Surgery for bile duct cancer

Surgery for bile duct cancer is a complex operation and should be done by an experienced surgeon working at a major medical center whenever possible.

There are 2 general types of surgical treatment for bile duct cancer -- potentially curative surgery and palliative surgery.

Potentially curative surgery is used when imaging tests indicate a good chance that the surgeon will be able to remove all of the cancer. Doctors may use the term resectable to describe cancers they believe can be removed completely (by potentially curative surgery) and unresectable to describe those they think have spread too far or are in too difficult a place to be entirely removed by surgery. Unfortunately, only a small portion of bile duct cancers are resectable at the time they are first found.

Palliative surgery may be performed to relieve symptoms or treat (or even prevent) complications, such as blockage of the bile ducts. This type of surgery is performed when the tumor is too widespread to be completely removed. Palliative surgery is not expected to cure the cancer, but it can sometimes help someone feel better and sometimes can even help them live longer. Palliative surgery is described in more detail in the section "Palliative therapy for bile duct cancer."

Surgery to remove bile duct cancer can have significant side effects and, depending on how extensive it is, may require several weeks for recovery. Patients whose cancer is not curable may want to carefully weigh the pros and cons of surgery or treatments that require significant recovery time. Unless there is clear evidence that such treatments will improve the patient's chance for longer survival or improved quality of life, some patients with very advanced stages of bile duct cancer may choose to avoid them.

If your surgical team is planning curative surgery, they first may perform a laparoscopy to get a better idea of the extent of the cancer. This procedure is described in the section, "How is bile duct cancer diagnosed?" Laparoscopy allows the surgeon to look for any spread of the cancer that may make curative surgery impossible.

Surgery for resectable cancers

For resectable cancers, the type of operation depends on the location of the cancer.

Intrahepatic bile duct cancer: These cancers have started in bile ducts within the liver. To treat these cancers, the surgeon cuts out the part of the liver containing the cancer. Removing part of the liver is called a partial hepatectomy. Sometimes this means that a whole lobe of the liver must be removed. This is called hepatic lobectomy. It is a complicated operation and requires an experienced team of surgeons and assistants. If the amount of liver tissue removed is not too great, the liver will function normally because its tissue has some ability to grow back.

Perihilar bile duct cancer: These cancers begin where the branches of the bile duct first exit the liver. Surgery for these cancers requires great skill, as the operation is quite extensive. Usually part of the liver must be removed, along with the bile duct, gallbladder, nearby lymph nodes, and sometimes part of the pancreas and small intestine. Then the surgeon must connect the remaining ducts to the small intestine. This is not an easy operation for the patient, and about 8% die from complications of this surgery.

Distal bile duct cancer: These cancers are further down the bile duct near the pancreas and small intestine. Along with the bile duct and nearby lymph nodes, in most cases the surgeon must remove part of the pancreas and small intestine. Just like the other operations, this is a complex procedure that requires an experienced surgical team.

Possible risks and side effects: The risks and side effects of surgery depend in large part on the extent of the operation and a person's general health before the surgery. All surgery carries some risk, including the possibility of bleeding, infections, complications from anesthesia, pneumonia, and even death in rare cases.

People will have some pain from the incision for some time after the operation, but this can usually be controlled with medicines.

Surgery for bile duct cancer is a major operation that might mean removing parts of several organs. This can have a significant effect on a person's recovery and health after the surgery. Because most of the organs are involved in digestion, eating and nutrition problems are often long-term side effects of surgery for this cancer.

Surgery for unresectable cancers

Liver transplant: For some people with unresectable intrahepatic or perihilar bile duct cancers, removing the liver and bile ducts and then transplanting a donor liver may be an option. In some cases it might even cure the cancer.

But even for people who are eligible for a transplant, getting a new liver may not be easy. Not many livers are available for patients with cancer because they are generally used for more curable diseases. People needing a transplant must wait until a liver is available, which can take too long for some people with bile duct cancer. An option that has become more popular in recent years is having a living donor give a part of their liver for transplant to a close relative. This can be successful, but it carries risks for the donor.

Like other surgeries for bile duct cancer, a liver transplant is a major operation with potential risks (bleeding, infection, complications from anesthesia, etc.). But there are also some additional risks after this surgery.

People who get a liver transplant have to be given drugs to help suppress the immune system and prevent the body from rejecting the new organ. These drugs have their own risks and side effects, especially the risk of getting serious infections. Some of the drugs used to prevent rejection can also cause high blood pressure, high cholesterol, diabetes, and can weaken the bones and kidneys. After a liver transplant, regular blood tests are important to check for signs of rejection. Sometimes liver biopsies are also taken to see if rejection is occurring and whether changes in the anti-rejection medicines are needed.

Palliative surgery: In some cases a doctor may think that a cancer is resectable based on the information available (imaging tests, laparoscopy, etc.), but once the surgery is started it becomes clear that the cancer is too advanced to be removed completely. At this point the surgeon may do a biliary bypass to allow the bile to flow into the intestines to reduce symptoms such as jaundice or itching.

In this palliative procedure, the surgeon creates a bypass around the tumor blocking the bile duct by connecting part of the bile duct before the blockage with a part of the duct that lies past the blockage. Often, the gallbladder is used to provide some of the bypass.

If a bypass can't be done, the surgeon may simply place a plastic or expandable metal tube (called a stent) through the bile duct to keep it open. This is discussed in the section "Palliative therapy for bile duct cancer."