Case selected by the ANZASM Committee

General Surgery

Case summary

An 85-year-old woman presented with painless obstructive jaundice due to presumed gallbladder cancer invasion of the common hepatic duct (diagnosed via CT scan). The jaundice was relieved with a percutaneous transhepatic cholangiography (PTHC) drain. A cholecystostomy drain was also inserted because of the gallbladder distension.

She recovered well from the procedure and a left hemihepatectomy was planned with curative intent. Three weeks after the drainage 
procedures a CT scan apparently showed no metastatic disease. Review by a physician indicated she was fit for surgery.

Two weeks later she was admitted for surgery. A midline laparotomy found metastatic disease to both lobes of the liver as well as malignant infiltration of the falciform ligament. An on-table decision was made to perform a segment III bypass and subtotal cholecystectomy. Postoperatively, she was managed in ICU for 48 hours then discharged to the ward. She was noted to be ‘confused’ and ‘delirious’ at times. 

On postoperative day 6 a tubogram was done, which reported no leakage of contrast at the segment III hepaticojejunostomy. The PTHC drain was removed.

Although the patient was reportedly well over the subsequent 48 hours, a stoma bag had to be placed over the site. She was unwell through postoperative day 9, although her observations were supposedly stable. A medical emergency team call occurred in the early hours the next morning. She had become tachycardic, hypotensive and febrile and was also complaining of abdominal pain. She was returned to ICU. Electrocardiography showed no ischaemic changes; echocardiography showed severe left ventricular dysfunction, thought to be Takotsubo cardiomyopathy. A coronary angiogram excluded coronary artery disease as a cause.

Blood cultures from the previous day grew primarily Escherichia coli and Enterococcus faecalis. A relook laparotomy on postoperative day 11 showed ‘turbid-looking fluid’, minimal soilage and an apparently intact anastomosis. Washout was performed and drains placed. Initially she improved, but three days after the second laparotomy bile was observed in one of the drains. Over the following week there was progressive decline with altered mental state and increasing lethargy.

Discussion between the surgeon and family members resolved that no further active intervention would occur. The patient passed away 21 days after the initial surgery.

Discussion

Issues for discussion comprise the patient, the disease and the surgery.

Although the patient was apparently healthy before her present illness, she was elderly. Major abdominal surgery in this age group is fraught with pitfalls and life-threatening complications. Serious consideration should have been taken before embarking on this course of action. Safer options are always preferable, whether the intent is curative or palliative.

It is unclear whether the primary pathology was gallbladder cancer infiltrating the common hepatic duct, or hepatic duct carcinoma that had infiltrated the neck of the gallbladder. Either scenario presents a grim prognosis, especially when the tumour has grown to the extent of causing obstructive jaundice. Cure rates in these cases are extremely poor, ranging from 5–30 per cent.

Hepatectomies are not without risk of morbidity and mortality.^{1, 2} These risks also depend on the type of hepatectomy. In this case, with a central lesion arising just below the porta, liver segments I, IV, V and VI are those most likely to be involved, necessitating their removal. This would leave the remaining left (segments II, III) and right lobes (segments VII, VIII) separated, requiring two biliary enteric anastomoses. The reason for proposing a left hemihepatectomy initially is unclear. Whichever route is taken, 1 (or 2) biliary enteric anastomoses are required, with the accompanying risk of leakage (as happened in this case), sepsis and death.

This patient had already received significant palliation of her jaundice with the placement of the PTHC drain. To offer her a hope of cure via major hepatic resection is to raise unrealistic expectations. Bile duct cancers do not present early. All the subsequent complications and problems stemmed from the initial decision to offer major curative surgery. This was an inappropriate course of action by the surgical team.

Clinical lessons

1. Always seek the safest option for high-risk patients during preoperative discussions with patients and family. In this case, a PTHC drain palliating the jaundice would have sufficed.
2. CT scans do not always reveal the whole picture. In this instance, when exploring curative surgical options, it would have been wiser to first offer a diagnostic laparoscopy before proceeding to a formal laparotomy. Intraoperative decision-making would have been less pressured if the metastatic disease had been diagnosed on laparoscopy.
3. Once confronted with metastatic disease and the need for an on-table decision, the safest option would have been to close the abdomen and leave the PTHC tube in place for palliation.
4. When postoperative patients decline, always look for a surgical cause first. A normal tubogram does not exclude the possibility of an anastomotic leak. The Takotsubo cardiomyopathy was merely a manifestation of a more serious underlying problem—that of intra-abdominal sepsis.

References
^[1] Stevens CL, Babidge WJ, Maddern GJ. Variability of perioperative mortality of hepatic resection in Australia. ANZ J Surg. 2018; 88:1022-7.
^[2] Longchamp G, Labgaa I, Demartines N, Joliat GR. Predictors of complications after liver surgery: a systematic review of the literature. HPB (Oxford). 2021; 23:645-55.

Disclaimer
Please note that these cases are edited from ANZASM first- or second-line assessments that have been generated by expert surgeons in the field. Any recommendations relate to these cases as they were presented.