Plate 104

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.

Next >