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Surgery for extrahepaticbile duct cancer
Surgery is the main treatment for extrahepatic bile duct cancer, when possible. Surgery is used to:
- potentially cure resectable extrahepatic bile duct cancer by completely removing it
- Surgery is the most effective treatment for extrahepatic bile duct cancer.
- reduce pain or relieve symptoms or blockages caused by advanced extrahepatic bile duct cancer (palliative treatment)
Doctors may classify extrahepatic bile cancer into 2 groups based on whether or not the cancer can be removed by surgery.
- Resectable tumours can be completely removed by surgery.
- Early stage or localized bile duct tumours are more likely to be completely removed by surgery.
- The cancer cannot be completely removed by surgery.
- Late stage or advanced bile duct tumours are likely unresectable.
Most people with extrahepatic bile duct cancer are diagnosed at an advanced stage because this cancer is difficult to diagnose at an early stage. Surgery to completely remove the cancer usually isn’t an option if the cancer has spread:
- too far into the liver
- into major blood vessels in the area
- to the lining of the abdominal cavity (peritoneum)
- to organs far from the bile duct (metastatic disease)
Surgery may not be an option if the cancer is in a place that makes it too difficult for surgeons to completely remove.
The type of surgery done depends mainly on the location and stage of the cancer and other factors, such as the person's age and overall health. Surgery for extrahepatic bile duct cancer is very difficult and complicated to perform. The surgeon tries to get a tumour-free margin (small amount of normal tissue around the tumour) during the surgery. Side effects of surgery depend on the type of surgical procedure.
Doctors will assess the extent of the extrahepatic bile duct cancer before surgery. They check for any signs of metastatic disease and review diagnostic tests to determine if the cancer is resectable.
Doctors will also make sure that the person with extrahepatic bile duct cancer is healthy enough to have surgery. The more extensive the surgery, the more important it is that the person is healthy enough to tolerate it. People with extrahepatic bile duct cancer may not benefit from surgery if they are in poor health or have other health conditions that make it difficult for them to tolerate the surgery or the long recovery period afterward.
Some people with jaundice may have procedures to place a catheter or stent to drain bile before the cancer surgery. These procedures are described below.
If the tumour is very small and only found in the bile duct, doctors may surgically remove (resect) the extrahepatic bile duct. A new bile duct is made by connecting the duct opening in the liver to the small intestine. Surrounding lymph nodes are usually removed and examined to see if they contain cancer.
Resection of just the extrahepatic bile duct by itself is not often possible because extrahepatic bile duct cancer is usually not diagnosed at an early enough stage.
Surgery for perihilar bile duct tumours usually involves removing nearby liver tissue. This is called a liver (or hepatic) resection. This surgery is complicated because of the anatomy of blood vessels that supply the liver (portal vein and hepatic artery) and the anatomy of the hepatic ducts. The doctor makes a cut (incision) in the abdomen and removes the tumour along with a margin of normal liver tissue around the tumour. The extent of the surgery depends on the size and location of the tumour and extent to which the cancer has spread to the liver. It also depends on how well the liver is working.
Surgery for perihilar bile duct cancer may include removing:
- the part of the bile duct containing cancer
- a part of the liver
- a wedge-shaped section of the liver near the bile duct (wedge resection)
- an entire lobe of the liver (hepatic lobectomy)
- a larger part of the liver
- surrounding lymph nodes
The surgeon attaches the remaining bile duct to the liver.
There are more risks and complications associated with this procedure (such as bleeding, infection, bile leak and liver failure) than with less extensive surgery for extrahepatic bile duct cancer.
Surgery for distal bile duct tumours usually involves doing a pancreatoduodenectomy (Whipple procedure). A Whipple procedure removes:
- the part of the bile duct containing cancer
- the gallbladder
- part of the pancreas
- the first part of the small intestine (duodenum)
- a section of the lower part of the stomach
- In some cases, doctors do not to have to remove the pylorus (the narrow, bottom part of the stomach near the small intestine).
- surrounding lymph nodes
After these organs have been removed, the surgeon connects the remaining bile duct to the small intestine to drain bile from the liver.
There are more risks and complications associated with this procedure (such as infection and problems with digestion and blood sugar level) than with less extensive surgery for extrahepatic bile duct cancer.
Palliative surgery or procedures are done when extrahepatic bile duct cancer cannot be removed by surgery or is too widespread. The goal of palliative procedures is to relieve signs and symptoms like jaundicejaundiceA condition in which the skin and whites of the eyes become yellow and urine is dark yellow. and pain and to help prevent infection. Jaundice can occur if the tumour causes a blockage (obstruction) in the bile duct so that the bile cannot flow normally and builds up. Biliary drainage procedures are palliative treatments that restore the flow of bile and relieve symptoms, but they do not treat the cancer. They can improve the quality of life for people with symptoms.
A stent is a small metal or plastic tube that is placed into the bile duct. Most biliary stents are made of expandable wire mesh. The stent helps keep the bile duct open and allows bile to flow into the small intestine.
There are several ways to place the stent into the bile duct:
- The most common way to insert a stent is by endoscopy. The stent is put into place during an endoscopic retrograde cholangiopancreatography (ERCP).
- Stents may be inserted during a surgical procedure, though this is not as common as endoscopy.
- Doctors can place a stent through the abdomen using an x-ray to guide them. This is percutaneous transhepatic cholangiography (PTC). The doctor inserts a needle through the skin into the bile duct, and then injects a dye into the bile duct. The dye helps show blockages in the biliary tract so the doctor knows where to place the stent. The doctor then uses a guide wire to insert the stent. Once the doctor places the stent, the needle and guide wire are removed.
Biliary stents may be used for people with advanced extrahepatic bile duct cancer who are:
- physically weak
- not well enough to have surgery
Doctors may need to replace the stent after a few months if it becomes blocked.
Sometimes a tube (catheter) can be used to help drain bile from around a blockage. The catheter drains the bile into a bag outside the body or into the small intestine. The catheter is usually secured to the skin with a stitch (suture). Doctors often insert a biliary catheter in the same way as a stent, using percutaneous transhepatic cholangiography (PTC).
A biliary bypass is an operation that creates a route for bile to drain around a blockage. A biliary bypass changes the flow of bile so it can go around the tumour. Different types of biliary bypass operations may be done depending on where the blockage occurs.
- A choledochojejunostomy joins the common bile duct to the jejunumjejunumThe middle part of the small intestine that receives partially digested food from the duodenum, absorbs most nutrients and fat and passes the remaining food matter to the ileum. of the small intestine.
- A hepaticojejunostomy joins the common hepatic duct to the jejunum.
Doctors may offer a biliary bypass to people with advanced extrahepatic bile duct cancer who are healthy enough to tolerate the operation when a stent isn't possible or doesn't work to relieve jaundice.
A liver transplant is rarely an option for perihilar bile duct cancer and is not a standard treatment. It may only be considered in a select number of people with a tumour that cannot be completely removed by surgery but has not spread outside the liver. It is rarely done because:
- Extrahepatic bile duct cancer has a high rate of recurrence.
- It is difficult to find a suitable donor.
- There are many risks associated with an organ transplant.
If a transplant is planned, chemotherapy and radiation therapy are usually given before the person receives the transplant. Doctors may do exploratory abdominal surgery to look for lymph node metastases, peritoneal metastases or spread of the cancer that would make complete removal of the tumour impossible. With a transplant, the entire liver and bile ducts are removed and replaced by those from a donor. The person is given drugs to help suppress the immune system and make sure the body doesn't reject the transplanted liver.
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