Surgical Procedures: Surgery and Staging for Bile Duct Cancer (Cholangiocarcinoma)

Your bile ducts carry bile from your liver to your small intestine (small bowel). Bile is a greenish liquid made in the liver and stored in the gallbladder. Bile helps digest/break down fats and helps get rid of hemoglobin from old red blood cells.

When there are cancer cells in the bile duct, it is called cholangiocarcinoma. There are two types of cholangiocarcinoma:

• Intrahepatic bile duct cancer forms inside the bile ducts of the liver.
• Extrahepatic bile duct cancer forms outside of the liver, in either the perihilar or distal extrahepatic bile duct.

What is staging and how is it done?

Staging is a way to find out if and how far cancer has spread in your body. Your provider will have you get a few tests to figure out the stage of your cancer. These tests may include:

Physical Exam: This is a general exam to look at your body and to talk about your past health issues.

Imaging: Radiology tests look inside your body to see if the cancer has spread. These tests can include:

• CAT scan (CT scan).
• Magnetic Resonance Imaging (MRI).
• Ultrasound.
• MRCP (magnetic resonance cholangiopancreatography).

Laboratory Tests: Certain blood tests may be done, such as liver function tests to look at bilirubin and alkaline phosphatase levels, carcinoembryonic antigen (CEA), and CA 19-9 tumor marker testing.

Procedures: These may include:

• Laparoscopy: Many small incisions (cuts) are made in the belly. The surgeon will place a laparoscope (thin, lighted tube with tools on the end of it) into the belly to take a biopsy.
• Percutaneous transhepatic cholangiography (PTC): A needle is used under x-ray guidance (with dye) to look at the liver and bile ducts. Biopsies may be taken and in cases of duct blockages, a stent may be placed.
• Endoscopic retrograde cholangiopancreatography (ERCP): A lighted tube with a camera (endoscope) is placed through the mouth and into the small intestine under x –ray guidance (with dye) to look at the bile ducts. Biopsies may be taken. A stent is placed if there is a blockage of the duct.

Cholangiocarcinoma spreads to other parts of the body through the tissue, lymph, and blood systems. Cholangiocarcinoma is assigned a stage from 1 to 4. The stage is based on how much cancer there is, how far it has spread, and what treatment course can be used.

When planning treatment for cholangiocarcinoma, the tumors are further described as resectable (localized) or unresectable. In some cases, surgery is used to treat cholangiocarcinoma. Those with localized disease may have surgery to remove the whole tumor (resectable). Unresectable cancers can’t fully be removed with surgery.

Surgical Procedures for Cholangiocarcinoma

• Bile duct removal: In cases of small, confined cancers (within the bile duct only), full or partial bile duct removal may be done. In some cases, the surgeon may look at and remove lymph nodes and lymph tissue during this procedure.
• Partial hepatectomy: A wedge-shaped piece of liver tissue, a whole liver lobe, or a larger part of the liver, with an area of normal looking tissue around the tumor are removed.
• Whipple procedure: The pancreatic head (and at times the body), gallbladder, bile duct, and a part of both the stomach (pylorus), small intestine (duodenum), and nearby lymph nodes are removed.
• Laparoscopy: Many small incisions (cuts) are made in the belly. The surgeon will place a laparoscope with tools on the end of it into the belly to get a biopsy.
• Biliary bypass: For those with a blockage in the bile duct from a tumor, a biliary bypass may be done. A bypass around the tumor to another organ is made, such as the gallbladder.
• Stent placement: A tube, called a stent, is placed into the bile duct to keep it open and working.

Your surgeon will talk with you about if your cancer is resectable (can be removed with surgery) or unresectable (often cannot be removed with surgery).

In some cases, in addition to a partial hepatectomy, part of the pancreas and small intestine is removed. Some patients may even have a liver transplant. Your healthcare team will talk to you about this if it is an option for you.

What are the risks of cholangiocarcinoma surgery?

As with any surgery, there are risks and possible side effects. These can be:

• Reaction to anesthesia (Anesthesia is the medication you are given to help you sleep through the surgery, not remember it, and manage pain. Reactions can include wheezing, rash, swelling and low blood pressure).
• Bleeding.
• Blood clots.
• Infection.
• Pneumonia (infection in the lungs).
• Bile leaking into the abdominal cavity (belly).
• Liver failure.
• Nutritional problems may occur in some cases.

Your surgeon will talk to you about any other risks based on your health and the type of surgery you are having.

What is recovery like?

Recovery from surgery to treat cholangiocarcinoma depends on the procedure you had done. A hospital stay may be needed.

You will be told how to care for your incision (surgical cut) before leaving the hospital.

Your care team will go over the medications you will be taking, such as those for pain, blood clot prevention and/or other conditions.

You may have to make changes to your activity level. Your provider will talk about these with you.

How can I care for myself?

You may need a family member or friend to help you with your daily tasks until you are feeling better. It may take some time before your team tells you that it is ok to go back to your normal activity.

Be sure to take your prescribed medications as directed to prevent pain, infection and/or constipation. Call your team with any new or worsening symptoms.

There are ways to manage constipation after your surgery. You can change your diet, drink more fluids, and take over-the-counter medications. Talk with your care team before taking any medications for constipation.

Taking deep breaths and resting can help manage pain, keep your lungs healthy after anesthesia, and promote good drainage of lymphatic fluid. Try to do deep breathing and relaxation exercises a few times a day in the first week, or when you notice you are extra tense.

• Example of a relaxation exercise: While sitting, close your eyes and take 5-10 slow deep breaths. Relax your muscles. Slowly roll your head and shoulders.

This article contains general information. Please be sure to talk to your care team about your specific plan and recovery.