THE ANATOMICAL BASIS FOR SEGMENT-III CHOLANGIOJEJUNOSTOMY WITH ANALYSIS OF 13 CASES

Background: The majority of patients who require palliation for jaundi ce and pruritus resulting from malignant hilar obstruction are treated by stenting. Stenting is usually achieved from below after performing an endoscopic retrogade cholangiopancreatography. In some cases the r endezvous technique is employed, negotiating the passage through a mal ignant structure from above and stenting from below. A minority of cas es, such as those who had a previous polyagastrectomy and those in who m attempts at stenting have failed, are considered to be suitable for a Segment III cholangiojejunostomy. We have investigated the anatomica l basis for Segment III duct bypass and have critically analysed the r esults in 13 patients. Ten patients were treated by Segment III duct b ypass alone, and three patients had a Segment III duct bypass combined with stenting of the right Liver. Methods: The anatomy of the biliary tree was investigated by dissection of 54 normal livers removed at au topsy. Clinical details of the 13 patients who had Section III cholang iojejunostomy were obtained from hospital records and by contacting tr eating practitioners, Results: In 64.8% of the anatomical dissections, the findings were favourable for a Section III cholangiojejunostomy. In these specimens the Segment III duct bypass would have drained Segm ents II, III and TV. In 35.2% of the specimens the anatomical disposit ion was potentially unfavourable, mainly due to the Segment II or IV d ucts joining close to the confluence and therefore liable to obstructi on by the tumour. In nine of the 54 specimens the true left hepatic du ct was less than 6 mm in length, making it unsuitable for a bypass pro cedure to drain the left hemi Liver. Of the 10 patients who were subje cted to a palliative Section III cholangiojejunostomy only, there was one postoperative death. Or the nine patients who survived, six obtain ed excellent palliation of jaundice and pruritus. Conclusions: In care fully selected cases, Section III cholangiojejunostomy achieves excell ent palliation in patients with unresectable hilar malignancies that h ave been unable to be stented pre-operatively or who have unresectable tumours at the time of laparotomy.