II, and III patients was 160, 131, and 62 days, respectively. Among type II and III patients the median survivals of groups A, B, and C were 145, 225, and 46 days, respectively. Survival was significantly longer in group A vs. group C (p < 0.001), group B vs. group C (p  < 0.001, and group A + B (165 days) vs. group C p < 0.001). There was no difference in group A + B versus type I (p = 0.90). In addition, when comparing single drain only (group A + C, 80 days) versus double drains (group B, 225 days), there was a significant survival advantage (p < 0.0001). Conclusion: In bifurcation tumors the best survival was noted in those with bilateral drainage, and the worst survival in those with cholangiographic opacification of both lobes but drainage of only one. (Gastrointest Endosc 1998;47:354-62.)

Section snippets

Patients and Methods

We undertook a retrospective chart review of all patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) from July 1990 to July 1995, with a presumed diagnosis of bifurcation tumor. There were 244 patients identified, among whom hospital and radiologic files were available in 224. After a review of the chart and x-ray films, 74 additional patients were excluded because of malignant strictures distal to the hilum in 47, strictures eventually diagnosed as benign in 19, and

Results

Among the 150 patients suitable for analysis, follow-up data were obtained in 141 patients. In nine patients neither family nor physicians could be contacted. There were 81 men and 60 women, mean age 70 years (range 35 to 95 years). The malignant strictures were due to cholangiocarcinoma, 84; metastatic cancer, 32; gallbladder carcinoma, 13; pancreatic carcinoma, 10; malignant lymphoma, 1; and hepatoma, 1. The age, sex, and tumor type were comparable in all groups (Table 1) The diagnosis was

Discussion

Hepatic duct bifurcation tumors are uncommon, accounting for less than 20% of extrahepatic bile duct carcinomas. Among the bifurcation tumors in this study 84 of 141 were primary cholangiocarcinomas. This tumor is usually localized and rarely manifests with preoperative evidence of metastatic disease, but satellite, noncontiguous lesions may occur in the bile duct, with spread of tumor along perineural planes.29, 30 A diagnosis of malignancy is often difficult to establish and percutaneous or

References (44)

  • T Childs et al.

    Aggressive surgical therapy for Klatskin tumors

    Am J Surg

    (1993)
  • JL Cameron et al.

    Management of proximal cholangiocarcinomas by surgical resection and radiotherapy

    Am J Surg

    (1990)
  • AG Speer et al.

    Randomised trial of endoscopic versus percutaneous stent insertion in malignant obstructive jaundice

    Lancet

    (1987)
  • H Bismuth et al.

    Management strategies resection for hilar cholangiocarcinoma

    Ann Surg

    (1992)
  • H Bismuth et al.

    Resection or palliation: priority of surgery in the treatment of hilar cancer

    World J Surg

    (1988)
  • CM Guthrie et al.

    Segment III cholangiojejunostomy for palliation of malignant hilar obstruction

    Br J Surg

    (1994)
  • CM Guthrie et al.

    Changing trends in the management of extrahepatic cholangiocarcinoma

    Br J Surg

    (1993)
  • JN Vauthey et al.

    Recent advances in the management of cholangiocarcinoma

    Semin Liver Dis

    (1994)
  • K Black et al.

    Management of carcinoma of the extrahepatic bile duct

    Can J Surg

    (1978)
  • N Soehendra et al.

    Palliative bile duct drainage—a new endoscopic method of introducing a transpapillary drain

    Endoscopy

    (1980)
  • GNJ Tytgat et al.

    Upper intestinal and biliary tract endoprosthesis

    Dig Dis Sci

    (1986)
  • J Lammer et al.

    Biliary endoprosthesis in tumors at the hepatic duct bifurcation

    Eur J Radiol

    (1986)

    • Cited by (379)

    • History of the Interventional Pancreaticobiliary Endoscopy

      2024, Gastrointestinal Endoscopy Clinics of North America

    • Role of ERCP in Malignant Hilar Biliary Obstruction

      2022, Gastrointestinal Endoscopy Clinics of North America

    • Endoscopic Retrograde Cholangiopancreatography Stenting for Hilar Cholangiocarcinoma

      2022, Techniques and Innovations in Gastrointestinal Endoscopy
      Citation Excerpt :

      The key reason behind that was that it is believed that only 25%-50% of liver needs to be drained for palliation.20,21 However, this observation is based upon retrospective data and evidence to support this approach is limited.22 Given that the goal of endoscopic drainage should be focused on drainage of involved liver segments, perhaps the better terminology should be use of single or multiple stents.23

    • Italian Clinical Practice Guidelines on Cholangiocarcinoma – Part II: Treatment

      2020, Digestive and Liver Disease

    • The importance of the “endoscopic oncologist” in the treatment of nonoperable cholangiocarcinoma

      2020, Gastrointestinal Endoscopy

    • S3 guideline "Diagnosis and treatment of hepatocellular carcinoma" - Long version 4.0

      2023, Zeitschrift fur Gastroenterologie
    View all citing articles on Scopus
    ☆

    From the Division of Gastroenterology, The Centre for Advanced Therapeutic Endoscopy and Endoscopic Oncology, The Wellesley Hospital, University of Toronto, Toronto, Ontario, Canada.

    ☆☆

    Reprint requests: Gregory B. Haber, MD, The Centre for Therapeutic Endoscopy and Endoscopic Oncology, 160 Wellesley St. East, Toronto, Ontario, Canada M4X 1J3.

    ★

    *Current address: Division of Gastroenterology, Mackay Memorial Hospital, Taipei, Taiwan.

    ★★

    37/1/88342

    View full text
    Copyright © 1998 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.