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Major hepatic resection for extrahepatic cholangiocarcinoma: Analysis of 38 patients
146A
AASLD ABSTRACTS
157 MAJOR HEPATIC RESECTION FOR EXTRAHEPATIC C H O L A N G I O C A R C I N O M A : ANALYSIS OF 38 PATIENTS. M Munoz-Juarez. MB FarnelL JH Donohue. D M Ilsa'uo*. D M Naeornev. Department of Surgery and Department of Health Sciences Research*, Mayo Clinic and Foundation, Rochester, M N The prognosis of patients with proximal extrabepatic eholangiocarcinoma (PEC) without curative intervention is poor. Although potentially curative resection of PEC by major hepatectomy, supradu,xtenal bile duct resection, regional lymphadenectemy; and Roux-Y hepaticojejunostomy is feasible in selected patients, limited data on this approach have precluded wide acceptance. Aim: To determine the relationship of clinicopathologic finding s to outcome, the records of 38 consecutive patients who underwent major hepatic resection for PEC between 1975 and 1994 were reviewed. Results: Twenty were m e n (53%) and eighteen women (47%) with a mean age of 59.8 years. Nineteen patients presented with Bismuth -Corlette type Rib lesions, twelve had type IIIa, and seven had type. l-I lesions. The latter group required bepatectomy due to involvement of hilar vascular structures or direct parenehymal extension. Excision with tumor free margins was possible in 76% of these patients. Operative mortality was 8% (3 patients). The median survival was 25 months with an overall five-year survival o f 17.6%. By univariate analysis, tumor length (P
159 TOLERANCE OF NORMOTHERMIC ISCHEMIA IN HEPATIC RESECTIONS IN CIRRHOSIS. E X P E R I M E N T A L STUDY. J.Figueras, L.Farran, F.G.Borobia, R.Fradera, J.Castellvi,C. Lama, Y.Ribas, E.Janrrieta. C.S.U. Bellvitge. University Barcelona. Spain. Hepatic resections with vascular occlusion are used frequently in the treatment of helmtocareinoma. The aim of this study is to evaluate the limits of normothermic liver ischaemia in different degrees of liver function in the rat. Hepatic cirrhosis was induced in male Wistar rats with Carbon tetraclorare. Hepatic function was graded determining ATIII, albumin, bilirubin in plasma and the presence of ascites. Rats were divide in four different groups, using the modified Child-Pough score: Group Control (non cirrhotic), Group A w e l l compensated cirrhosis, Group B decompensated cirrhosis, Group C decompensated cirrhosis with ascites. All groups were different between them p < 0 . 0 5 . Liver ischaemia was performed using the model of ASAKAWA for periods of 0, 30, 45, 60 and 75 minutes. At the end of procedure the non ischaemic lobes were resected. Survival for the different times of ischaemia is shown in the table 0 min
30 min
Ctr n = 2 3 A n=14 B n=21
7/7 100
5/7 71
45 min
60 min
75min
7/7 100
7/7 100
4/9 44
7/7 100
1/7 14
1/7 14
C n=12 0/5 0 1/7 14 Conclusions: The ischa me tolerated for cirrhot wers ~s shorter than in normal rats. The limits of hilar vascular occlusion depends on the degree of hepatic failure. Decompensated cirrhosis with ascites cannot tolerate any surgical procedure in the liver.
158
HEPATOLOGY O c t o b e r 1995
TRENDS IN BILIARY TRACT INJURIES FROM LAPAROSCOPIC CHOLECYSTECTOMY. RM Walsh, JM Henderson, DP Vogt, JT Mayes, S Grundfest-Broniatowksi, and RE Hermann. The Cleveland Clinic Foundation, Department of General Surgery, Cleveland, Ohio.
Biliary tract injuries (BTI) which occur with laparoscopic cholecystectomy (LC) are associated with major morbidity and are partially related to the level of operative experience. A retrospective, four year review of pts. referred to the Cleveland Clinic with BTI following LC was undertaken to study the spectrum of injuries, presentation, and outcome over time. A total of 50 pts. have been treated with a mean age of 47 yrs. The number of referrals has not reduced over time. Nine, 17, 10, and 14 pts. were treated each year 1991-1994, respectively. The incidence has not changed despite a relative increase in operative cho!angiograms, from 29% to 67%. Intre-operative diagnosis of a bile duct injury was made in 15 (30%), and in the remainder the median time to diagnosis was 5 days. Twenty-eight pts. (56%) had been re-operated prior to referral; 22 having undergone an attempt at ductal repair. The mean time to referral was 5.5 weeks if no repair had been attempted versus 20 weeks following a failed repair. Presentation at the time of referral has been constant; 20 (40%) bile leak, 20 (40%} obstruction, 8 {16%} combined obstruction and leak, 2 (4%) fistula. The type of injury has remained similar with 15 (30%) having cystic duct leaks, and 34 (68%) with Bismuth Levels II, III, or IV. A total of 19 (38%) were definitively treated nonoperatively with biliary stents. Of the 31 operated pts., 22 underwent a biliary-enteric bypass; Patients have been followed an average of 21.4 months. Twelve {24%} have sustained complications including 3 post-operative strictures, 3 persistent cystic duct or anastomotic leaks, and 2 with intermittent cholangitis. In conclusion, the referral of BTI following LC has not abated over time despite increased utilization of cholangiography. The type of injuries and presentation have not changed with presumed increased surgical experience. Complications remain frequent but may be altered by earlier pt. referral.
160 CONVERSION OF FAILED TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPS) TO DISTAL SPLENORENAL SHUNT (DSRS) IN CHILDS A/B CIRRHOTICS. GD Branum, MJ Fendlev. TD Borer. JG Galloway: Departments of Surgery and Medicine, Emory University School of Medicine, Atlanta, GA. TIPS is widely used as a bridge to transplantation in patients with uncontrollableor sclerotherapy-resistantesophageal hemorrhage and poor liver function. TIPS also is performed in patients with intact synthetic function in whom the need for liver transplantation is not anticipated in the immediatefuture. This latter group ofpatiants are good candidates for DSRS. In the past 18 months three patients with good liver function have been converted from TIPS to DSRS because of TIPS failure and/or complication. Materials: The records of three patients, two with EtOH cirrhosis and one with cryptogenic cirrhosis, were reviewed. Two patients were ChildsTurcotte Class A, while one was Class B. All had galactose elimination capacities (GEC) of over 450 rag/rain. All three patients had TIPS placed for uncontrolled (1) or scleretherapy resistance (2) varieeal hemorrhage. In all 3 the TIPS stenosed l to 8 months after placement with recurrent variceal hemorrhagerequiring TIPS revision or dilatation. One patient suffered stent migration to the superior mesenterie vein that was removedat the time of DSRS. DSRS was performed without difficulty and patients were discharged after normal post-DSRS arteriogram/venogram demonstratingno pressure gradient across the shunts at 8, 8 and 16 days post-operatively. None of the patients has had recurrent hemorrhage in 6, 10 and 18 months post-operatively. Summary: DSRS can be performed safely in patients followingTIPS if they have good hepatic function, Conclusions: (1) In patients with Childs A/B cirrhosis TIPS failure can be salvaged by DSRS. (2) Poor control ofvarieeal bleeding by TIPS in patients with good liver function is as an indication for DSRS and for transplantation.
AASLD ABSTRACTS
157 MAJOR HEPATIC RESECTION FOR EXTRAHEPATIC C H O L A N G I O C A R C I N O M A : ANALYSIS OF 38 PATIENTS. M Munoz-Juarez. MB FarnelL JH Donohue. D M Ilsa'uo*. D M Naeornev. Department of Surgery and Department of Health Sciences Research*, Mayo Clinic and Foundation, Rochester, M N The prognosis of patients with proximal extrabepatic eholangiocarcinoma (PEC) without curative intervention is poor. Although potentially curative resection of PEC by major hepatectomy, supradu,xtenal bile duct resection, regional lymphadenectemy; and Roux-Y hepaticojejunostomy is feasible in selected patients, limited data on this approach have precluded wide acceptance. Aim: To determine the relationship of clinicopathologic finding s to outcome, the records of 38 consecutive patients who underwent major hepatic resection for PEC between 1975 and 1994 were reviewed. Results: Twenty were m e n (53%) and eighteen women (47%) with a mean age of 59.8 years. Nineteen patients presented with Bismuth -Corlette type Rib lesions, twelve had type IIIa, and seven had type. l-I lesions. The latter group required bepatectomy due to involvement of hilar vascular structures or direct parenehymal extension. Excision with tumor free margins was possible in 76% of these patients. Operative mortality was 8% (3 patients). The median survival was 25 months with an overall five-year survival o f 17.6%. By univariate analysis, tumor length (P
159 TOLERANCE OF NORMOTHERMIC ISCHEMIA IN HEPATIC RESECTIONS IN CIRRHOSIS. E X P E R I M E N T A L STUDY. J.Figueras, L.Farran, F.G.Borobia, R.Fradera, J.Castellvi,C. Lama, Y.Ribas, E.Janrrieta. C.S.U. Bellvitge. University Barcelona. Spain. Hepatic resections with vascular occlusion are used frequently in the treatment of helmtocareinoma. The aim of this study is to evaluate the limits of normothermic liver ischaemia in different degrees of liver function in the rat. Hepatic cirrhosis was induced in male Wistar rats with Carbon tetraclorare. Hepatic function was graded determining ATIII, albumin, bilirubin in plasma and the presence of ascites. Rats were divide in four different groups, using the modified Child-Pough score: Group Control (non cirrhotic), Group A w e l l compensated cirrhosis, Group B decompensated cirrhosis, Group C decompensated cirrhosis with ascites. All groups were different between them p < 0 . 0 5 . Liver ischaemia was performed using the model of ASAKAWA for periods of 0, 30, 45, 60 and 75 minutes. At the end of procedure the non ischaemic lobes were resected. Survival for the different times of ischaemia is shown in the table 0 min
30 min
Ctr n = 2 3 A n=14 B n=21
7/7 100
5/7 71
45 min
60 min
75min
7/7 100
7/7 100
4/9 44
7/7 100
1/7 14
1/7 14
C n=12 0/5 0 1/7 14 Conclusions: The ischa me tolerated for cirrhot wers ~s shorter than in normal rats. The limits of hilar vascular occlusion depends on the degree of hepatic failure. Decompensated cirrhosis with ascites cannot tolerate any surgical procedure in the liver.
158
HEPATOLOGY O c t o b e r 1995
TRENDS IN BILIARY TRACT INJURIES FROM LAPAROSCOPIC CHOLECYSTECTOMY. RM Walsh, JM Henderson, DP Vogt, JT Mayes, S Grundfest-Broniatowksi, and RE Hermann. The Cleveland Clinic Foundation, Department of General Surgery, Cleveland, Ohio.
Biliary tract injuries (BTI) which occur with laparoscopic cholecystectomy (LC) are associated with major morbidity and are partially related to the level of operative experience. A retrospective, four year review of pts. referred to the Cleveland Clinic with BTI following LC was undertaken to study the spectrum of injuries, presentation, and outcome over time. A total of 50 pts. have been treated with a mean age of 47 yrs. The number of referrals has not reduced over time. Nine, 17, 10, and 14 pts. were treated each year 1991-1994, respectively. The incidence has not changed despite a relative increase in operative cho!angiograms, from 29% to 67%. Intre-operative diagnosis of a bile duct injury was made in 15 (30%), and in the remainder the median time to diagnosis was 5 days. Twenty-eight pts. (56%) had been re-operated prior to referral; 22 having undergone an attempt at ductal repair. The mean time to referral was 5.5 weeks if no repair had been attempted versus 20 weeks following a failed repair. Presentation at the time of referral has been constant; 20 (40%) bile leak, 20 (40%} obstruction, 8 {16%} combined obstruction and leak, 2 (4%) fistula. The type of injury has remained similar with 15 (30%) having cystic duct leaks, and 34 (68%) with Bismuth Levels II, III, or IV. A total of 19 (38%) were definitively treated nonoperatively with biliary stents. Of the 31 operated pts., 22 underwent a biliary-enteric bypass; Patients have been followed an average of 21.4 months. Twelve {24%} have sustained complications including 3 post-operative strictures, 3 persistent cystic duct or anastomotic leaks, and 2 with intermittent cholangitis. In conclusion, the referral of BTI following LC has not abated over time despite increased utilization of cholangiography. The type of injuries and presentation have not changed with presumed increased surgical experience. Complications remain frequent but may be altered by earlier pt. referral.
160 CONVERSION OF FAILED TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPS) TO DISTAL SPLENORENAL SHUNT (DSRS) IN CHILDS A/B CIRRHOTICS. GD Branum, MJ Fendlev. TD Borer. JG Galloway: Departments of Surgery and Medicine, Emory University School of Medicine, Atlanta, GA. TIPS is widely used as a bridge to transplantation in patients with uncontrollableor sclerotherapy-resistantesophageal hemorrhage and poor liver function. TIPS also is performed in patients with intact synthetic function in whom the need for liver transplantation is not anticipated in the immediatefuture. This latter group ofpatiants are good candidates for DSRS. In the past 18 months three patients with good liver function have been converted from TIPS to DSRS because of TIPS failure and/or complication. Materials: The records of three patients, two with EtOH cirrhosis and one with cryptogenic cirrhosis, were reviewed. Two patients were ChildsTurcotte Class A, while one was Class B. All had galactose elimination capacities (GEC) of over 450 rag/rain. All three patients had TIPS placed for uncontrolled (1) or scleretherapy resistance (2) varieeal hemorrhage. In all 3 the TIPS stenosed l to 8 months after placement with recurrent variceal hemorrhagerequiring TIPS revision or dilatation. One patient suffered stent migration to the superior mesenterie vein that was removedat the time of DSRS. DSRS was performed without difficulty and patients were discharged after normal post-DSRS arteriogram/venogram demonstratingno pressure gradient across the shunts at 8, 8 and 16 days post-operatively. None of the patients has had recurrent hemorrhage in 6, 10 and 18 months post-operatively. Summary: DSRS can be performed safely in patients followingTIPS if they have good hepatic function, Conclusions: (1) In patients with Childs A/B cirrhosis TIPS failure can be salvaged by DSRS. (2) Poor control ofvarieeal bleeding by TIPS in patients with good liver function is as an indication for DSRS and for transplantation.