Ch. 54 – Biliary System

1584 Section X Abdomen
Figure 54-36 Computed tomography scan visualizes mass at
hepatic duct bifurcation (arrow) resulting in bilateral biliary
dilation and extensive perihilar malignancy.
tumor, including involvement of the bile ducts, liver, hilar
vessels, and distant metastases. The initial radiographic
studies consist of either abdominal ultrasound or CT
scanning (Fig. 54-36). Intrahepatic cholangiocarcinomas
are easily visualized on CT scans; however, perihilar and
distal tumors are often diffi cult to visualize on ultrasound
and standard CT scan. Cholangiocarcinoma can be
enhanced by using delayed-phase CT acquisition (10
minutes after contrast injection). A hilar cholangiocarcinoma
gives a picture of a dilated intrahepatic biliary tree
and a normal or collapsed gallbladder and extrahepatic
biliary tree. Distal tumors lead to dilation of the gallbladder
and both the intrahepatic and extrahepatic biliary
tree.
After documentation of bile duct dilation, biliary
anatomy has been traditionally defi ned cholangiographically
through either the percutaneous transhepatic or the
endoscopic retrograde route. The most proximal extent
of the tumor is the most important feature in determining
resectability in patients with perihilar tumors, and the
percutaneous route is favored in these patients because
it defi nes the proximal extent of tumor involvement most
reliably. PET will detect unsuspected distant or intrahepatic
metastases in up to 30% of patients with cholangiocarcinoma.
MRC offers good resolution of both the
intrahepatic and extrahepatic biliary tree, but should be
substituted with PTC or ERCP in patients that will require
preoperative or palliative biliary drainage. Biliary drainage
is necessary if the patient’s bilirubin is more than
10 mg/dL, but it has been associated with an increased
risk for cholangitis and longer postoperative hospital stay
in patients with obstructive jaundice who then undergo
resection. 46 Cholestasis, biliary cirrhosis, and liver dys-
Box 54-8 Radiologic Criteria to Suggest
Unresectability of Cholangiocarcinoma
Bilateral hepatic duct involvement up to secondary radicals
Bilateral hepatic artery involvement
Encasement of the portal vein proximal to its bifurcation
Atrophy of one hepatic lobe with contralateral portal vein
encasement
Atrophy of one hepatic lobe with contralateral biliary radical
involvement
Distant metastasis
Adapted from Anderson CD, Pinson CW, Berlin J, Chari RS: Diagnosis
and treatment of cholangiocarcinoma. Oncologist 9:43-57, 2004.
function develop rapidly in the face of unrelieved biliary
obstruction.
Percutaneous fi ne-needle aspiration biopsy, brush and
scrape biopsy, and cytologic examination of bile all have
been used to establish a tissue diagnosis; however, the
sensitivity in detecting a malignancy is low, and a benign
result should be considered unreliable. Seven to 15% of
patients with preoperative symptoms and imaging studies
and intraoperative fi ndings consistent with malignant
biliary obstruction will ultimately have benign lesions on
histologic analysis of resection specimens.
Management
Hepatic lobar atrophy and hepatic ductal extension
predict the need for hepatectomy in order to achieve a
margin-negative resection. 45,47 All available data must be
used to distinguish resectability from unresectability (Fig.
54-37). Radiographic criteria that suggest unresectability
of perihilar tumors include bilateral hepatic duct involvement
up to secondary radicals, encasement or occlusion
of the portal vein proximal to its bifurcation, atrophy of
one liver lobe with encasement of the contralateral portal
vein branch, involvement of bilateral hepatic arteries, or
atrophy of one liver lobe with contralateral secondary
biliary radical involvement (Box 54-8). Ipsilateral portal
vein involvement and involvement of secondary biliary
radicals do not preclude resection, nor does ipsilateral
lobar atrophy. 48 Curative treatment of patients with cholangiocarcinoma
is possible only with complete resection
(R0).
Patients with unequivocal evidence of unresectable
cholangiocarcinoma at initial evaluation are palliated
nonoperatively. Nonoperative palliation can be achieved
both endoscopically and percutaneously. Percutaneous
biliary drainage has several advantages over endoscopic
management in patients with perihilar cholangiocarcinoma,
whereas endoscopic palliation is the preferred
approach in patients with distal cholangiocarcinoma.
More recently, metallic stents have been used to palliate
patients with malignant biliary obstruction. These stents
remain patent longer than plastic stents and require fewer
subsequent manipulations.
Operative Approach
Surgical exploration should be undertaken in good-risk
patients without evidence of metastatic or locally unre-