Recovery patterns of liver function after complete and partial surgical biliary decompression

doi:10.1016/S0002-9610(97)89554-2

The American Journal of Surgery

Volume 171, Issue 2, February 1996, Pages 230-234

https://doi.org/10.1016/S0002-9610(97)89554-2 Get rights and content

Background

Recovery patterns of liver function after surgical drainage of obstructing biliary system have not been studied properly, particularly after a single-lobe biliary decompression where atrophic-hypertrophic changes of the liver may affect the recovery of liver functions.

Patients and methods

Thirty patients with malignant obstructive jaundice had their liver functions evaluated biochemically both 1 week and 1 day preoperatively, and at 4 points postoperatively: 3 days, 1 week, 3 weeks, and 6 weeks. Half of them underwent complete biliary drainage procedures, whereas the remaining half had partial drainage (decompression of the left lobe only by means of segment III duct-enteric bypass).

Results

For those with complete drainage, serum alkaline phosphatase (AP) and gamma glutamyl transpeptidase (GGT) were 40% to 50% of preoperative levels 3 days after surgery (P <0.005), and were about twice the norm at 6 weeks. Their serum total and direct bilirubins (TB, DB) were approximately 60% reduced 1 week after the drainage (P <0.05). For partial drainage, serum AP and GGT decreased by 50% at 1 week (P <0.05), but were still very high 6 weeks after the drainage. The TB and DB decreased significantly 1 week postoperatively, and were three times the norm at 6 weeks. Serum albumin decreased sharply at 3 days and returned to normal levels 3 weeks after either complete or partial biliary drainage. Aminotransferase enzymes responded differently between the two groups. The levels dramatically declined one week after complete drainage and were slightly higher than normal thereafter. Following partial drainage, the enzyme levels were unchanged throughout the study period.

Conclusion

Complete biliary drainage can nearly normalize the liver functions by 6 weeks, and biliary drainage of one lobe of the liver can effectively recover the liver functions.

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Cited by (31)

Cholangitis: Causes, Diagnosis, and Management
2019, Surgical Clinics of North America
Citation Excerpt :
Alkaline phosphatase is the most consistently elevated marker, with elevations found in 74% to 93% of cases of acute cholangitis. Alkaline phosphatase also exhibits a quicker recovery pattern following successful drainage than other markers of obstruction, such as bilirubin, and may provide a more accurate early indicator of adequate drainage.23 Other laboratory findings, such as elevated amylase and prothrombin time, have been more variable.19
A predictive scoring system for insufficient liver hypertrophy after preoperative portal vein embolization
2018, Surgery (United States)
Citation Excerpt :
In our experience, many patients have increased ALP levels even if adequate biliary drainage is performed and the serum total bilirubin level decreases to <2 mg/dL. Watanapa et al26 also reported that a decrease in the ALP level was delayed compared with that in the total bilirubin level after operative biliary decompression. These observations suggest that the recovery of the liver function from cholestasis does not correlate with a decrease in the serum total bilirubin, and increased ALP levels may reflect insufficient recovery from cholestatic liver.
The factors which affect hypertrophy of the future liver remnant after portal vein embolization remain unclear. The aim of this study was to clarify the clinical factors affecting the hypertrophy rate after portal vein embolization and to develop a scoring system predicting insufficient liver hypertrophy.
The cases of a total of 152 patients who underwent portal vein embolization of the right portal branch between 2006 and 2016 were reviewed retrospectively. The score to predict insufficient (<25%) hypertrophy was established based on logistic regression analyses of the clinical parameters before portal vein embolization.
After portal vein embolization, the future liver remnant volume, expressed as the median (range), significantly increased from 364 (151–801) mL, 33% (18%–54%), to 451 (242–866) mL, 42% (26%–65%). The median hypertrophy rate was 24% (−5% to 96%). A preoperative predictive scoring system for insufficient liver hypertrophy was constructed using the following 3 factors: an initial future liver remnant volume ≥35% (2 points), alkaline phosphatase ≥450 IU/dL (1 point), and cholinesterase <220 mg/dL (1 point). The constructed scoring system indicated the proportion of patients with insufficient liver hypertrophy (<25%) to be 6 out of 42 (14%) in the low-score group (0 points), 44 out of 77 (57%) in the medium-score group (1–2 points), and 30 out of 33 (91%) in the high-score group (3–4 points). The hypertrophy rate of future liver remnant was different among the 3 groups (low-score group, 38.9% [−2.4% to 81.4%]; medium-score group, 22.7% [−5.1% to 95.5%]; high-score group, 18.2% [2.4%–30.7%]) (P < .001).
The constructed scoring system was able to stratify patients before portal vein embolization according to the possibility of developing insufficient liver hypertrophy.
The optimal duration of preoperative biliary drainage for periampullary tumors that cause severe obstructive jaundice
2013, American Journal of Surgery
Citation Excerpt :
In-hospital mortality and the length of hospital stay were assessed. The definitions of complications have been used in previous studies that evaluated the management of complications on the basis of generally accepted criteria.18,23–30 Details on the definitions of complications are listed in Table 1.
Despite routine preoperative biliary drainage (PBD) with periampullary cancer, its optimal duration has not been established. The objective of this study was to investigate PBD in severely jaundiced patients.
A total of 120 patients with periampullary tumors who underwent surgery with intent to cure after PBD for severe obstructive jaundice were enrolled. According to the duration of PBD, 66 and 54 patients were classified into the long-term (≥2 weeks) and short-term (<2 weeks) groups.
PBD-related complications occurred in 6 (9.1%) and 14 (25.9%) patients in the short-term and long-term groups, respectively (P = .014). Rates of surgery-related complications and mortalities were not significantly different between the 2 groups. The R0 resection rate tended to be lower (P = .054) and the mean length of hospital stay was significantly longer (P = .039) in the long-term group.
PBD duration <2 weeks is more appropriate in severely jaundiced patients with periampullary cancer.
Role of preoperative biliary drainage of liver remnant prior to extended liver resection for hilar cholangiocarcinoma
2009, HPB
Citation Excerpt :
The primary aim of this study was to determine which patients benefit most from preoperative biliary drainage. Prior studies have shown that successful drainage of merely 30% of the liver in a patient with obstructive jaundice will normalize bilirubin level.38,39 In patients with hilar cholangiocarcinoma, isolation of the right and left biliary systems is common, and it is therefore possible to relieve jaundice by draining only one side of the liver, provided the drain is not placed in an atrophic lobe.
In patients with hilar cholangiocarcinoma, ipsilateral en bloc hepatic resection improves survival but is associated with increased morbidity. Preoperative biliary drainage of the future liver remnant (FLR) and contralateral portal vein embolization (PVE) may improve perioperative outcome, but their routine use is controversial. This study analyses the impact of FLR volume and preoperative biliary drainage on postoperative hepatic insufficiency and mortality rates.
Patients who underwent hepatic resection and for whom adequate imaging data for FLR calculation were available were identified retrospectively. Patient demographic, operative and perioperative data were recorded and analysed. The volume of the FLR was calculated based on the total liver volume and the volume of the resection that was actually performed using semi-automated contouring of the liver on preoperative helical acquired scans. In patients subjected to preoperative biliary drainage, the preoperative imaging was reviewed to determine if the FLR had been decompressed. Hepatic insufficiency was defined as a postoperative rise in bilirubin of 5 mg/dl above the preoperative level that persisted for >5 days postoperatively. Operative mortality was defined as death related to the operation, whenever it occurred.
Sixty patients were identified who underwent hepatic resection between 1997 and 2007 and for whom imaging data were available for analysis. During this period, preoperative biliary drainage of the FLR was used selectively and PVE was used in only one patient. The mean age of the patients was 64 ± 11.6 years and 68% were male. The median length of stay was 14 days and the overall morbidity and mortality were 53% and 10%, respectively. Preoperative FLR volume was a predictor of hepatic insufficiency and death (P= 0.03). A total of 65% of patients had an FLR volume ≥30% (39/60) of the total volume. No patient in this group had hepatic insufficiency, but there were two operative deaths (5%), both occurring in patients who underwent preoperative biliary drainage. By contrast, in the group with FLR < 30% (21/60, 35%), hepatic insufficiency was seen in five patients and operative mortality in four patients, and were strongly associated with lack of preoperative biliary drainage of the FLR (P= 0.009). Patients with an FLR ≥ 30% were more likely to have radiographic evidence of ipsilateral lobar atrophy and hypertrophy of the FLR (46.2% vs. 9.5% in patients with FLR < 30%; P= 0.004).
In patients undergoing liver resection for hilar cholangiocarcinoma, FLR volume of < 30% of total liver volume is associated with increased risk for hepatic insufficiency and death. Preoperative biliary drainage of the FLR appears to improve outcome if the predicted volume is < 30%. However, in patients with FLR ≥ 30%, preoperative biliary drainage does not appear to improve perioperative outcome and, as many of these patients have hypertrophy of the FLR, PVE is likely to offer little benefit.
Radical Resection of Biliary Tract Cancers and the Role of Extended Lymphadenectomy
2009, Surgical Oncology Clinics of North America
Citation Excerpt :
If the right and left hepatic duct are separated by the invasion of hilar bile duct cancer, percutaneous transhepatic biliary drainage (PTBD) for only the future remnant liver is the first choice.5,23,68–70 Hemihepatic biliary drainage is sufficient to enable liver dysfunction caused by obstructive jaundice to recover.68,69,71 The endoscopic route is not advocated for hilar bile duct cancer of Bismuth type 2–4 because of the high incidence of cholangitis in the undrained area.65,72–74
Extended hemihepatectomy and/or pancreatoduodenectomy plus extrahepatic bile duct resection and an extended lymphadenectomy of up to the group 2 lymph nodes can enable long-term survival in patients with extrahepatic bile duct (EBD) cancer with acceptable surgical risks. Surgeons should dissect and examine at least 10 or more nodes in curative intent surgeries for local disease control and accurate staging. Radical surgical procedures for EBD cancer, including a right lobectomy, left trisectoriectomy, hepatopancreatoduodenectomy, and combined vascular resection and reconstruction, are useful options for obtaining a negative margin, but the benefits of such procedures to long-term survival rates is limited to selected patients without nodal metastasis and with negative surgical margins.
Treatment of hilar cholangiocarcinoma
2001, Cirugia Espanola
Los colangiocarcinomas hiliares son neoplasias poco frecuentes que, por su localización anatómica, plantean importantes dificultades técnicas en la resección quirúrgica. La supervivencia a largo plazo sólo se consigue en los casos resecados, por lo que es importante la identificación de los pacientes que presentan factores de riesgo, así como el diagnóstico precoz y la valoración de la resecabilidad por un cirujano experimentado en cirugía hepatobiliar. En este trabajo se pretende dar una visión de conjunto del colangiocarcinoma hiliar, que abarca los factores de riesgo, el diagnóstico (las pruebas de laboratorio, las técnicas de diagnóstico por imagen, la anatomía patológica) y las distintas modalidades de tratamiento, especialmente la resección quirúrgica. Se comparan las tasas de resecabilidad y la supervivencia a largo plazo tras la resección con intención curativa en las series más relevantes de la bibliografía. Asimismo, se exponen las modalidades de tratamiento paliativo quirúrgico y radiológico en los casos irresecables y las terapias adyuvantes utilizadas por los diferentes autores.
Hilar cholangiocarcinomas are rare neoplasms. Due to their anatomical location, surgical resection is technically difficult. Long-term survival is only achieved in patients who have undergone resection. Consequently, identification of patients with risk factors, early diagnosis and evaluation of resectability by a surgeon with experience in hepatobiliary surgery are essential. The aim of this study was to provide an overall view of hilar cholangiocarcinoma, including its risk factors, diagnosis (laboratory investigations, diagnostic imaging techniques, pathologic anatomy) and the various treatment modalities, especially surgical resection. We compare resectability and longterm survival rates after curative resection in the most important series reported in the literate. In addition, the treatment modalities used in palliative surgery and radiological treatment in non-resectable cases, as well as the adjuvant therapies used by different authors, are discussed.

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View full text

Recovery patterns of liver function after complete and partial surgical biliary decompression

Background

Patients and methods

Results

Conclusion

Surg Clin North Am

Surgical approaches to cholangiocarcinoma at confluence of hepatic ducts

Lancet

Management strategies in resection for hilar cholangiocarcinoma

Ann Surg

Neoplasm of the hepatic hilum: the role of resection

Hepatogasmenterol

Prolongation of survival for carcinoma at the hepatic duct confluence

Surgery

Surgical treatment of carcinoma of the hepatic duct confluence: analysis of 55 resected carcinomas

World J Surg