In patients with biliary-enteric drainage, reflux of intestinal contents into the bile duct may occur and cause cholangitis, which is regarded as the most serious complication of these procedures.
Two events suggested to favor the late onset of cholangiocarcinoma are lithiasis of the biliary tract and a previous biliary-enteric anastomosis.
In order to evaluate the correlation between biliary-surgical drainage and the late development of cholangiocarcinoma of the biliary tract, a study of consecutive patients attending the Department of Surgery at the Medical School of the University of Rome, Italy, has been conducted by Dr Adriano Tocchi and colleagues.
A total of 1003 patients were included in the 30-year study, which was concluded in 1997 and is reported in the journal Annals of Surgery.
The study examined patients undergoing 3 different procedures of biliary-enteric anastomosis. These were transduodenal sphincteroplasty, choledochoduodenostomy, and hepaticojejunostomy.
| cholangiocarcinoma rates|
- highest after choledochoduodenostomy
|Annals of Surgery|
In each case the postoperative clinical course and long-term outcome were evaluated by a retrospective review of the hospital records and follow-up. Mean follow-up was 129.6 months.
55 (5.5%) cases of primary bile duct cancer were found among the 1003 patients, at intervals of 132 to 218 months from biliary-enteric anastomosis.
The incidence of cholangiocarcinoma was found to be highest in patients undergoing choledochoduodenostomy, with 7.6% of this group developing cancer.
There was a lower risk of primary bile duct cancer in transduodenal sphincteroplasty patients (5.8%), and an even further reduced risk in hepaticojejunostomy patients (1.9%).
The incidence of malignancy related to the different underlying diagnosis was 5.9%, 7.2%, and 1.9% in patients with choledocholithiasis, sphincter of Oddi stenosis, and postoperative benign stricture, respectively.
Although only one patient who developed cholangiocarcinoma had previous concurrent lithiasis of the biliary tract, 40 patients had experienced mostly severe, recurrent cholangitis.
No case of malignancy occurred in patients scored as having no cholangitis in the early and long-term postoperative outcome.
Univariate and multivariate analyses indicated the presence of cholangitis as the only factor affecting the incidence of cholangiocarcinoma.
Dr Tocchi, speaking on behalf of his fellow authors, said the study showed that "chronic inflammatory changes consequent to biliary-enteric drainage should be closely monitored for the late development of biliary tract malignancies."