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Cancer of the bile ducts
CHAPTER
50D
Cancer of the bile ducts: interventional techniques in hilar and intrahepatic biliary structures Karen T. Brown OVERVIEW Malignant disease resulting in high bile duct obstruction (Fig. 50D.1)—that is, obstruction above the junction with the cystic duct—is not uncommon. Although frequently related to primary tumors of the biliary tree (see Chapters 49, 50A, and 50B), hilar obstruction, and even intraductal tumor, can be seen with other common malignancies such as breast, pancreatic, and colorectal cancers. Significant technical progress has occurred in both endoscopic and percutaneous biliary drainage, allowing safer palliative treatment of patients with such obstructions. Because these patients are often asymptomatic at presentation, the goals of treatment should be clearly defined prior to committing the patient to even a minimally invasive procedure. First and foremost, whether the patient is a surgical candidate should be determined. With the exception of patients who are clearly in a palliative situation, we prefer to discuss these patients in a multidisciplinary group with hepatobiliary surgeons, interventional radiologists, oncologists, and gastroenterologists to outline a plan of treatment. A thorough understanding of this plan and of the patient’s prognosis facilitates the development of a strategy for drainage. Accepted indications for palliative biliary drainage in these patients include intractable pruritus, cholangitis, the need to restore liver function to allow for administration of chemotherapeutic agents with biliary metabolism/excretion, access for intraluminal brachytherapy or choledochoscopy, and diversion for bile leak. Given the availability of high-quality magnetic resonance cholangiopancreatography (MRCP), direct cholangiography as a diagnostic tool is rarely warranted (see Chapters 17 and 18; Choi et al, 2008; Park et al, 2008).
INDICATIONS FOR BILIARY DRAINAGE Neither hyperbilirubinemia alone nor the computed tomographic (CT) or ultrasound finding of dilated bile ducts is an indication for biliary drainage. Pruritus, cholangitis, and the need to lower the bilirubin to administer certain chemotherapeutic agents, on the other hand, are all accepted indications for biliary drainage. Patients who have undergone biliary-enteric bypass as part of curative resection for a benign or malignant lesion may develop postoperative bile leaks that require drainage for diversion. In some cases, access to the biliary tree may be undertaken as a method of delivering local treatment for primary bile duct cancer, such as brachytherapy or photodynamic therapy. Many physicians have the impression that patients feel better and have improved performance status after relief of jaundice; however, this has not been confirmed in clinical studies. Indeed, in a prospective trial, we have shown that in patients
with malignant biliary obstruction, percutaneous drainage does not significantly improve quality of life (QOL), except for improving pruritus (Robson et al, 2007). Controversy remains in regard to the role of biliary drainage prior to surgery (Johnson & Ahrendt, 2006; Mezhir et al, 2009; Wang et al, 2008).
ENDOSCOPIC VERSUS PERCUTANEOUS DRAINAGE (SEE CHAPTERS 18, 27, AND 28) Patients with low bile duct obstruction are typically treated endoscopically. Patients with high bile duct obstruction, particularly when the obstruction extends above the hilus, have traditionally been treated percutaneously. This is because the success rate of percutaneous drainage has been higher, and the complication rate lower, when compared with endoscopic methods (Rerknimitr et al, 2004). This perspective is evolving as endoscope technology becomes more advanced, and endoscopists become better trained and more experienced in wireguided procedures and have better guidewires and stents with which to work. The two biggest drawbacks to endoscopic drainage for high bile duct obstruction have been the lack of ability to reliably target a specific area of the liver for drainage and the risk of contamination, by retrograde injection of contrast, of parts of the biliary tree that will not be drained. It is not uncommon to see a patient who is thought to have undergone successful endoscopic stenting of the right and left liver only to find, upon repeat imaging, that is not the case at all (Fig. 50D.2). Despite this, endoscopic management is indicated in some cases of high bile duct obstruction. This is particularly so when the risk of the patient having a permanent exteriorized catheter is high or when a patient has a higher risk of contaminating the entire biliary tree if approached percutaneously. One exciting new endoscopic approach is the placement of a transgastric segment III stent using endoscopic ultrasound. This procedure is considered when a patient is best treated by draining the left lateral segment, and the percutaneous approach is technically difficult, or where the risk of contaminating the right-sided bile ducts is thought to be high with or without being able to cross the obstruction. This is particulary indicated when draining the right liver would be of no clinical benefit, either because of replacement of right liver by tumor or occlusion of the right portal vein (Fig. 50D.3). When technically feasible, this procedure can be gratifying for the patient, with relief of pruritus and lowering of bilirubin without the added burden of a percutaneous catheter. Endoscopic drainage is almost never indicated in patients with papillary intraductal tumor because it can easily grow into a metallic stent and result 801
50D
Cancer of the bile ducts: interventional techniques in hilar and intrahepatic biliary structures Karen T. Brown OVERVIEW Malignant disease resulting in high bile duct obstruction (Fig. 50D.1)—that is, obstruction above the junction with the cystic duct—is not uncommon. Although frequently related to primary tumors of the biliary tree (see Chapters 49, 50A, and 50B), hilar obstruction, and even intraductal tumor, can be seen with other common malignancies such as breast, pancreatic, and colorectal cancers. Significant technical progress has occurred in both endoscopic and percutaneous biliary drainage, allowing safer palliative treatment of patients with such obstructions. Because these patients are often asymptomatic at presentation, the goals of treatment should be clearly defined prior to committing the patient to even a minimally invasive procedure. First and foremost, whether the patient is a surgical candidate should be determined. With the exception of patients who are clearly in a palliative situation, we prefer to discuss these patients in a multidisciplinary group with hepatobiliary surgeons, interventional radiologists, oncologists, and gastroenterologists to outline a plan of treatment. A thorough understanding of this plan and of the patient’s prognosis facilitates the development of a strategy for drainage. Accepted indications for palliative biliary drainage in these patients include intractable pruritus, cholangitis, the need to restore liver function to allow for administration of chemotherapeutic agents with biliary metabolism/excretion, access for intraluminal brachytherapy or choledochoscopy, and diversion for bile leak. Given the availability of high-quality magnetic resonance cholangiopancreatography (MRCP), direct cholangiography as a diagnostic tool is rarely warranted (see Chapters 17 and 18; Choi et al, 2008; Park et al, 2008).
INDICATIONS FOR BILIARY DRAINAGE Neither hyperbilirubinemia alone nor the computed tomographic (CT) or ultrasound finding of dilated bile ducts is an indication for biliary drainage. Pruritus, cholangitis, and the need to lower the bilirubin to administer certain chemotherapeutic agents, on the other hand, are all accepted indications for biliary drainage. Patients who have undergone biliary-enteric bypass as part of curative resection for a benign or malignant lesion may develop postoperative bile leaks that require drainage for diversion. In some cases, access to the biliary tree may be undertaken as a method of delivering local treatment for primary bile duct cancer, such as brachytherapy or photodynamic therapy. Many physicians have the impression that patients feel better and have improved performance status after relief of jaundice; however, this has not been confirmed in clinical studies. Indeed, in a prospective trial, we have shown that in patients
with malignant biliary obstruction, percutaneous drainage does not significantly improve quality of life (QOL), except for improving pruritus (Robson et al, 2007). Controversy remains in regard to the role of biliary drainage prior to surgery (Johnson & Ahrendt, 2006; Mezhir et al, 2009; Wang et al, 2008).
ENDOSCOPIC VERSUS PERCUTANEOUS DRAINAGE (SEE CHAPTERS 18, 27, AND 28) Patients with low bile duct obstruction are typically treated endoscopically. Patients with high bile duct obstruction, particularly when the obstruction extends above the hilus, have traditionally been treated percutaneously. This is because the success rate of percutaneous drainage has been higher, and the complication rate lower, when compared with endoscopic methods (Rerknimitr et al, 2004). This perspective is evolving as endoscope technology becomes more advanced, and endoscopists become better trained and more experienced in wireguided procedures and have better guidewires and stents with which to work. The two biggest drawbacks to endoscopic drainage for high bile duct obstruction have been the lack of ability to reliably target a specific area of the liver for drainage and the risk of contamination, by retrograde injection of contrast, of parts of the biliary tree that will not be drained. It is not uncommon to see a patient who is thought to have undergone successful endoscopic stenting of the right and left liver only to find, upon repeat imaging, that is not the case at all (Fig. 50D.2). Despite this, endoscopic management is indicated in some cases of high bile duct obstruction. This is particularly so when the risk of the patient having a permanent exteriorized catheter is high or when a patient has a higher risk of contaminating the entire biliary tree if approached percutaneously. One exciting new endoscopic approach is the placement of a transgastric segment III stent using endoscopic ultrasound. This procedure is considered when a patient is best treated by draining the left lateral segment, and the percutaneous approach is technically difficult, or where the risk of contaminating the right-sided bile ducts is thought to be high with or without being able to cross the obstruction. This is particulary indicated when draining the right liver would be of no clinical benefit, either because of replacement of right liver by tumor or occlusion of the right portal vein (Fig. 50D.3). When technically feasible, this procedure can be gratifying for the patient, with relief of pruritus and lowering of bilirubin without the added burden of a percutaneous catheter. Endoscopic drainage is almost never indicated in patients with papillary intraductal tumor because it can easily grow into a metallic stent and result 801