The Anatomical Basis for Segment Iii Cholangiojejunostomy With Analysis of 13 Cases

Abstract

Background:The majority of patients who require palliation for jaundice and pruritus resulting from malignant hilar obstruction are treated by stenting. Stenting is usually achieved from below after performing an endoscopic retrograde cholangiopancreatography. In some cases the rendezvous technique is employed, negotiating the passage through a malignant stricture from above and stenting from below. A minority of cases, such as those who had a previous polyagastrectomy and those in whom attempts at stenting have failed, are considered to be suitable for a Segment 111 cholangiojejunostomy. We have investigated the anatomical basis for Segment 111 duct bypass and have critically analysed the results in 13 patients. Ten patients were treated by Segment 111 duct bypass alone, and three patients had a Segment 111 duct bypass combined with stenting of the right liver. Methods: The anatomy of the biliary tree was investigated by dissection of 54 normal livers removed at autopsy. Clinical details of the 13 patients who had Section 111 cholangiojejunostomy were obtained from hospital records and by contacting treating practitioners. Results: In 64.8% of the anatomical dissections, the findings were favourable for a Section I11 cholangiojejunostomy. In these specimens the Segment 111 duct bypass would have drained Segments 11,111 and IV. In 35.2% of the specimens the anatomical disposition was potentially unfavourable, mainly due to the Segment I1 or IV ducts joining close to the confluence and therefore liable to obstruction by the tumour. In nine of the 54 specimens the true left hepatic duct was less than 6 mm in length, making it unsuitable for a bypass procedure to drain the left hemi liver. Of the 10 patients who were subjected to a palliative Section 111 cholangiojejunostomy only, there was one postoperative death. Of the nine patients who survived, six obtained excellent palliation of jaundice and pruritus. Conclusions: In carefully selected cases, Section III cholangiojejunostomy achieves excellent palliation in patients with unresectable hilar malignancies that have been unable to be stented pre-operatively or who have unresectable tumours at the time of laparotomy .

Surgical palliation for unresectable hilar cholangiocarcinoma

“…The left hepatic duct is extrahepatic in its course and is contained within a peritoneal extension that includes the left portal vein and hepatic artery [14]. It has a mean length of 1.3 cm [15], but in 17% of cases it is 56 mm [16], making it susceptible to tumour involvement in the presence of a hilar lesion. The length of the left hepatic duct is proportional to the length of the base of segment IV [14].…”

“…The length of the left hepatic duct is proportional to the length of the base of segment IV [14]. The commonest of the described variations occurs in 78-85% of cases when segments II and III join in the umbilical sulcus and segment IV drains at a variable point between this and the confluence of the left and right hepatic ducts [16,17]. In this transverse segment it is always superior to the portal vein and if there is late union of the left hepatic duct, the segment II duct tends to lie posterosuperiorly and the segment III/IV duct anterosuperiorly before uniting just before the hilum [17].…”

“…It has a mean length of 1.3 cm [15], but in 17% of cases it is 56 mm [16], making it susceptible to tumour involvement in the presence of a hilar lesion. In 10-15% of cases the left hepatic duct is duplicated whereby segment III and IV join initially and then converge with segment II at a variable point before the main confluence [16,17]. Having traversed the base of segment IV the triad of structures reaches the umbilical fissure where vessels divide into segmental branches II, III and IV, with the equivalent segmental duct tributaries converging to form the left hepatic duct.…”

“…It may be bridged by a band of liver tissue which joins segments III and IV. Classically the bile ducts are related intimately to the umbilical plate [16] and are the first structures encountered with an anterior approach to the ligamentum. Classically the bile ducts are related intimately to the umbilical plate [16] and are the first structures encountered with an anterior approach to the ligamentum.…”

“…Classically the bile ducts are related intimately to the umbilical plate [16] and are the first structures encountered with an anterior approach to the ligamentum. The main segment III duct runs adjacent to the left border of ligamentum teres [16] into the umbilical sulcus where it joins with the segment II duct. The segment III duct is formed from an anteroinferior and posterosuperior duct.…”