Obstructive jaundice secondary to ruptured of a hepatocellular carcinoma into the common bile duct: Diagnosis and surgical treatment

Obstructive jaundice secondary to the rupture of a hepatocellular carcinoma into the common bile duct is a rare circumstance. Eighteen patients with this condition have been encountered over a 12-year period at Chang Gung Memorial Hospital. The patients included eleven males and seven females, ranging in age from 36 to 65 years with a mean age of 48. Nine patients (50%) had had a past history of hepatitis. Clinical presentations included jaundice in eight, acute cholangitis in seven and right upper abdominal pain in three patients. Pre-operative diagnosis was correct in nine patients (50%), based on a preoperative work-up including liver function tests, HbsAg, alphafetoprotein, sonography, cholangiography, CT scanning and angiographic study. Acute cholangitis or severe jaundice was relieved using percutaneous transhepatic biliary drainage in five patients. Operative procedures included choledochotomy with T-tube drainage in 18 patients, right hepatectomy in 2, left hepatic artery ligation in 1, and cholecystectomy with suture ligation of bleeders in another. Subsequent transcatheter hepatic artery embolization (TAE) was performed in two patients with stenting of the common bile duct. Intraoperative choledochoscopy was utilized to detect the rupture sites in 13 patients, and postoperative choledochoscopy for the removal of tumor fragments in the common bile duct was done in another 4 patients. There were three hospital deaths (16.6%) from septic shock. The overall length of survival for 11 patients with T-tube intubation was 3.9 months with range of 2 to 7 months. Two patients with T-tube stenting and TAE survived for eight months. The two patients undergoing surgical resection had the best postoperative survival times, with one living for more than five years.