Resection of Hepatic Duct Bifurcation Tumor (Klatskin)

Cholangiocarcinomas arising at or near the bifurcation of the common hepatic duct, commonly referred to as Klatskin tumors, are being diagnosed earlier and treated more promptly by palliative or curative surgical procedures. The majority of patients exhibit jaundice of increasing intensity and many have had recent biliary exploration, where the diagnosis was suggested by operative cholangiography. There is a wide patient age range and occasionally a preceding history of ulcerative colitis or sclerosing cholangitis. Although the number who can be cured may be limited, many patients are benefited by palliative procedures.

The seriousness of the lesion, the difficulty in determining the extent of involvement, and the necessity for avoiding infection from the required preoperative studies in an obstructed jaundiced patient requires meticulous preoperative evaluation. Early endoscopy of the common duct and consultation with an expert in interventional radiology are essential. The jaundiced patient should undergo transcutaneous transhepatic cholangiography with bile cultures taken and appropriate antibiotics given. These diagnostic procedures are usually performed by an interventional radiologist familiar with the technic. Following cholangiography, ring catheters may be placed bilaterally, directed if possible through the obstructing lesion into the duodenum with palliation of the jaundice (Figure 1). If there is cholangiographic evidence of tumor extending into the right or left hepatic ducts, the patient may eventually be explored to relieve the obstruction on the side of the involved duct. Palliation, however is usually possible with internal drainage into the duodenum through the ring catheters. The catheters also serve as invaluable technical aids to the surgeon at the time of laparotomy.

Hepatic arteriography or special imaging scans are also helpful in showing any occlusion of the hepatic artery as well as possible encasement of the main portal vein, either of which contraindicates a surgical attempt at resection of the tumor. About 20 percent of patients will show a stage of tumor involvement that makes attempts at surgical excision impossible.

Appropriate antibiotic therapy, intravenous alimentation, and vitamin K are given, and blood volume deficits are corrected.

The deeply jaundiced patient should be considered a poor surgical risk meriting special consideration by the anesthesiologist in planning the anesthesia.

The patient is placed on the table in a slightly reversed Trendelenburg position. Intravenous catheters should be placed in both arms. Catheter drainage of the bladder may be advisable as well as nasogastric suction.

The skin of the lower chest and upper abdomen as well as the right flank should be prepared.

Either a liberal bilateral subcostal incision with a midline extension to the xiphoid or a midline incision from over the xiphoid to below the umbilicus is made.

Bimanual palpation of the liver is carried out in a search for possible metastases. Despite the history of deep jaundice, the gallbladder and common duct appear normal. Metastases to regional lymph nodes or liver are unusual, but any enlarged lymph nodes are excised for immediate frozen section examination. The tumor tends to be well hidden and careful palpation of the previously placed ring catheters is performed up into the hilus of the liver until the tumor is localized. The distortion of the ring catheters is helpful in localizing the area of tumor involvement.

Before proceeding with the tumor excision, some prefer to divide the falciform ligament and ligate both ends with a transfixing suture. This procedure may enhance the exposure (Figure 2). If a hepatic bridge or plate is present, it is divided. The exposure of the tumor area is further improved by dividing and ligating the cystic duct followed by enucleation of the gallbladder from the liver bed.

A Kelly hemostat is applied to the fundus of the attached gallbladder to be used for improved traction of the common duct. The duodenum is thoroughly mobilized by the Kocher maneuver and the common duct dissected free as far downward as possible.

The anterior wall of the lower most portion of the common duct is opened and the ends of the ring catheters brought out (Figure 3). The common duct is divided and the lower end is oversewn.

The gallbladder and end of the common duct are reflected upward to expose the posterior aspects of the region of the tumor (Figure 4). This is the most delicate portion of the procedure. Very gently the adhesions above the posterior aspects of the tumor and adjacent structures, such as branches of the hepatic artery, must be gently determined and divided. Likewise the portal vein is very close as well as the caudate lobe of the liver. Involvement of the caudate lobe of the liver with tumor may be overlooked with prompt recurrences of the tumor. The possibility of removing the caudate lobe should be considered if there is suspicion of tumor involvement.

All bleeding is controlled by metal clips or ligature. The lower small hepatic vein going to the caudate lobe may be ligated.

The tissue about the left hepatic duct is carefully divided to provide sufficient exposure of the left duct for a right-angle clamp to be carefully inserted under the duct to permit the placement of a blood vessel loop for possible traction (Figure 5). The duct should be palpated for possible tumor involvement.

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The right duct is freed up a short distance and a blood vessel loop passed around it for traction (Figure 6). If the tumor has involved the wall of either major duct with probable extension into the liver, the need for added lobectomy must be seriously considered. Occasionally, a third large duct, or even more, may be found on the right side, which must be conserved for implantation. Traction sutures are placed in the major ducts at the point of division for each duct (Figure 7).

The two ducts of the specimen should be marked with different colored sutures for specific identification by the pathologist of possible infiltration of tumor at the point of division. Should this be found on frozen section study, more duct must be resected.

The Silastic transhepatic biliary stents are positioned using a Coudé catheter as a preceding dilator that is drawn up the ducts and through the liver by the ring catheters. First, the ring catheters with the guide wires inside are brought out the open left and right hepatic ducts. Each curled (ring) end is cut off and the remaining straight ring catheter is placed into the cut leading end of a No. 16 French Coudé catheter. Each ring catheter is then secured with a mattress suture through itself and the Coudé. Both catheters are pulled up into the ducts (Figure 8) using traction on the ring catheter at the surface of the liver. The Coudé catheters may need to be manipulated back and forth so as to dilate the ductal systems.

A No. 14 French Silastic transhepatic biliary stent is positioned in the open end of the No. 16 Coudé French catheter and anchored with mattress sutures of silk which are passed through the wall of the Coudé catheter. With traction on the Coudé catheters the Silastic stents with multiple holes are drawn into the liver in a position with no holes beyond the exit of the plastic tubes (Figure 9). Thus, there are holes present within the liver and the portion that projects into the Roux-en-Y of the jejunum. Short horizontal mattress sutures of absorbable material are placed around the stents on the surface of the liver at their point of exit. The liver is compressed without disruption about each catheter.

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A Roux-en-Y loop of upper jejunum is brought into the right upper quadrant through an avascular area of the mesocolon and anterior to the second and third portions of the duodenum. The opening in the mesocolon is closed about the jejunum and its mesentery after making certain the end of the Roux-en-Y extends up to and slightly beyond the hepatic duct openings. The end of the jejunum is closed with staples or in layers of running or interrupted sutures. The posterior wall of the jejunum in the region of the anastomosis should be anchored to the capsule of the liver or adjacent tissue.

It is helpful to insert interrupted sutures through the lateral angles of each open duct for positioning and sizing an accurate anastomosis on the jejunum (Figure 10). A posterior row of sutures is placed using the full thickness of each duct. None of these sutures is tied until all posterior sutures are in place for each duct. The middle suture in the posterior row may also be used to tie about the stent, so as to help prevent migration of this tube.

The knot of the back suture line will be on the inside. The sutures are cut at the knot, except for the suture at each angle. A small incision parallel to the posterior suture line is made in the jejunum (Figure 11).

The ends of the Silastic biliary stents are gently introduced into the lumen of the jejunum (Figure 12). Anterior, full-thickness suture lines are closed on both ducts (Figures 13 and 14). Last, the jejunum is anchored to the adjacent liver. Regional closed-system Silastic suction catheters are placed and the Silastic transhepatic stents are doubly sutured to the skin with 5-0 nylon (Figure 15). The abdomen is closed in a routine manner and the stents are connected to a sterile plastic bag to allow drainage by gravity.

The closed system Silastic sump drains are removed after 5 or 6 days unless there is a significant bile output or a leak is shown on cholangiography. If no leaks are found from the superior surface of the liver or the anastomosis, three-way stopcocks are attached to the end of the catheters. The patients are trained to self-administer injections of sterile saline into the stents three times per day. Consultation with radiation medicine and medical oncology is recommended to guide the next steps in therapy. This should be done prior to removal of the stents as these may be used to guide placement of radioactive seeds. External radiotherapy of 5,000 to 6,000 rads may be given as an outpatient procedure. Following this, patients may be readmitted for 48 hours while iridium 192 seeds are drawn into the transhepatic biliary system, and 2,000 additional rads are given by this means. Irrigations are continued by the patient three times per day. The old stents are replaced every three or four months and new ones are introduced under fluoroscopic surveillance by placing guide wires down through the old stent. The old stent is removed and used as a template for the number and position of the holes. The new stent is easily placed in proper position, and the guide wire is removed. Bile cultures are taken from time to time, and appropriate antibiotics may be required. Duodenal obstruction rarely occurs after radiation therapy. The long-term salvage rate is relatively low, but a significant increase in average length of survival, coupled with an increased quality of life, justifies this major procedure.