Ch. 54 – Biliary System

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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-
sectable disease; however, intraoperatively, more than half of these patients are found to have either peritoneal or hepatic metastases or, more likely, locally unresectable disease. Selective use of laparoscopy in patients with locally advanced but potentially resectable perihilar cholangiocarcinoma may avoid laparotomy in some patients with metastatic disease. In patients who are found to have extensive metastatic disease, the preoperatively placed biliary stents should be left in place. However, a cholecystectomy should be performed to avoid the risk of acute cholecystitis, which occurs in patients with longterm indwelling biliary stents. In patients with locally advanced unresectable perihilar tumors, several operative approaches are available for palliation, including a Roux-en-Y hepaticojejunostomy to segment III or V. Distal cholangiocarcinoma—Distal lesions are usually treated with pancreaticoduodenectomy (Whipple’s procedure). A pylorus-preserving Chapter 54 Biliary System 1585 Figure 54-37 Flow chart depicting the workup and treatment of a patient with suspected hilar cholangiocarcinoma. CT, computed tomography; ERCP, endoscopic retrograde cholangiopancreatography; MRCP; magnetic resonance cholangiopancreatography; PTC, percutaneous transhepatic cholangiography. (From Anderson CD, Pinson CW, Berlin J, Chari RS: Diagnosis and treatment of cholangiocarcinoma. Oncologist 9:43-57, 2004.) operation is preferable and feasible in most patients, with 5-year survival rates averaging 15% to 25%, but can be as high as 54% in selected patients who undergo complete resection for node-negative disease. If resection is not possible owing to vascular encasement, cholecystectomy, Roux-en-Y hepaticojejunostomy proximal to the tumor, and a gastrojejunostomy to prevent gastric outlet obstruction should be performed. Intrahepatic cholangiocarcinoma—Intrahepatic cholangiocarcinoma is treated by hepatic resection, and outcomes depend on disease stage (particularly the status of the lymph nodes) and the ability to achieve negative margins. There is a broad range of long-term outcomes in patients undergoing complete resection (3-year survival rates of 22%-66%). Perihilar cholangiocarcinoma—For perihilar cholangiocarcinomas, bile duct resection alone
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Ch. 54 – Biliary System

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