MODERN OPERATIVE TECHNICS
A Safe Method of lntrahepatic Biliary Drainage in Obstructive Jaundice Hideo Ozaki, MD, Tokyo, Japan Keiichi Hojo, MD, Tokyo, Japan Kiyoshi Miwa, MD, Tokyo, Japan
In cases of severe obstructive jaundice, operative death after reconstructive surgery of the bile duct is frequent because of severe functional disturbance of the liver, kidney, and other organs. Cholecystostomy is one of the safer methods of biliary diversion in obstruction of the distal bile duct, but in obstruction of the proximal ducts, diversion of stagnant intrahepatic’ bile is not always easy, especially when the condition of the patient is poor. In these patients, operative intervention, such as excision of the tumor, hepaticojejunostomy, Longmire procedure, or hepaticostomy, is often fatal. A safe method of intrahepatic biliary drainage that can be carried out with local anesthesia is necessary. A method of draining the intrahepatic bile duct at the anterior edge of the liver is reported herein and its clinical value is described. Operative Technic
Laparotomyis performed using local anesthesia (or light general anesthesia). An upper median incision about 6 to 10 cm long is made at the palpated edge of the enlarged liver. (Figure 1A.) Moist gauze is inserted under the inferior surface of the liver to prevent outflow of bile into the free peritoneal cavity. Two mass ligatures are placed on the anterior edge of the liver (usually left lobe) approximately 4 cm apart to decrease oozing from the cut surface. Wedge resection of the liver edge approximately 3 X 3 cm is done between these ligatures so as to expose the dilated bile duct. (Figure 1B.) Usually, reflux of bile from the cut stump of the bile duct (a branch of the lateral inferior duct of the left lobe) is seen at the point of wedge resection. A sterile Argyle infant feeding tube (#8 French, 15 inches long, catalogue number MAR2606, Sherwood Medical Industries Inc) with two or three side holes at the tip of the tube is inserted as From the Department of Surgery, NationalCancerCenterHospital, Tokyo, Japan.ThisworkwassuppatedinpertbyaganttromtheMlnlstr/of~)th and Welfare of Japan. Reprint requests should be addressed to Hideo Ozaki, MO. Department of Surgery, National Cancer Center Hospital, Tsukiji IChome. Chuo-ku, Tokyo, Japan.
velenm 133, werdl1977
near to the hepatic hilum as possible. (Figure 1C.) After adequate drainage of the stagnant bile, bleeding is checked using mosquito clamps or mass ligatures. The Argyle tube is put on the anterior surface, and cut margins of the liver are approximated by several sutures. (Figure 1D.) Exploration of the peritoneal cavity should be minimal in severely ill patients. After removal of the moist gauze, a silicone tube is inserted under the inferior surface of the liver for drainage. Closure of the abdominal wall is done gently and without accidental removal of the Argyle and silicone tubes. (Figure 1E.) This operation can be performed in a short time without distress and strain on the patient. The silicone tube may be removed three to seven days postoperatively. When the level of jaundice subsides postoperatively, the site of the stenotic bile duct and its condition are examined by cholangiogram using the Argyle tube. Radical excision of the tumor with or without hepatectomy, hepaticojejunostomy, or Longmire procedure should be done if the patient’s general condition improves. However, retention of this external drainage is better for those patients who cannot tolerate radical surgery. Using this drainage, infection of the bile duct rarely occurred. When external drainage is continued for a long period and the amount of bile is abundant, it is advisable to reinstill the bile into the jejunum via an artificial fistula. The Longmire procedure utilizing this technic for external drainage is now described. Under general anesthesia, an upper median abdominal incision is done. Wedge resection of the liver is performed at the site of insertion of the Argyle tube. (Figure 2A.) Bleeding points on the cut surface of the liver are checked. The proximal jejunum is trammcted approximately 20 cm distal to Treitx’s ligament for Roux-en-Y anastomosis. The distal jejunum is closed by sutures and raised to the liver antecolically. Sutures are placed between the inferior edge of the liver and the posterior wall of the jejunum, and the distal end of the Argyle tube (which may be exchanged for a new one) is guided into the jejunum through a hole made on the side wall of the jejunum and then is drawn out from the jejunal stump by a clamp. (Figure 2B.) Using two or three stitches, exact approximation of duet-to-mucosa anastomosis is made. After this, sutures are placed between the superior edge of
Ozaki, Hojo, and Miwa
Figure 1. Technic of intrahepatlc biliary drainage at the anterior edge of the left ftepatic lobe.
the cut surface of the liver and the anterior wall of the jejunum. (Figure 2C.) End-to-side enterostomy is performed approximately 30 cm distal to the hepaticojejunostomy. The distal end of the Argyle tube is placed extraperitoneally, and closure of the abdominal wall is made in the routine manner. The tube is removed after one week. In other operations at the hepatic hilum, including radical resection, this external drainage may be left intact for a few days. It is often effective postoperatively in preventing stagnation of bile at the site of anastomosis. Results
Between 1963 and 1974, there were sixty patients with obstructive jaundice due to malignant tumor of the proximal bile duct at the National Cancer Center Hospital. In the early years, excision of the tumor, hepaticojejunostomy, Longmire procedure, hepaticostomy with T-tube insertion and hepatic puncture with tube insertion for hepatic decompression were performed under general anesthesia even in severely ill cases. Sometimes only exploratory laparotomy was performed. The mortality rate in this period was 50 per cent. (Table I.) Since 1970, intrahepatic biliary drainage at the anterior edge of the liver was per-
Figure 2. Longmire procedure utilizing the external blllary drainage affer decrease of jaundke.
formed as a primary procedure in thirty-two severely ill patients and lowered the mortality rate to 9 per cent. Operative death occurred in three patients with far advanced cancer associated with peritonitis carcinomatosa or massive liver metastasis. In this series, twelve patients with carcinoma of the bile duct, seven with carcinoma of the gallbladder, and thirteen with metastasis or direct invasion from carcinoma of the pancreas and the stomach were included. (Table II.) Depending on the patient’s general condition, sixteen procedures were performed under local anesthesia and the other sixteen under general anesthesia. Usually, percutaneous transhepatic cholangiography was performed preoperatively to determine the extension of tumor. According to this
The American Journal of Surgry
Drainage in Obstructive Jaundice
due to Obstruction
of the Proximal
Bile Ducts and Operative
1963-1969 Procedure lntrahepatic biliary drainage Hepatic puncture and tube insertion Longmlre procedure Hepaticojejunostomy Hepaticostomy Excision Exploratory laparotomy Total * In a patient, mire procedure.
Number of Cases
3 6 2 3 4 4 22
1 (33%) 2 (33%) 2 (100%) 2 (66%) 3 (75%) 1 (25%) 11(50%)
finding, intrahepatic biliary drainage was made at the anterior edge of the left lobe in thirty patients. In this left lateral inferior area, the dilated bile duct is detected easily, as proposed by Hepp [l]. However, in two patients, the duct of the right hepatic lobe was used for drainage because the preoperative study indicated that the drained hepatic parenchyma of the left lobe was not sufficient. In six of the recovered patients, excision of the tumor (1 patient), hepaticojejunostomy (l), or Longmire procedure (4) was carried out safely as a secondary procedure and in twenty-one patients, anticancer agents were used with continued external biliary drainage. On the other hand, Longmire procedure or bile duct dilatation with T-tube insertion was performed in five patients in fairly good condition as the primary procedure without operative death. (Table I.) In two other severe cases, although intrahepatic biliary drainage was attempted, only exploratory laparotomy was done because of multiple liver metastasis, and these resulted in operative death. In this period, operative mortality was 13 per cent of the total cases. (Table I.) The average survival period, excluding the operative deaths, was 4.8 months in carcinoma of the gallbladder, 5.6 months in carcinoma of the hepatic duct, 2.6 months in carcinoma of the pancreas, and 6.2 months in carcinoma of the stomach. Only five patients, one with carcinoma of the gallbladder, two with carcinoma of the hepatic duct, and two with metastasis from carcinoma of the stomach, survived for one year or longer. (Table III.) Comments
In obstruction of the proximal bile duct which includes the hepatic ducts and triple junction, the general condition of the patient is worse than in those cases with simple choledochal obstruction. One of the reasons seems to be the loss of the buffer action of the gallbladder on intrahepatic intraductal pressure. The
out for recurrence
Carcinoma Gallbladder Bile duct Pancreas Stomach Total
Carcinoma Gallbladder Hepatic
Number of Cases
2 (100%) 5 (13%)
Drainage Number of Cases
7 12 5 8 32
1 Year Survivals
1 0 1 1 3
(14%) (20%) (13%) (9%)
Intrahepati’c biliary drainage Longmire procedure lntrahepatic biliary drainage Excision of tumor Bile duct dilatation with T-tube insertion lntrahepatic biliary drainage Anticancer chemotherapy Longmire procedure lntrahepatic biliary drainage
14 13 15 15 12
operative mortality associated with excision of tumor, bypass procedure, or hepatic decompression in these patients is very high. In such cases, liver and kidney function is extremely disturbed and there is an increased hemorrhagic tendency. After operation to decompress the biliary system, continued bilirubinemia, anuria, and gastrointestinal hemorrhage due to peptic ulcer are often encountered, which are all life-threatening complications. It is highly advisable that simple external drainage be performed first, followed by excision of the tumor after decrease of jaundice. If anastomosis is indicated, simple external drainage should be performed as a primary procedure if definitive operative intervention seems to be overstressful.
Ozaki. Hojo, and Miwa
The usefulness of intrahepatic biliary drainage in two cases of severe obstructive jaundice was reported by us in 1970 (in Japanese) . The first case was carcinoma of the gallbladder in a sixty-three year old woman and the second was carcinoma of the pancreas in a seventy-three year old man. Until 1974, we experienced thirty-two cases of intrahepatic biliary drainage with three operative deaths. Cause of these operative deaths was the general poor condition due to advance of cancer rather than the degree of jaundice. Intrahepatic biliary drainage was performed under general anesthesia in patients in relatively good condition. In these cases, the icteric index was elevated to some degree during a few postoperative days, indicating functional disturbance of the liver by anesthetic agents, whereas in local anesthesia, elevation of icteric index was not! observed. Considering other methods of external biliary drainage, cholecystostomy is effective only in patients with common duct obstruction that does not include the triple junction. In these patients, jaundice often recurs by tumor infiltration of the triple junction a short time after cholecystostomy. It is preferable to carry out intrahepatic biliary drainage first in patients in whom this is possible. Hepaticostomy through the tumor is often hazardous in severely ill patients and the tube is frequently compressed by the increasing tumor after some time. External drainage utilizing percutaneous transhepatic cholangiography [3-5] is often used in Japan. In this method there are some problems in tube maintenance over long periods of time, such as displacement of the tube or bacterial infection. Compared with these methods, intrahepatic biliary drainage at the anterior edge of the liver has the following advantages: (1) operative intervention is minimized and can be performed under local anesthesia; (2) there are no adhesions in the operative field during a second operation such as excision of tumor, hepatic resection, or various bypass procedures; (3) it is effective regardless of the site of obstruction; and (4) before everything else, it is a very reliable method to use for a long period. Altemeier et al , Thorbjarnarson , and Whelton et al  have pointed out that many cases of carcinoma of the proximal bile ducts are of low malignancy and biliary diversion is indicated for long-term palliation. In our clinic, long-term survival has not yet occurred, although operative mortality was lowered by this technic. Recently, radical oper-
ation with hepatic lobectomy for carcinoma of the proximal bile ducts was reported by several authors [!+13]. In the patient with these indications, intrahepatic biliary drainage as a preliminary procedure is very advisable, because more complete resection of the organ can be safely performed at a second operation. Summary
In malignant disease with severe obstructive jaundice, survival after operative intervention is extremely low. Simple external biliary drainage is desirable for these patients, as a preliminary procedure for radical operation or long-term palliation. Intrahepatic biliary drainage at the anterior edge of the liver can be performed easily and safely under local anesthesia in case of obstruction of the proximal bile ducts, just as cholecystostomy is indicated for obstruction of the common bile duct. References 1. Hepp J: Place des hepatectomies dans les anastomoses biliodigestives intrahepatiques. Rev Int H&at 10: 1005, 1960. 2. Ozaki H, Hojo K, ltoh I: lntrahepatic biliary drainage for severe obstructive jaundice. Geka Chiryo 23: 250, 1970 (in Japanese). 3. Kaplan AA, Traitz JJ, Mitchel SD, Block AL: Percutaneous transhepatic cholangiography. Ann Intern Med 54: 656, 1961. 4. Glenn F, Evans JA, Mujahed Z, Thorbjarnarson B: Percutaneous transhepatic cholangiography. Ann Surg 156: 451, 1962. 5. Shaldon S, Barber KM, Young WB: Percutaneous transhepatic cholangiography. A modified technique. Gasfroenterology 42: 371, 1962. 6. Altemeier WA, Gall EA, Zinninger MM, Hoxworth PI: Sclerosing carcinoma of the major intrahepatic bile ducts. Arch Surg 75: 450, 1957. 7. Thorbjarnarson B: Carcinoma of the intrahepatic bile ducts. Arch Surg 77: 908, 1958. 8. Whelton MJ, Petrelli M, George P, Young WB, Sherlock S: Carcinoma at the junction of the main hepatic ducts. 0 JMed New Series 38, No. 150: 211, 1989. 9. Haynes CD, Gingrich GW, Thoroughman JC: Carcinoma of the bile duct; diagnosis and treatment. Am Surg 30: 578, 1964. 10. Quattlebaum JK, Quattlebaum JK Jr: Malignant obstruction of the major hepatic ducts. Ann Surg 161: 876, 1965. 11. Cady 6, Fortner JG: Surgical resection of intrahepatic bile duct cancer. Am J Surg 118: 104, 1969. 12. Kelly KA: Successful resection of adenocarcinoma of junction of right, left, and common hepatic biliary ducts: report of case. Mayo Clin Rot 47: 48, 1972. 13. Klippel AP, Shaw RB: Carcinoma of the common bile duct: report of a case of successful resection. Arch Surg 104: 102, 1972.
The American Journal of Surgery