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Bile Duct Tumors Treatment & Management

  • Author: Todd A Nickloes, DO, FACOS; Chief Editor: John Geibel, MD, DSc, MSc, MA  more...
 
Updated: Nov 18, 2015
 

Approach Considerations

Indications and contraindications for surgical treatment

Indications for bile duct tumor surgery include the following:

  • The tumor is resectable - Criteria for resectability include absence of liver metastases, absence of carcinomatosis, and absence of vascular invasion
  • The patient is fit for surgery

If the tumor is limited to the bifurcation of the hepatic ducts or a single lobe of the liver or if it involves the portal vein or hepatic artery on the same side, the lesion may be resectable. Preoperative imaging is aimed at establishing whether a viable unit of liver that is large enough to maintain adequate liver function will remain after surgical removal of the tumor. The remaining liver tissue must contain a normal branch of the portal vein and hepatic artery and must also contain a bile duct large enough to anastomose to the bowel (see the image below).

Operative photograph of choledochojejunostomy, sho Operative photograph of choledochojejunostomy, showing ample size of common duct.

Contraindications for surgery include the following:

  • Unresectable tumors - If tumors are extensive or fixed to adjoining structures, including the main portal vein or hepatic artery, they are unresectable; cholangiographic findings of invasion of the secondary hepatic duct in both lobes of the liver or angiographic evidence of encasement of the main portal vein or hepatic artery indicate unresectability.
  • Metastases including diffuse peritoneal involvement
  • Vascular invasion
  • Patients who are at high risk from general anesthesia and surgery because of general medical conditions
  • Advanced age

Future and controversies

The role of adjuvant radiotherapy and chemotherapy is controversial.[21, 22, 23] The use of hormones in treatment, including somatostatin analogues, cholecystokinin, and cholecystokinin antagonists, is being investigated.

It has been suggested that preoperative endoscopic retrograde cholangiopancreatography (ERCP) with biliary drainage in patients with tumors of the bile duct increases the risk of implantation metastases after resection of the tumor.[24] Therefore, preoperative radiotherapy is advocated in such patients, but the benefit has not been definitely proved.[25]

Transarterial chemoembolization (TACE), infusion of 5-fluorouracil (5-FU) into the hepatic artery or bile ducts, and percutaneous injection of ethanol (PEI) into the lesions are other modalities that are investigational.

Photodynamic therapy may be useful in relieving obstruction, especially when obstruction occurs as a result of tumor outgrowth into an endoprosthesis.[26]  Radiofrequency ablation is being studied as well.[27]

Liver transplantation, when performed for cholangiocarcinoma, is associated with poor survival.[28]

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Medical Therapy

Medical therapy is indicated for patients who are unfit for surgery or who have an unresectable tumor. Jaundice and itching can be reduced with the placement of an endoprosthesis, either endoscopically or percutaneously, across strictures.

Endoscopic techniques for the relief of obstruction include sphincterotomy, balloon dilatation of the stricture, and the placement of stents.[16] Larger, expandable metal stents, which have better patency rates than do plastic stents, include Metal-Palmaz, Strecker, Gianturco Z stent, and Wall stents.[29] One meta-analysis suggested that covered self-expandable metal stents have a trend toward later obstruction compared with uncovered self-expandable metal stents.[30]

Percutaneous transhepatic endoprosthetic insertion also is successful, but an increased risk of complications, such as blood and bile leakage, exists. Ninety percent of stents can be placed by a combination of endoscopic and percutaneous techniques after a failed endoscopic attempt.

Chemotherapy has been tried in these patients but has not been proved to be of definite benefit.[21]

Radiotherapy may be administered by external beam therapy; intraoperative radiotherapy using biliary stents with iridium (192Ir), radium, or cobalt (60Co); radioimmunotherapy using sodium iodide (131I) anti-carcinoembryonic antigen (CEA) as a component of therapy; or charged particle irradiation. Internal radiotherapy may be combined with biliary drainage, but the value of this approach remains to be proved.[22, 23]

Pain may be relieved with the injection of 50% alcohol for chemical splanchnicectomy.

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Surgical Therapy

Resection is the best treatment for bile duct tumors and provides the best palliation in terms of duration and freedom from infectious complications.[31, 32] Benefits of resection include the possibility of cure or long-term survival, especially for patients with distal tumors. The type of surgical procedure performed depends on the site and extent of the disease.

Choice of surgical approach

Proximal tumors (Klatskin tumors) may be managed by a variety of techniques, including the following:

  • Patients with perihilar tumors (Bismuth classification I and II), without evidence of vascular invasion, are candidates for local excision; if achieving negative margins are not possible with local excision, resection of the corresponding lobe is indicated
  • Type III tumors are managed best by right or left hepatic lobectomy; resection of the adjacent caudate lobe (segment I) may ensure adequate tumor-free margins in cases of involvement of the hepatic duct bifurcation
  • Sometimes, extended right or left hepatectomy and (rarely) central liver resection may need to be combined for adequate resection of the tumor

Following resection of the bile duct, which may be combined with hepatic resection, reconstruction can be performed by means of unilateral or bilateral hepaticojejunostomy, using transhepatic stents.[29]

Surgical exploration is indicated in patients who are fit for surgery when preoperative evidence of metastases is absent or when locally unresectable disease exists. If metastases are detected at the time of surgical exploration, bilateral stents that may have been placed preoperatively are left in situ, and cholecystectomy is performed to prevent the subsequent development of acute cholecystitis. Locally advanced and unresectable perihilar tumors also can be managed by means of Roux-en-Y cholecysto(docho)jejunostomy with intraoperative placement of Silastic biliary catheters or a segment III or V cholangiojejunostomy.

Midduct tumors can be managed with bile duct resection and Roux-en-Y reconstruction. Distal tumors may be amenable to Whipple resection (radical pancreaticoduodenectomy; see the image below) or pylorus-preserving pancreaticoduodenectomy. Unresectable tumors may be managed by cholecystectomy, a Roux-en-Y hepaticojejunostomy, or choledochojejunostomy proximal to the tumor, and additional gastrojejunostomy and chemical sympathectomy are considered.

Reconstruction after classic radical pancreaticodu Reconstruction after classic radical pancreaticoduodenectomy requires 3 anastomoses: pancreaticojejunostomy, choledochojejunostomy, and gastrojejunostomy. Illustration used with permission from Carol EH Scott-Conner, MD, PhD (ed), Chassin's Operative Strategy in General Surgery, Springer-Verlag, 2002.

Reconstruction involves anastomosis of bile ducts to a loop of jejunum (see the image below).

Cholangiogram showing completed choledochojejunost Cholangiogram showing completed choledochojejunostomy with widely patent anastomosis.

Palliation

Surgical bypass is indicated in patients in whom placing a stent by means of either endoscopic or percutaneous techniques is impossible and in patients who are found to have unresectable disease or metastases at exploration.[16]

Bypass may be accomplished by performing either a Roux-en-Y hepaticojejunostomy with intraoperative placement of a Silastic transhepatic stent or a segment III bypass to the left intrahepatic ducts. In patients with distal bile duct tumors, the operation of choice is biliary enteric bypass using the upper end of the extrahepatic bile duct or gallbladder. Consider prophylactic gastrojejunostomy in these patients, because some of these individuals may develop gastroduodenal obstruction prior to death. Bypass is less commonly required, because stents have improved, and even duodenal obstruction can now be effectively palliated.

Procedural details

Staging of the disease is determined by evaluating the findings from computed tomography (CT) and magnetic resonance imaging (MRI).[10, 11]  Delineation of the tumor and its extent may be assessed by means of cholangiography (endoscopic and transhepatic) and magnetic resonance cholangiography.[13]  Vascular involvement can be identified and assessed by means of CT, MRI, and angiography, as previously described (see Workup, Imaging Studies).

Patient risk for surgery and anesthesia is determined, and cardiac and pulmonary assessment is performed.

If the clinical condition of the patient does not rule out surgical intervention, the resectability and extent of tumor involvement are assessed, and metastases are sought. Tumors in the lower and middle portions of the bile duct usually are resectable if angiography and venography exclude vascular invasion. Cancer of the hilar region tends to be less amenable to resection.

At surgery, further assessment is performed with intraoperative ultrasonography and a search for lymph node involvement. Laparoscopy in patients with bile duct tumors can be useful in the identification of metastases and peritoneal disease and, hence, may assist in assessing resectability. Intraoperative ultrasonography also is useful and may be combined with laparoscopy.

Exploratory laparotomy is performed in patients who are fit for surgery and who are without any definite evidence of metastases or unresectability on preoperative investigation. One half of these patients are found to have evidence of intraperitoneal dissemination of the tumor or extensive involvement of the porta hepatis; therefore, they are candidates for minimal intervention, including bypass.

Postoperative care

These patients are at risk for the development of general complications, including pneumonia, deep venous thrombosis (DVT), and infection. Routine perioperative antibiotic prophylaxis and coagulopathy are administered. Active physiotherapy, breathing exercises, and early ambulation are encouraged.

Complications specific to the procedure performed include anastomotic leakage and bile leakage. Stents may be placed across anastomoses and removed after cholangiography confirms the absence or healing of the leak.[29]

Complications

Postoperative complications may be general or local. General complications include the following:

  • Myocardial infarction
  • Pneumonia
  • Surgical site infection
  • DVT
  • Pulmonary embolism (PE)

Technical complications related to the procedure performed include the following:

  • Bile leak
  • Stricture
  • Postoperative hemorrhage
  • Pancreatic fistula – May occur after radical pancreaticoduodenectomy

Complications arising from the placement of stents include the following:

  • Early - Cholangitis (7%) and perforation
  • Late - Blockage and migration of stent
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Long-Term Monitoring

Patients who have evidence of positive tumor margins after resection or who develop recurrence may be candidates for adjuvant radiotherapy.[22, 23] This usually takes the form of extracorporeal therapy for positive surgical margins and intraluminal radiotherapy for positive duct margins. Chemotherapy has not been shown to be of benefit.[21]

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Contributor Information and Disclosures
Author

Todd A Nickloes, DO, FACOS Associate Professor, Department of Surgery, Division of Trauma/Critical Care, University of Tennessee Medical Center-Knoxville

Todd A Nickloes, DO, FACOS is a member of the following medical societies: American Medical Association, American Osteopathic Association, Association for Academic Surgery, Society of Critical Care Medicine, Society of Laparoendoscopic Surgeons, Southeastern Surgical Congress, Southern Medical Association, Eastern Association for the Surgery of Trauma, American College of Osteopathic Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Ravi Pokala Kiran, MBBS, MS, FRCS 

Disclosure: Nothing to disclose.

Naveen Pokala, MBBS, MS, FRCS 

Disclosure: Nothing to disclose.

Brian Reed, MD Staff Physician, Department of Surgery, University of Tennessee Medical Center

Brian Reed, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Medical Association

Disclosure: Nothing to disclose.

LaMar O Mack, MD Resident Physician, Department of Surgery, University of Tennessee Medical Center

LaMar O Mack, MD is a member of the following medical societies: American Urological Association, National Medical Association, Student National Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

John Geibel, MD, DSc, MSc, MA Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow

John Geibel, MD, DSc, MSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, Society for Surgery of the Alimentary Tract

Disclosure: Received royalty from AMGEN for consulting; Received ownership interest from Ardelyx for consulting.

Additional Contributors

Marc D Basson, MD, PhD, MBA, FACS Associate Dean for Medicine, Professor of Surgery and Basic Science, University of North Dakota School of Medicine and Health Sciences

Marc D Basson, MD, PhD, MBA, FACS is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Gastroenterological Association, Phi Beta Kappa, Sigma Xi

Disclosure: Nothing to disclose.

Acknowledgements

Richard E Glass, MBBS, MS, FRCS Consultant General and Gastrointestinal Surgeon, Department of Gastrointestinal and General Surgery, Princess Margaret Hospital, UK

Disclosure: Nothing to disclose.

Michael A Grosso, MD Consulting Staff, Department of Cardiothoracic Surgery, St Francis Hospital

Michael A Grosso, MD is a member of the following medical societies: American College of Surgeons, Society of Thoracic Surgeons, and Society of University Surgeons

Disclosure: Nothing to disclose.

Carol EH Scott-Conner, MD, PhD Professor, Department of Surgery, University of Iowa College of Medicine

Carol Eh Scott-Conner is a member of the following medical societies: American Association for Cancer Research, American Association for the Surgery of Trauma, American Burn Association, American Cancer Society, American College of Gastroenterology, American College of Surgeons, American Medical Association, American Society for Gastrointestinal Endoscopy, Association for Academic Surgery, Association for Surgical Education,Association of VA Surgeons, Iowa Medical Society, Sigma Xi, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Critical Care Medicine, Society of Surgical Oncology, Society of University Surgeons, and Southeastern Surgical Congress

Disclosure: Nothing to disclose.

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Operative photograph of choledochojejunostomy, showing ample size of common duct.
Distal common bile duct tumor excised by radical pancreaticoduodenectomy. The tumor measured 1.2 cm in diameter.
Reconstruction after classic radical pancreaticoduodenectomy requires 3 anastomoses: pancreaticojejunostomy, choledochojejunostomy, and gastrojejunostomy. Illustration used with permission from Carol EH Scott-Conner, MD, PhD (ed), Chassin's Operative Strategy in General Surgery, Springer-Verlag, 2002.
Cholangiogram showing completed choledochojejunostomy with widely patent anastomosis.
Endoscopic retrograde cholangiopancreatography (ERCP) shows a narrowed area in the distal common bile duct with dilatation of the proximal biliary tree.
 
 
 
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