Malignant obstructive jaundice is jaundice caused by the compression or obstruction of the extrahepatic bile duct by malignant tumors such as pancreatic head cancer, bile duct cancer, gallbladder cancer, duodenal tumors or jugular abdominal tumors.
Malignant obstructive jaundice is due to the fact that most tumors are in advanced stages when jaundice appears and most patients have lost the opportunity for radical surgery. Once jaundice appears, the patient’s prognosis is poor and the natural course of the disease is only 1 to 3 months. If biliary obstruction is not removed as soon as possible, patients often die of liver failure or cholangitis within a short period of time. Therefore, for patients who have lost the chance of radical surgery, palliative means should be taken to remove biliary obstruction as soon as possible to avoid further aggravation of jaundice and prevent progressive deterioration of liver function, so as to prolong the survival of patients and improve their quality of life.
The general principle of procedure selection is to conform to physiology as much as possible. Common palliative biliary drainage procedures include surgical drainage, transendoscopic biliary drainage, and percutaneous hepatic puncture biliary drainage, each with its own advantages and disadvantages
Judgment criteria of palliative surgical treatment
According to the TNM staging standard of the International Union Against Cancer, the tumor is at stage III or above; radical resection cannot be achieved due to tumor infiltration or metastasis to surrounding tissues and organs, vascular invasion or limited resection scope.
The main reasons for not being able to perform radical tumor resection are.
(1) Most patients have difficulty in tolerating radical surgery due to advanced age and concomitant diseases of multiple important organs.
(2) The mass is large and many important vessels such as mesenteric arteries and veins, abdominal artery trunk and its branches are surrounded by tumor; the head of pancreas or around the jugular has been closely adhered to the inferior vena cava or aorta.
(3) Metastasis to the liver; metastasis to the common bile duct and hepatic duct; extensive metastasis to the hilar, peribiliary duct and lymph nodes above the pancreas.
(4) Rarely, extensive abdominal metastases are seen.
Palliative open bile duct surgery for drainage
Bile duct obstruction is divided into low and high obstruction according to the site of the tumor. Low obstruction includes bile duct obstruction caused by carcinoma of the head of the pancreas, carcinoma of the lower end of the common bile duct, carcinoma around the jugular abdomen, etc. High-grade obstruction refers to bile duct obstruction at and above the hepatic hilum, such as bile duct cancer in the hilum, gallbladder cancer invading the liver or hepatoduodenal ligament. For low biliary obstruction, the commonly used surgical procedures include cholecystojejunostomy, common bile duct jejunostomy, common bile duct duodenal anastomosis, and T-tube drainage. For high biliary obstruction, intrahepatic bile duct jejunostomy is required, but the procedure is more difficult and provides durable bile drainage compared with non-surgical methods, but the complication rate and morbidity and mortality are higher.
Endoscopic biliary drainage
Endoscopic endobiliary drainage is the use of a biliary stent to drain bile into the duodenum. This method is physiologic, has less impact on digestive function, and is indicated for patients who require drainage for a longer period of time. Studies have shown that it can result in a median survival similar to that of surgical internal drainage with less surgical damage. It can be used as the treatment of choice for malignant obstruction of the biliary tract without an indication for surgery. The main stents in use today are metal stents and plastic stents. The main problem after endoprosthesis placement is how to maintain stent patency for a longer period of time. Plastic stents tend to attract bacteria and form biofilms on the inner surface of the stent, followed by deposition of calcium bilirubin and calcium palmitate in the stent and eventually bile sludge formation and obstruction of the stent. In vitro studies have shown that quinolone antibiotics such as ciprofloxacin can reach high concentrations in bile, and prophylactic administration of ciprofloxacin can significantly reduce the number of Escherichia coli adhering to the stent, indicating that prophylactic antibiotics are effective in preventing stent obstruction.
Although metal stents are expensive, the drainage effect and duration of patency are significantly better than plastic stents due to their large caliber and less susceptibility to occlusion and slippage. Studies have shown that the internal diameter of the self-expanding metal stents currently in clinical use can be three times that of plastic stents after complete expansion. In addition, both metal and plastic stents can be blocked again due to longitudinal growth of tumor beyond the end of the stent, and metal stents can also be blocked due to inward growth of tumor tissue through the mesh of the stent. The recently developed metal stents with polyurethane coating over the metal screen can prevent the growth of tumor tissue into the stent mesh and prolong the usual drainage time of the stent. The average time for plastic stents to cause obstruction is generally about 3 months. Therefore, for patients whose expected survival is likely to exceed 3-6 months, metal stents are appropriate; for those whose expected survival is less than 3 months and/or economic conditions do not allow, plastic stents can be used.
Mild to moderate abdominal pain and a small amount of biliary bleeding may occur in a few patients within 24 h after drainage, which is due to the compression of the bile duct wall by the balloon and stent and the tearing of the tumor tissue during dilation. After excluding pain caused by complications such as acute pancreatitis and perforation, antispasmodic and analgesic drugs can be given.
Percutaneous hepatic puncture bile duct drainage
Percutaneous hepatic puncture biliary drainage is simple to operate, easy to master and has few complications, which can effectively relieve obstruction and improve liver function. It can be done under ultrasound and X-ray guidance, but ultrasound allows dynamic multi-angle observation of the bile duct course and identification of the vascular system to avoid large vessel injury and accurate introduction of the puncture needle into the bile duct. ERCP is still used as the preferred option for palliative treatment of low-grade malignant biliary obstruction in most centers. For those patients who cannot tolerate ERCP without success, or for those who have poor drainage despite successful ERCP, percutaneous hepatic puncture biliary drainage is not the best option.
Exploration of radical surgery for malignant obstructive jaundice
Pancreaticoduodenectomy for carcinoma of the jugular abdomen and the head of the pancreas. Pancreaticoduodenectomy includes 3 main steps: exploration, resection and GI reconstruction. Exploration is the necessary step to decide whether resection is possible; resection is to remove the head of the pancreas, the pyloric sinus part of the stomach, all of the duodenum and the lower part of the common bile duct and regional lymph nodes; reconstruction is to anastomose the common bile duct, pancreatic duct and stomach with the jejunum respectively.
Therefore, pancreaticoduodenectomy is a complex and invasive abdominal surgery, which includes part of the pancreas, adjacent duodenum, lower bile duct, part of the stomach and upper jejunum, and requires anastomosis of the common bile duct, pancreatic duct, stomach and jejunum.
Pylorus-preserving pancreatic head duodenectomy.
Because standard pancreatic headoduodenectomy is often associated with weight loss and nutritional impairment, many surgeons have sought to modify it, as is the case with pylorus-preserving pancreatic headoduodenectomy. This procedure preserves gastric storage and digestive function, promotes digestion, prevents dumping syndrome, and facilitates improved nutrition after surgery. Although the extent of surgery has been reduced, it has not decreased the survival rate after surgery and has been adapted to the recent demand for improved quality of survival after surgery, so it has gained some popularity since the 1970s. The main concern, however, is whether this modification affects the degree of cure and long-term survival of malignant tumors. Although there are many reports in the literature on the nutritional status of patients after surgery and the degree of cure compared to standard pancreaticoduodenectomy, there are still no convincing data to draw conclusions on this issue. This is because a key issue is that patients cannot be randomly selected for both procedures and the decision to perform the procedure is often made on a patient-by-patient basis. It is generally considered that benign lesions around the head of the pancreas, carcinoma of the potbelly, tumors of the head of the pancreas with less malignancy, and carcinomas that have not yet infiltrated the pylorus and duodenum can be used for this procedure. Reconstruction of the malignant gastrointestinal tract is performed in the order of pancreatic, biliary and gastric. According to the diameter of the pancreatic duct and the size of the residual pancreatic volume, pancreatic jejunostomy or pancreatic duct jejunostomy can be used, and a drainage catheter can be placed inside the pancreatic duct; bile duct and jejunostomy can be used, and a T-shaped tube can be placed inside. The anterior duodenal bulb of the colon should be anastomosed with the jejunum, and the blood circulation of the duodenum should be fully affirmed before the anastomosis, and the anastomosis should not be sewn with the pyloric ring muscle to avoid affecting the function of the pylorus.
Principles of radical surgery treatment for gallbladder cancer.
Since patients with gallbladder cancer are often not in early stage when they are diagnosed, according to the analysis of bulk cases, only about 23% of gallbladder cancer can be radically resected. Overall, the median survival time of gallbladder cancer patients is 3 months. Therefore, some surgeons have a pessimistic attitude towards the treatment of gallbladder cancer.
In recent years, due to the development of radical surgery for gallbladder cancer, the 5-year survival rate after surgery has been significantly improved. The scope of radical surgery mainly includes gallbladder resection, partial hepatectomy and lymph node dissection. The liver is usually resected around 3 cm around the gallbladder bed.
Lymph node dissection is based on its confluence pathway and metastasis. Usually the lymph nodes are cleared to the next station of the metastatic lymph nodes. Early stage gallbladder cancer only requires removal of gallbladder lymph nodes, but most resectable gallbladder cancers should be cleared of lymph nodes in the hepatoduodenal ligament and, if necessary, lymph nodes in the superior pancreaticoduodenum and posterior pancreatic head.
Principles of palliative surgical treatment for advanced gallbladder cancer
For advanced gallbladder cancer cases that cannot be cured, the principle of surgery is to reduce pain and improve life quality. The more prominent problem of advanced gallbladder cancer is the obstructive yellow bile caused by the cancer invading the biliary system.
Internal drainage should be considered as much as possible for surgery. Internal drainage methods include bile duct jejunostomy, etc. However, due to the deep infiltration of local cancer, especially those with hepatoportal infiltration, internal bile-intestinal drainage is often not easy to perform.
For such patients, internal drainage by bridging is feasible. For cases with very poor systemic condition, external drainage can also be performed. In patients with severe portal hepatic invasion who are unable to undergo these procedures, the right liver can be incised by scraping and suctioning to find dilated hepatic ducts in the right liver so that they can be drained. It is worth noting that jaundiced patients are in poor health and cholangiocarcinoma is not particularly sensitive to chemotherapy
Radical resection of upper bile duct cancer
It is also called radical resection of proximal cholangiocarcinoma; radical resection of high-grade cholangiocarcinoma of the portal bile duct or upper bile duct refers to the tumor occurring in the extrahepatic bile duct above the opening of the cystic duct, which can occur in the common hepatic duct, the bifurcation of the hepatic duct (Klatskin’s tumor), the first and second branches of the left and right hepatic duct. The site of origin of the tumor varies, as do the early diagnosis and surgical treatment methods.
Radical resection includes extrahepatic biliary resection, “skeletonization” of blood vessels on the hepatoduodenal ligament, extensive resection of fibrofatty tissue, nerves and lymph in the duodenal ligament, and if necessary, resection of one liver lobe and reconstruction of hepatic duct jejunostomy. The caudate lobe must be resected if it invades the confluence or the left or right hepatic duct, and it is considered that whether or not to combine caudate lobe resection is one of the main factors affecting the long-term survival of patients with hilar cholangiocarcinoma. The square lobe of the liver can be resected prior to the treatment of the hilar region to increase the exposure of the surgical field
Finally, the whole extrahepatic bile duct and its bifurcation tumor, gallbladder, lymph, fat, nerve tissue of the hepatoduodenal ligament, and sometimes part of the liver are removed. The left and right hepatic duct openings were left at the hepatic hilum, pending reconstruction and repair.