Nicholas S. Hadjis

Clinicopathological aspects of high bile duct cancer. Experience with resection and bypass surgical treatments.

This report reviews the experience of the Hepatobiliary Unit, Royal Postgraduate Medical School, Hammersmith Hospital, London with 16 patients having proximal extrahepatic bile duct malignancy who underwent resection and a comparable group of 15 patients who had surgical bypass. The purposes of the review were to evaluate morbidity and mortality in both treatment groups, to assess whether either treatment influenced the natural history of the disease, and to examine the pathological features of the resected lesions, attempting to correlate the macroscopic and microscopic features with radiological and surgical observations and survival. The presenting symptoms, average age, clinical data, and length of hospital stay were similar in both groups. Hospital mortality, despite 12 major liver resections, was less in the resectional than in the bypass group--19% versus 26%. The average survival for resectional patients was 16.5 months with six of the 13 patients who left hospital still alive, one at 5 years. The bypass patients lived an average of 7 months with no patients surviving beyond 11 months. Both resectional and bypass treatments appeared to influence survival in this disease with greater length and quality of survival being associated with resection. While there were a number of distinctive pathological features associated with the resected tumors, none correlated with survival.

Liver atrophy complicating benign bile duct strictures. Surgical and interventional radiologic approaches.

The hepatic atrophy and hypertrophy complex has been described in a selected group of nine patients with benign bile duct stricture. The clinical features common to this group were a high biliary stricture and a long-standing history of cholangitis and intermittent jaundice. A history of multiple surgical procedures and associated vascular damage or portal hypertension is strongly suggestive of the atrophy and hypertrophy complex. The radiologic criteria for the diagnosis of this condition are presented. Computerized tomography and HIDA scintigraphy were valuable as noninvasive means to diagnose lobar liver atrophy. The atrophy and hypertrophy complex described herein poses significant therapeutic problems and demands approaches other than those normally applicable for high biliary strictures. A combined surgical and radiologic approach with additional interventional radiologic procedures may be appropriate in patients in whom hilar anastomosis is difficult or impossible.

Nonoperative approach to hilar cancer determined by the atrophy-hypertrophy complex

Twenty-seven of 135 patients with malignant hilar stricture who had associated liver atrophy or hypertrophy or both were treated by the percutaneous insertion of an endoprosthesis in the hypertrophied lobe only. The procedure was successful in 25 patients. Three patients died within 30 days of drainage. Procedure-related nonfatal complications occurred in seven patients. Effective decompression was accomplished in 21 patients, with complete relief of jaundice in 15. Late complications were experienced by 10 patients. The median total hospital stay was 22 days. Thirteen patients survived from 6 weeks to 12 months (median 5 months), 8 were alive from 3 to 18 months (median 8 months), and 1 patient was lost to follow-up. On the available evidence, we suggest that the preoperative demonstration of the atrophy-hypertrophy complex in jaundiced patients with irresectable hilar cancer is an indication for nonoperative therapy. Patients without the atrophy-hypertrophy complex and those with the complex but associated nonneoplastic disease are likely to fare better with surgical decompression and direct mucosa-to-mucosa anastomosis.

Percutaneous transhepatic endoprostheses for hilar cholangiocarcinoma

In patients with unresectable hilar cholangiocarcinoma, percutaneous transhepatic endoprosthesis insertion is one of the available methods of palliation. We reviewed our experience with it in 35 consecutive patients with hilar cholangiocarcinoma who were judged on clinical or radiologic evidence to be unsuitable for resective or palliative surgery. The 30-day mortality rate was 14 percent (5 of 35 patients). Of the remaining 30 patients, endoprosthesis placement was successful in 28, with 2 patients discharged with a permanent external drainage catheter. Twenty-four patients survived a median of 3 months (range 1 to 17 months), and 2 were lost to follow-up. Good or fair palliation of symptoms was achieved in 50 percent of the discharged patients and in 66 percent of those living longer than 3 months. We believe that percutaneous transhepatic endoprostheses can provide useful palliation in patients with hilar cholangiocarcinoma, even in the presence of advanced disease.

Primary sclerosing cholangitis associated with liver atrophy

Of 27 patients with primary sclerosing cholangitis, 4 were found on investigation and subsequently at operation to have gross lobar atrophy. The disease was particularly severe in the hilar region. Three of the four patients were asymptomatic prior to the onset of jaundice. The presence of atrophy precipitated laparotomy to exclude cancer in two cases. Marked disparity in size between liver lobes precluded a hilar approach to relieve extrahepatic obstruction in two patients. Prolonged follow-up excluded coincident malignant disease. Selective liver atrophy should be considered part of the disease spectrum in primary sclerosing cholangitis.

Mirizzi syndrome associated with liver atrophy Diagnostic and management considerations

It is not often appreciated that the Mirizzi syndrome represents a spectrum of pathological lesions of the proximal extrahepatic biliary tree consequent on chronic gallbladder disease. A patient with this syndrome and associated liver atrophy is presented, emphasising the view that the syndrome has neither uniform appearance nor typical features and that a high index of suspicion and comprehensive investigations are required for diagnosis and optimal therapy.

Anicteric Presentation of Hilar Cholangiocarcinoma: Anatomical and Pathological Considerations

Anicteric presentation was noted in 2 of 116 cases of hilar cholangiocarcinoma. Another 2 patients, although initially icteric, lost their jaundice spontaneously. In 3 of these 4 patients, more than 7

Clinical Spectrum and Diagnostic Strategies in Non-Calculous Lower Bile Duct Obstruction

The clinical spectrum and the diagnostic strategies in 99 patients with non-calculous distal common bile duct (CBD) obstruction seen over a period of 5 years have been studied. A benign stricture was