Surgical Resection

 

Deciding whether a patient can undergo surgery for extra-hepatic bile duct cancers is a very complicated process. The medical team will review staging information to decide if the tumor can be removed by surgery. For hilar CCA, it is important to surgically remove all of the liver containing diseased ducts.

 

If the remaining liver is too small to perform well on its own, a portal vein embolization (PVE) is performed before surgery, to help the remaining liver grow after the tumor is removed. Cancers in the distal bile duct (the part closest to the small intestine) are treated like pancreatic cancer, by removing part of the pancreas, the distal bile duct and the duodenum (whipple surgery). General surgical approach for bile duct cancer below.

 

For common bile duct (CBD) cholangiocarcinomas, all of the extra-hepatic bile ducts and the lymph nodes need to be removed. Most extra-hepatic cholangiocarcinoma involve the hilum, which includes the hepatic duct and the left and right branches of hepatic duct.

 

The decision about whether an intra-hepatic cholangiocarcinoma can be removed surgically depends on whether the portion of the liver containing the tumor can be completely removed and whether the patient can tolerate this major procedure if they have other major medical conditions (such as heart and lung disease, poorly controlled diabetes).

 

The tumor has to be contained within either the right or left lobe of the liver and not in both lobes or outside the liver. Tumors that form visible masses generally have a better survival after surgery than those that penetrate the bile ducts.

 

The Mayo Clinic in Rochester, Minnesota, developed a standard treatment protocol (plan) using preoperative radiation therapy and 5-FU chemotherapy. This treatment before transplantation is called neoadjuvant therapy and includes high dose external beam radiation therapy, additional radiation given through the inside of the bile duct (“brachytherapy”), and chemotherapy.

 

After completing the pre-operative treatments and prior to transplantation, patients undergo abdominal exploratory surgery. This staging operation is done to make sure that the tumor has not spread beyond the liver in which case transplantation would hurt rather than help the patient.

 

The “Mayo Clinic” protocol has strict criteria designed to avoid transplantation for patients who would not benefit from the procedure. Patients must not have intrahepatic cholangiocarcinoma, no evidence of extra hepatic disease (metastases), or gallbladder involvement, no active infection, or a medical condition that would preclude preoperative therapy or liver transplantation. This protocol should be offered only by medical centers, which have the physicians who are knowledgeable and experienced in this type of specialty care.

 

The decision about whether an extrahepatic cholangiocarcinoma can be removed surgically depends on whether the portion of the liver containing the tumor can be completely removed and whether the patient can tolerate this major procedure if they have other major medical conditions (such as heart and lung disease, poorly controlled diabetes).

 

The tumor has to be contained within either the right or left lobe of the liver and not in both lobes or outside the liver. Tumors that form visible masses generally have a better survival after surgery than those that penetrate the bile ducts.