The biliary tree is the final pathway as well as an access site to most of the major organs in the hepatobiliary and pancreatic system. As such the biliary tree is often the first to manifest disorders of the liver, pancreas, gallbladder and duodenum and often the most convenient access to these organs. This year's meeting emphasized minimally invasive techniques, more sophisticated surveillance, early detection and quality of care with better surgical outcomes.
Dr Henry Pitt (USA), the outgoing president of the IHPBA, stressed the concerning problem of obesity worldwide. Dr Pitt emphasized that our diet and sedentary activities have a direct bearing on biliary stones, fatty livers and pancreas, increasing the difficulty in surgical approaches. Dr Palepa Jagannath (India) presented the largest population-based study in the field of HPB surgical diseases. He identified the Ganges catchment area as having an association of carcinoma of the gallbladder and environmental contamination with heavy metals. He emphasized that this is a world concern, especially in the third world where there are more lenient environment regulations. A second large population-based study by Yuji Nimura (Japan), discussed intrahepatic cholangiocarcinoma. Dr Nimura stressed the difficulty in accurately staging intrahepatic cholangiocarcinoma and that anatomical considerations alone are probably insufficient for accurate prognosis and that the morphology and biobehaviour of the tumour are probably more important for prognosis. He stressed that R0 resection for intrahepatic cholangiocarcinomas can usually be achieved by en bloc techniques.
The IHPBA sponsored a symposium on approaches to gallbladder cancer. The three presenters were Xabier Arextabala (Chile), Bill Jarnigan (USA) and Masura Miyazaki (Japan). Gallbladder cancer remains a lethal malignancy in the hepatobiliary tree and appears to have an increasing frequency. There are still multiple areas of controversy regarding staging and resectability and selection of patients. An important point is that preoperative suspicion of gallbladder cancer is crucial for appropriate, timely and effective management of this malignancy. Retrospective reviews showed that a tumour of the gallbladder could be diagnosed by the radiologist in more than half the cases on ultrasound. This should then change the approach from a laparoscopic cholecystectomy to more of an oncologic approach, with staging and imaging in preparation for resection if malignancy can be identified preoperatively. There was universal agreement that partial dissection, incomplete resection, or an unprepared patient were important negative factors in successful management of gallbladder cancer. The authors stressed that the surgeon must personally look at the images before carrying out cholecystectomy. If a tumour is suspected, laparoscopic staging is useful in identifying metastases, associated liver disease or other signs that would preclude operative intervention. The presenters felt that gallbladder cancer is resectable only in stages I–III, that stage IV has a poor prognosis and the patients are palliative, and that major surgery has little value. There was controversy regarding the type of operation that should be performed for resectable gallbladder cancers. Although the lymph nodes should be removed for prognostic evaluation, there does not appear to be a surgical advantage for radical lymphadenectomy. The same can be said for the hepatic duct. Resection of the lymph nodes and the bile duct may add significantly to the surgical procedure; however, resection and reconstruction of the bile duct have not been clearly shown to have a survival advantage. It was therefore agreed that if the gallbladder cancer is present near the cystic duct and in the apex of the triangle of Calot and resection of the bile duct is necessary for clearance then bile duct resection would seem prudent. If the tumour was close to the right hepatic duct, a more extensive liver resection may be necessary so as to include the right hepatic duct and surrounding tissue. A less radical liver resection may be necessary if the tumour was at the fundus of the gallbladder with minimal invasion of the liver. There was general consensus that the type of liver resection for resectable gallbladder cancer is still not clear. In summary, this symposium suggests that preoperative suspicion is the most important aspect of appropriate management. Once identified, a cautious approach to the gallbladder after an oncological work-up is advisable, so that the surgeon is prepared for either cholecystectomy or a more radical resection if needed. It is most prudent that for stages IB, II and III beyond the mecosa of the gallbladder resection of the gallbladder cancer is appropriate. The type of surgery is yet to be clarified because of the lack of prospective randomized trials.
Certain abstracts were highlighted as interesting to the majority of hepatobiliary surgeons and presented new and enlightening data. One such abstract addressing duodenal invasion secondary to gallbladder cancer was written by Agarwal et al. (New Delhi, India). This was a prospective trial of 252 patients. This impressive series demonstrated that duodenal infiltration of the gallbladder carcinoma is not a contraindication for resection and can usually be performed with the addition of a partial or segmental duodenectomy with primary reconstruction. However, if the patient has jaundice secondary to common bile duct invasion, resection is almost never possible for curative intent.
A symposium on bile duct injuries included Steven Strasberg (USA), Yaman Tekant (Turkey), James Garden (UK) and Eduardo de Santibanes (Argentina). All authors presented large interesting series and the highlights of their presentations emphasized prevention as the ultimate goal. The term ‘critical view’, popularized by Dr Strasberg, is gaining wider appreciation and acceptance in the surgical community as a critical step in preventing the misidentification of the anatomy in the triangle of Calot. Dr Garden emphasized that sepsis, vascular injury and delayed recognition are associated with very poor outcomes. If your patient is not getting better after 24–48 h, a bile duct injury must be ruled out if the patient has undergone a laparoscopic cholecystectomy. Progress in metal stenting for even severe bile duct structuring is finding a place. There is increasing evidence that ‘covered’ expandable metal stents, which are removable, may be appropriate in stenting bile duct injuries as an alternative to transhepatic percutaneous stenting for severe bile duct strictures. Dr Eduardo de Santibanes noted that the initial management of a bile duct stricture is the most critical step in the prevention of long-term complications such as secondary biliary cirrhosis, portal hypertension and the need for a liver transplant. He emphasized that if a bile duct injury is identified it should be sent to or repaired by an experienced surgeon, who is familiar with bile duct reconstruction. There was an alternative opinion that fundus down may be as safe as initial identification of the structures of the triangle of Calot. Opinions were equally defended. Surgeons from Europe and North America tended to believe that the critical view is most appropriate before proceeding, whereas South-Asian surgeons felt that the fundus down approach was the safest. There was no agreement as to technique at the end of the discussion.
There were several interesting abstracts addressing bile duct injuries. Fiocca et al. (Rome) described a minimally invasive treatment for even complete transection of the main bile duct. Their technique involved a combined ERCP and interventional radiology approach, in which the endoscopic surgeon retrieves the wire pass percutaneously through the liver where a covered expandable metal stent can be railroaded beyond the two ends of the bile duct, allowing the bile duct to heal. They reported a higher rate of success for this procedure; however, this series was relatively small and spread out over a number of years, although their experience is increasing. Ramos et al. from the Mayo Clinic reported on the clinic's experience with stricture dilation of benign biliary strictures. They reported an approximately 70% success rate with benign biliary strictures that can be fully dilated, and that both endoscopic and radiological approaches still have a place in treating benign biliary strictures. Dr de Santibanes (Argentina) reported his experience in dealing with benign biliary bile duct injuries by posterior right sectionectomy and hepaticojejunostomy. This technique describes the approach to the posterior sector bile duct from the right side and similar approach to the contralateral side in a segment II/III bypass. With the ability to approach both sides of the liver in this fashion, high and complex bile duct injuries can be addressed surgically.
The subject of challenging biliary strictures was addressed by a symposium of four presenters and moderators: Xuegueng Zhu (China), Steve Ahrendt (USA), Surendra Kumar Mathur (India) and Philippus Bornman (South Africa). Despite this problem having been addressed in many meetings in the past, several interesting findings arose from the symposium. Dr Zhu reported that despite the modernization of China, recurrent pyogenic cholangitis (RPC) and intrahepatic ductal lithiasis is not disappearing; however, it is being recognized at an earlier and more treatable stage. The reason why this is not disappearing is still not clearly understood. Despite early identification of RPC in its earlier stages, minimally invasive surgery does not seem to control it and resection is often still necessary. Dr Kumar (India) described an impressive series of tubercular stric tures of the biliary tree. This rare diagnosis is seldom made unless tuberculosis is considered as a possible cause. The approach to bile duct stricturing is multidisciplinary but stenting is often necessary to maintain biliary patency during antibiotic therapy. Dr Ahrendt (USA) presented his extensive series in the multimodality approaches to dominant strictures in primary sclerosing cholangitis. The important lessons demonstrated by his series are that the initial stricture is often the malignant one, and that dominant stricture management by stricture dilation is frequently the best approach. Patients require close surveillance to prevent secondary biliary cirrhosis and ultimately liver transplant. Dr Bornman (South Africa) discussed bile duct strictures in chronic pancreatitis and recommended that benign pancreatic strictures rarely need stenting; if they are stented you often commit your patient to chronic stenting as pancreatic bile duct strictures seldom resolve. They never resolve if the pancreas is calcified, thus his recommendation is not to stent benign pancreatic strictures unless they are complicated. Dr Parks (UK) discussed preoperative biliary drainage and whether this is appropriate or not. Still, despite multiple trials to try and clarify this question, there does not appear to be a physiological reason for preoperative biliary drainage. It is associated with increased sepsis postoperatively and the bile duct probably should not be stented unless the patient cannot tolerate the pruritus. Most patients are diagnosed at the time of the ERCP and the contaminated bile requires drainage. An update on cholangiocarcinoma by Pierre-Alain Clavien of Switzerland showed that there is an apparent wordwide increase in cholangiocarcinoma and that the staging, clarification and surgical approaches are significantly enhanced by PET-CT. PET-CT has > 90% sensitivity in detecting bile duct cancer; however, the lack of PET-CT facilities is still a major challenge for surgeons in accurate staging and mapping of this difficult tumour. Laparoscopic common bile duct exploration was discussed by Dr Nathanson (Australia). Dr Nathanson's experience is significant in this area and he reports that transcystic duct exploration is the most appropriate when possible, and it is possible in the majority of patients with small common duct stones. Laparoscopic exploration of the common duct using a choledochotomy is challenging and should be performed by experienced surgeons; he cautions surgeons about approaching a common duct that is not dilated more than 8 mm as there is a risk of stricturing.
Dr Thomas van Gulik (Netherlands) and Dr Charles Rosen (USA) debated resection or transplantation for cholangiocarcinoma. It was agreed that surgery has likely maxed out its effectiveness. The < 50% long-term survival rate is more likely one-third and these patients often have favourable tumours. In Dr Rosen's series, now over 80 patients with an aggressive chemotherapeutic and radiation programme have > 50% long-term survivorship for non-resectable cholangiocarcinomas due to either non-resectability of the tumour or significant comorbid liver disease. These results are superior to surgical resection in highly selected patients. The challenge is organ availability for these patients. Drs Padbury and Palmer from Australia and the UK, respectively, argued local excision versus Whipple procedure for small ampullary lesions. The consensus was that benign simple lesions should be resected by endoscopic ampullectomy and that severe dysplasia probably means cancer and Whipple's resection is the most appropriate. This leaves surgical ampullectomy with few indications.
Macrobiotic preparations for patients with cancer seems to be gaining favour in many countries. Nagino et al. (Japan) described a synbiotic treatment to prevent postoperative infections complicating biliary tract cancer surgery. This was a randomized trial favouring the synbiotic diet. Dr Pattison (UK) noted that nutritional risk index predicts a high risk of postoperative complications for patients with obstructive jaundice. Whether this can be altered preoperatively still remains a challenge. Abstracts discussing the surgical management of severe acute cholecystitis still reflect a controversy regarding delayed or early surgical treatment for acute cholecystitis. Dr Jenkins (UK) emphasized that the need for open cholecystectomy still remains, that this should not be considered a surgical complication. Dr Hadad (UK) reported that delay increases the conversion rate in laparoscopic cholecystectomy for acute cholecystitis. However, Dr Tzovara (Greece) reported in a prospective study that delay does not seem to alter the conversion rate for acute cholecystitis.
Malpractice litigation for bile duct injuries is still a concern for the hepatobiliary surgeon. Drs de Reuver and Gouma (Netherlands) report that litigious patients do not resolve their symptoms secondary to bile duct injury until a settlement is in place.
Further discussions involving cholangiocarcinomas are showing improved survival. Three abstracts presented by Dr Quyn (UK) showed that the addition of photodynamic therapy appears to improve survival for cholangiocarcinoma. Dr Cleary et al. (USA) showed that surgical excision of proximal cholangiocarcinomas can be successful with a high number of patients with good long-term results. Dr Nishio et al. from Nagoya, Japan, discussed trisectionectomy for hilar cholangiocarcinoma, showing that although more tumours can be excised, the success rate in dependent on background liver disease and that there are more complications with a larger resection.
Dr Kang et al. (Korea) discussed inflammatory pseudotumour of the liver mimicking a cholangiocarcinoma. Pseudotumours in the gallbladder area and porta are not common but are seen by hepatobiliary surgeons and should be considered as they do not require surgical removal. They tend to resolve on their own. Dr Urakami et al. (Japan) reported that bile duct injuries in Japan have the same frequency as in North America and Europe. This was a relief to many.
Dr Ha et al. (Hong Kong, China) and Dr Alhamdani (UK) both gave abstracts on primary bile duct closure versus T-tube drainage after laparoscopic common duct exploration. In this prospective randomized trial from China, primary closure was generally thought to be appropriate once the bile duct is clear. These findings were echoed by Dr Alhamdani.
Improvements in laparoscopic technology have led to more and more major hepatobiliary procedures being done laparoscopically. Dr Jang et al. (Korea) demonstrated a resection of choledochal cyst laparoscopically with reconstruction using a four-hole technique. Dr Toyota et al. (Japan) discussed their series on the treatment of acute cholecystitis by placing a naso-biliary catheter within the gallbladder and draining it this way rather than surgical interventions for high-risk patients. Dr Karigiri et al. (UK) discussed the need for early ERCP after cholecystectomy, showing that ERCP can be used after cholecystectomy, even in patients with recognized common bile duct stones.
In summary, several themes through the meeting suggested the use of aggressive surgical procedures. However, if surgical aggression is matched by a low complication rate and high degree of resectability, this would seem appropriate management for a particular malignancy and the term aggressive surgery should probably be substituted by appropriate R0, en bloc or complete resection. Further, surgical experience, skill sets and patient care factors in the highly technical area of hepatobiliary and pancreatic surgery are creating recognition of HPB as a subspecialty within surgery. There were symposia at this meeting discussing the merits of specialized teaching programmes and fellowships for HPB to be formalized so that a curriculum of knowledge and a skill set can be developed that would be broadly applied for trainees in HPB surgery. This would decrease the learning curve and increase exposure of trainees to this complex surgery. Lastly, the meeting suggested a systems approach to HPB surgery. However, it is clear that multimodality management requires multiple individual skills such as laparoscopic, endoscopic and open surgical techniques all being performed by a single person. This allows for better communication with other specialties, thus making the interdisciplinary and multiple disciplinary expertise readily available and the formation of the HPB multimodality team would likely improve patient management.