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BILE DUCT TUMOURS
273
very difficult to treat. This is particularly so if the stricture progresses into
the sectoral ducts. These patients are certainly candidates for an access limb
which may, by allowing a radiological approach to the site of the anastomosis,
prevent the need for further surgery.
Creation of access limbs merely requires the afferent limb of a Roux loop
used for a hepaticojejunostomy to be left about 10cm longer than normal so
that it comfortably reaches the abdominal wall. Usually the end of the limb
( Fig. 5.12 ) is simply sutured to the underside of the peritoneum in the midline,
above the transverse incision (some authors place the limb subcutaneously
analogous to a jejunostomy where the skin has not been breached, with or
without a small tube). The end of the tube is marked traditionally with metal
clips or wire but this does not allow orientation and even single wire loops give
no three-dimensional information. This resulted in further modification of
the technique utilizing two wire loops at 90 degrees to each other (Cameron
and Frazer, 1995 ). The wire loops are placed outside the bowel, just proximal
to the end of the afferent limb, and the orientation helps the radiologist to
enter and direct the instrumentation down the lumen of the limb.
Bile duct tumours
Cholangiocarcinoma ( Fig. 5.14 )
Cholangiocarcinoma can occur anywhere in the biliary tract but is most
common at the confluence (Klatskin tumour) (Khan et al ., 2008 ). The inci-
dence of tumours at the hilum has remained constant at 40–60% and only
10% of lesions occur within the intrahepatic bile ducts (Fong et al ., 1996 ).
Cholangiocarcinomas are uncommon and have an incidence of 1–2/100 000,
generally occurring in patients over 65 years of age with a peak incidence at
seventy (Carriaga and Henson, 1995 ). The vast majority of cholangiocarcino-
mas are adenocarcinomas irrespective of the location and other cell types are
very rare (Rogers et al ., 1981 ). They are believed to be generally slow growing
but this is not always the case, particularly in younger patients (Akwari and
Kelly, 1979 ). Many tumours express carcinoembryonic antigen and CA 19.9
but not with sufficient consistency to be used for diagnostic purposes (Koea
et al ., 2004 ).
Suspected or proven cholangiocarcinoma represents the most CBD tumour
requiring surgical intervention. Obtaining a firm preoperative diagnosis can
be challenging and the diagnosis is often made using a combination of radio-
logical appearance, tumour markers, and laparoscopy with ultrasound and
biopsy. Preoperative ERCP brushings and even duct biopsy may be available
but expose the patient to risk of infection in an undrained biliary system and
BILIARY TRACT
274
Fig. 5.14 Management of extrahepatic cholangiocarcinoma.
Presentation
Pain CT, MRI, MRCP
Jaundice
Jaundice >20x
normal and renal
impairment
Jaundice <20x
normal
otherwise fit
Chemotherapy
Chemotherapy
Metastases
omental/peritoneal
disease
Unresectable
due to local
spread
Resectable
Endoscopic
drainage
Resectable
Laparoscopy
Resection
Chemotherapy
Chemotherapy
Unfit
Resection
Fit
Surgery
Inoperable
BILE DUCT TUMOURS
275
should be reserved for patients with an incomplete obstruction or those where
drainage has been endoscopically or radiologically achieved.
Management
Table 5.1 summarizes the interventions most appropriate for those patients
suitable for surgery. Lower-third tumours require a Whipple’s resection (pan-
creaticoduodenectomy) as described in Section 1. Middle-third lesions usually
require a pancreaticoduodenectomy, bile duct resection, and lymphadenec-
tomy as outlined in Table 5.1 . In patients who are elderly, or unfit for surgery,
a local resection may be considered adequate. The operation that is not
described elsewhere is the excision of the tumour involving the confluence of
the bile ducts, the Klatskin tumour. Preoperative assessment with CT and MRI
is important to determine the lower limit of the tumour. MRCP may help
define the upper limits. ERCP should be avoided as the risk of infection in the
inadequately drained portion is considerable and can turn a relatively well
patient into a severely compromised one.
Internal drainage preoperatively should be avoided as it not only may lead
to infection, it may also lead to induration of the proximal and distal bile duct
wall making assessment of the extent of the tumour by palpation impossible.
Surgical treatment
Preoperative laparoscopy is essential to determine the extent of the disease.
Although extensive peritoneal disease is uncommon, more extensive disease
at the hilum (involving adjacent structures) is not unusual. Satellite liver
Table 5.1 Surgical treatment of cholangiocarcinoma depending on site
Lower third Middle third Upper third Intrahepatic
Pancreaticoduodenectomy Treatment
of choice if
resectable
Difficult to
obtain
clearance
— —
Bile duct resection and
lymphadenectomy
— Usually
performed
Rarely possible
Combined duct and liver
resection. Roux loop
reconstruction
— — Generally the
only way to
achieve
adequate
clearance
Possible if
clearance can
be combined
with formal
resection (right,
left, or central)
Segment III or IV bypass — — Occasionally
necessary if
extensive
If clearance not
possible
BILIARY TRACT
276
metastases are also not infrequently found and any disease dissemination
means that stenting is the more appropriate option (Callery et al ., 1997 ;
Jarnagin et al ., 2000 ). We prefer to perform a laparoscopic assessment just
prior to definitive surgery (5–10 days) and if there is no evidence of dissemi-
nated disease and the intraoperative ultrasound does not suggest that the
tumour is inoperable (vascular involvement, extension of the tumour signifi-
cantly beyond what was demonstrated on the preoperative imaging) then it is
well worth proceeding. The possibility of a right or left hepatectomy must
always be considered with hilar lesions and for the majority will be required to
obtain adequate clearance and achieve a Ro resection. On occasions a central
hepatectomy (involving Segments IV, V, VII, and sometimes I) may be the
only way to achieve clearance of awkwardly placed tumours while at the
same time retaining a safe volume of liver. Following a central resection, a
bilioenteric anastomosis will be required to second order (sectoral) ducts on
both sides.
Resection for cholangiocarcinoma ( Figs. 5.15 – 5.19 ) The operation will
commence with a thorough laparotomy, cholecystectomy, and manual exami-
nation of the hilum. Intraoperative ultrasound is then repeated (having been
performed at the laparoscopy) to examine the relationships particularly with
vascular structures and tumour invasion at the hilum.
Intraoperative ultrasound with colour Doppler is very good at detecting
vascular involvement but is also valuable for excluding small volume
intra hepatic metastases.
Fig. 5.15 Upper-third bile duct tumour dissected free of surrounding structures.
BILE DUCT TUMOURS
277
Fig. 5.16 Once respectability is confirmed, the bile duct is divided above the
duodenum and mobilized from surrounding structures.
Fig. 5.17 Portal vein and
hepatic artery separated
from the bile duct. The
left and right ducts are
mobilized.
BILIARY TRACT
278
If there are no contraindications to a curative resection at this point, the bile
duct mobilization should begin well below the tumour (usually at the upper
border of the pancreas ( Fig. 5.16 ).
Once the duct has been mobilized, a vascular loop is passed around it and
used to apply gentle traction so that the duct can be freed from the underlying
and medial structures ( Fig. 5.17 ).
Mobilization continues up to the confluence and if the tumour is still thought
to be resectable the hilar plate can be brought down to enable palpation of the
right and left hepatic ducts. At this point a decision needs to be made to either
continue with a resection or stop the operation. If a decision is made to con-
tinue, the bile duct is ligated and divided as far distally as possible and the lower
end oversewn. The freed CBD can now be lifted up and further mobilized.
Fig. 5.18 Frozen section defines the extent of the bile duct resection.
BILE DUCT TUMOURS
279
Palpable margins should be identified and the right and left ducts cut. These
must be sent for a frozen section ( Fig. 5.18 ).
If clearance is not confirmed, then further sections of duct are required for
frozen section. If one side cannot be cleared while the other is free then the
affected portion should be resected in conjunction with a bilioenteric anasto-
mosis (see Section 1). If both sides are free, a Roux loop is attached to the left
and right ducts ( Fig. 5.19 ).
Some believe that the caudate lobe should routinely be resected in Klatskin
tumours but this remains to be established and is not our practice. The decision
on resection can be a difficult challenge particularly if pathological confirma-
tion of cancer is not available. Usually tumours are obstructing and even if
inflammatory need to be resected.
Fig. 5.19 A Roux-en-Y anastomosis is performed to the right and left hepatic ducts.
BILIARY TRACT
280
Fig. 5.20 Intraoperative
ultrasound is helpful and
accurately locates the
dilated duct to segment III.
Surgical bypass Lesions known to be irresectable preoperatively, or found to
be so at laparoscopy, should be treated with percutaneous, endoscopic, or
combined stents if at all possible. Sometimes this is not possible or the decision
not to resect is only made at laparotomy (sometimes after a lengthy dissection).
In these circumstances, and providing the bile ducts are dilated, a Segment III
or V bypass should be considered and can provide excellent palliation
frequently with significantly less problems than associated with stents.
Segment III bypass ( Figs. 5.20 – 5.22 ) Defining the structures as they enter the
liver from under the ligamentum teres enables the duct for Segment III to be
displayed. It is usually found posterior to the portal vein and in front of the
artery.
Once opened, a 10 mm anastomosis should be performed. This procedure,
however, will only succeed if the bile duct is greater than 5mm in diameter,
and the liver has not become too rigid from longstanding obstruction. This
procedure is generally technically easier than a Segment V bypass, which is
usually only considered if there is direct tumour invasion of the base of the
falciform ligament.
Segment V bypass ( Fig. 5.23 ) If Segment III bypass is not appropriate and the
biliary tree is dilated on the right side, a Segment V bypass may be possible.
BILE DUCT TUMOURS
281
Fig. 5.21 The segment III bile duct is opened and anastomosed to a Roux loop.
Fig. 5.22 A completed bilio-enteric anastomosis to segment III.
BILIARY TRACT
282
The gallbladder is removed and an intraoperative ultrasound used to locate the
duct.
Providing it is not too deeply placed and the liver is compliant, then a side-
to-side anastomosis is possible. The need to drain both sides of the liver is
controversial and one side well drained, without infection on the other side,
will suffice in the majority of patients (Jarnagin et al ., 1998 ). An undrained,
infected lobe of liver will usually prove fatal.
Fig. 5.23 Use of intraoper-
ative ultrasound to locate
the dilated segment V
duct (after cholecystectomy)
to decide whether it is
suitable for an anastomosis.