Cystic duct (CD) patency in malignant biliary obstruction (MBO): Consideration for laparoscopic cholecystojejunostomy (CCJ)

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Abstract

BACKGROUND: CCJ may offer advantages over other procedures in the palliative management of unresectable MBO. Tamasky et al. reported that only 22% of non-hilar tumor patients were eligible for CCJ, as the distance from obstruction to CD takeoff was frequently less than 1cm (Ann Surg 1996;221:265-271). Our aim was to define the frequency of potential CCJ candidacy in our patient population. METHODS: Retrospective analysis was performed on 249 consecutive MBO patients who underwent ERCP from 1/94-8/96. Patients with either hilar tumors or previous biliary surgery were excluded. ERCPs were reviewed specifically for CD or gallbladder filling. If the CD was not seen, degree of intrahepatic filling was used to assess completeness of total ductal filling. In patients with patent CD, the distance from the cephalad tumor rim to the CD takeoff was classified as > or < 1cm. RESULTS: 249 patients underwent 358 ERCPs (1.44/patient). ERCP failed in 16 cases (4.5%), usually due to duodenal obstruction. Of the remaining 233 patients, 138 (59%) were excluded, leaving 95 patients (41%) as potentially eligible for CCJ. In 41/95 (43%) of the potential candidates, the CD was not visualized, but 25/41 (61%) had incomplete intrahepatic filling (usually intentional to limit cholangitis risk). Of 12 eligible patients who had 2 ERCPs, 3/6 had underfilling of the intrahepatic bile ducts and non-visualization of the CD, but subsequent complete cholangiography had CD filling. Forty-six patients (48%) had patent choledochocystic junctions; only 34 had biliary obstruction > 1cm away from the CD takeoff (36%). Eight patients had choledochocystic junctions clearly obstructed by tumor. SUMMARY: In our series of MBO patients, 41% were initially eligible for CCJ, and only 36% of these satisfied the cystic duct criteria. After exclusion of hilar lesions, patients with prior biliary surgery and those with occluded CD, only 14% of MBO patients are theoretical candidates for CCJ. Underfilling on cholangiography may give false CD patency data. CONCLUSION: CCJ will probably play a very minor role in management of MBO patients. Further studies assessing accuracy of CD patency determination (position, contrast volume, cholangitis risk, etc.) are awaited.

Original languageEnglish (US)
Pages (from-to)AB131
JournalGastrointestinal endoscopy
Volume45
Issue number4
DOIs
StatePublished - Jan 1 1997

ASJC Scopus subject areas

  • Radiology Nuclear Medicine and imaging
  • Gastroenterology

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