Cholangiocarcinoma surgery
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Suveenkrishna Pothuru, M.B,B.S. [2]
Overview
The predominant therapy for cholangiocarcinoma is surgical resection. Surgical resection of tumors with negative margins is the best option for all subtypes of cholangiocarcinoma although it is only achieved in less than 50% of cases.
Surgery
Surgical exploration may be necessary to obtain a suitable biopsy and to accurately stage a patient with cholangiocarcinoma. Laparoscopy can be used for staging purposes and may avoid the need for a more invasive surgical procedure, such as laparotomy.[1][2] The options for the treatment of cholangiocarcinoma are limited and associated with high rates of perioperative mortality, recurrence, and short survival times. Surgical resection of tumors with negative margins is the best option for all subtypes of cholangiocarcinoma although it is only achieved in less than 50% of cases.
- Curative resection, or resection of tumor-free surgical margins (R0), remains the best chance for long-term survival, and lymph node status is the most important prognostic factor following R0 resection.
- Routine lymphadenectomy at the time of surgical resection has been proposed in order to increase the chance of survival. However, it can be omitted in patients with solitary, small peripheral cholangiocarcinoma because the probability of lymph node metastasis is very low.
- Surgical resection is not recommended for cholangiocarcinomas in patients with primary sclerosing cholangitis because the recurrence rate is very high, close to 90%.
Intrahepatic cholangiocarcinomas
- In intrahepatic cholangiocarcinomas, resection has usually been indicated in patients with a solitary tumor and with no underlying hepatic disease.
- Some studies have concluded that major hepatectomy for intrahepatic cholangiocarcinoma is also indicated in selected cirrhotic patients because the overall morbidity, hospital mortality rates, and the appearance of liver failure and other complications (superficial wound infection, abscesses, sepsis, pancreatic leakage, delayed gastric emptying, or biliary leakage) are similar in patients with and without cirrhosis.
Extrahepatic cholangiocarcinomas
- Resection is a suitable treatment option for extrahepatic cholangiocarcinomas, depending on the extent in the biliary tree and hepatic vasculature.
- When such tumors are restricted to one lobe, there is no metastasis, and liver function is preserved, resection is recommended.
- Partial hepatectomy is the only factor associated with better outcome, probably because this option permits negative margins to be achieved.
- Tumor ablation performed percutaneously with sonographic guidance using radiofrequency or microwave energy can offer efficient therapy for nonoperable tumors up to 5 cm in size.
Biliary Stent
- For some patients with non-operable cholangiocarcinomas, biliary drainage through a tiny metal or plastic tube (‘‘biliary stent’’) may result in an improvement of the patient’s situation due to relief of the obstructive cholestasis.
- This can be done percutaneously, although with these external drainage systems patients may experience certain discomfort, and it is the only option in cases of complete biliary obstruction.
- Stents may eventually cease to function because of tumor overgrowth, obstruction, or other reasons.
- Plastic stents need to be changed every 3 months, while metal stents can be maintained for longer times.
- Cholestasis is a risk factor for hepatic failure after liver resection and stents are now widely used for preoperative drainage.
- Self-expanding metal stents are preferred because they provide rapid biliary decompression and a reduced complication rate after insertion.
Liver Transplant
- Liver transplantation is usually reserved for patients with cholangiocarcioma with either:
- Perihilar cholangiocarcinoma in the early stages, which cannot be removed surgically
- No detected metastase
- Tumors developed in livers with reduced function or underlying a biliary inflammation pathology, such as primary sclerosing cholangitis
References
- ↑ Weber S, DeMatteo R, Fong Y, Blumgart L, Jarnagin W (2002). "Staging laparoscopy in patients with extrahepatic biliary carcinoma. Analysis of 100 patients". Ann Surg. 235 (3): 392–9. PMID 11882761.
- ↑ Callery M, Strasberg S, Doherty G, Soper N, Norton J (1997). "Staging laparoscopy with laparoscopic ultrasonography: optimizing resectability in hepatobiliary and pancreatic malignancy". J Am Coll Surg. 185 (1): 33–9. PMID 9208958.