Male 64 years-old with obstructive jaundice serum bilirrubines= 10 dl/ml and ca 19.9 =9000 dl/ml. This patient presents none comorbidity.
At abdomen CT = it was observed gallbladder with multiple stones and diffuse thickening associated with dilatation of intrahepatic bile ducts and peri- hilar stenosis together infundibulum of gallbladder. Tere was thrombosis of right portal vein with patency of main trunk. Hepatic artery is free without anatomic variations. magnetic resonance cholangiopancreatography (MRCP) _ hepatic estenosis with 0.5 cm envolving common hepatic duct and cystic duct very close of bile duct confluence. Pet-CT= without captation as hepatic ducts as gallbladder. Hepatic volumetry = total 3323 cc and left lobe 673 cc. FRL = 18 % for right trisectioniectomy. Diagnostic hypothesis: 1) Bismuth I-II hilar cholangiocarcinoma? 2) Infiltrative gallbladder adenocarcinoma type hylum bed tumor?? 3)Type 1 Mirizzi's Syndrome ??????
What do i do?
1) First external or internal billiary drainage
2) Laparoscopic evaluation for statment and N2 lymphadenectomy (biopsies)
3) If N2 negative and malignant neoplasm will confirmed - we should perform laparotomy and Hilar Lymphadenectomy followed right trisectioniectomy with Alpps approach?
or if biopsies were negative for malignant neoplasm = Type 1 Mirizzi's Syndrome therefore we will perform only partial cholecystecthomy ? or total with biliary drainage with T-tube and hepaticoplasty ? Or even a hepaticojejunal bypass???
Is there CT imagings?
If right trisectioniectomy is proposed, billiary drainage using ENBD or PTBD of left biliary duct should be first porformed, PVE or ALPPS in this case is not needed, because the right portal vein is thrombosed.
The main problem is that frl for right trisectioniectomy is only 18 % and this patient presents high risk of postoperative líver faillure. Nonetheless right porta is closed , LIVER PARTITION STIMULATES HEPATIC REGENERATION.
I've got a few questions to ask
1. Liver Steatosis: yes or no
2. Patient BMI
3. Portal hypertension: yes or no
4. PT, INR
1. Moderate liver steatosis.
2. Overweight.
3. Without portal hipertension.
4. normal INR.
Instead oriental centers we have not ICG.
Operative treatment for Klatskin tumor combined with preoperative biliary drainage (PBD) has been established as a safe management strategy. However, still there is controversy about the preferred technique of PBD among percutaneous transhepatic biliary drainage (PTBD), endoscopic biliary stenting (EBS), and endoscopic nasobiliary drainage.
I agree, but we have no nasobiliary drainage. So this patient underwent first ebs without sucess. Ptbd was no possible too. As he mas presented cholangitis, we submitted him surgical approach.
We started by laparoscopy, intraoperative biopsies revealed no malignant disease at frozen section. Due to the fact that it was difficult dissection of biliary tree surgery underwent open conversion. He presented extensive fibrosis around as main hepatic duct as choledoco , we hardly could perform retrograde cholecistectomy and to realize a cholangiogram which it observed slightly enlarged biliary tree. There was no stenosis, but choledocolithiasis besides narrowing of distal choledoco which it was interpreted as inflammatory process around vaters ampulla. As cystic was very large, we remove gallstones of biliary tree trough cystic instrumentation with sucess. Next , we lead transcystic external biliary drainage .
It is only indicated if bilirubin level is over 20 mg/dl, but not as a routine procedure
There are many controversies in this theme. Some authors consider over 10 or 15 OR still 20 MG ml of bilirubin levels. Mainly oriental centers consider operate patients without jaundice. Occidental centers have resected patients since those with jaundice. Studies with high level of evidence are difficult for interpretation due the fact that they are very heterogeneous. Thus, I have considered biliary drainage for major plurisegmentectomies ie more than 4 segments associated with portal embolization if FRL is less than 40 %, FOR OTHER RESECTIONS I PREFER UPFRONT RESECTION BECAUSE THE RISKS of tumor implantion mainly external biliary drainage by tph route.
Other indications for biliary drainage are either cholangitis or undernourished patients.
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