Resection of Hepatic Duct Bifurcation and Transhepatic Stenting for Sclerosing Cholangitis

Abstract

Thirty-one patients with sclerosing cholangitis underwent reconstruction of their hepatic duct bifurcation and long-term stenting between 1980 and 1987. Indications for surgery were persistent jaundice in 29 and recurrent cholangitis in two. The mean serum bilirubin level before surgery was 10.4 mg/dl. Liver biopsy revealed that 26 patients had varying degrees of hepatic fibrosis, and five patients had progressed to secondary biliary cirrhosis. In 29 patients the major obstructive duct disease was at or near the hepatic duct bifurcation, and in two patients it was in the distal common duct. The operative procedure consisted of: (1) excision of the hepatic duct bifurcation and extrahepatic biliary tree, (2) dilatation of the intrahepatic ducts, (3) insertion of Silastic transhepatic biliary stents, and (4) bilateral hepaticojejunostomies. Two of the five patients (40%) with cirrhosis died after surgery. In contrast, only one of 26 patients (3.9%) with hepatic fibrosis died after operation. The 1-, 3-, and 5-year actuarial survival rates for patients with cirrhosis were 20%, 20%, and 20%, respectively. The only long-term survivor underwent a liver transplant. The 1-, 3-, and 5-year actuarial survival rates for patients with hepatic fibrosis were 92%, 87%, and 71%, respectively. In addition, the mean serum bilirubin levels of patients with hepatic fibrosis at 1, 2, 3, 4, and 5 years were 3.4 mg/dl, 2.9 mg/dl, 4.0 mg/dl, 5.4 mg/dl, and 4.3 mg/dl, respectively. Two of the long-term survivors subsequently underwent a liver transplant. Patients with sclerosing cholangitis, persistent jaundice, and biliary cirrhosis should be referred for consideration of liver transplantation. However, in the absence of biliary cirrhosis, if the major obstructive disease is at the hepatic duct bifurcation, primary biliary reconstruction and long-term stenting should be considered.

Primary sclerosing cholangitis

“…29,35,36 In particular, those patients with cirrhotic-stage PSC can experience considerable mortality 37,38 and a shorter survival than noncirrhotic patients undergoing biliary surgery. 28 Therefore, biliary surgery in patients with PSC, other than simple cholecystectomy, should be minimized and reserved for selected noncirrhotic patients who have marked cholestasis or recurrent cholangitis caused by a dominant extrahepatic or hilar stricture not amenable to endoscopic or percutaneous dilatation.…”

Primary Sclerosing Cholangitis

“…Diverticular outpouchings of the common bile duct, once considered diagnostic of the disorder, are seen in 25% of patients with PSC [124]. In a more recent report by Cameron et al, 24/36 patients with PSC had extensive involvement of the bifurcation making endoscopic treatment more challenging as well as creating considerable confusion regarding the possibility of cholangiocarcinoma [125].…”

“…With the advent of cyanoacrylate ("glue") for fundal varices and transjugular intrahepatic portosystemic shunts, it is uncommon for patients to require surgical decompression. Some reports have suggested that if patients have had previous biliary surgery, future liver transplantation was compromised [125]. Two recent reports have suggested the contrary, that previous biliary surgery was not associated with a decreased survival after liver transplantation [194,195].…”

The Changing Role of Surgery for Sclerosing Cholangitis

“…In a more recent study, Cameron et al [28] evaluated the results of primary biliary recon struction and long-term stenting in 31 pa tients with PSC. The majority of patients had a dominant stricture at or near the hepatic duct bifurcation.…”

“…This is especially true in PSC patients without biliary cirrhosis. In this sub set of patients, successful biliary drainage is associated with 5-year survival rates of 70-100% [28,30], Techniques now exist to estab lish effective and durable biliary enteric drainage thus avoiding the need for transanastomotic stents that predispose to recurrent cholangitis and require repeated tube changes.…”