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-yellow liquid made in your liver and stored in your gallbladder. Bile helps digest (break down) fats. It also 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 that forms inside the bile ducts of the liver.
• Extrahepatic bile duct cancer that forms outside 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. You will need to get a few tests to figure out the stage of your cancer, such as:

Physical Exam: This is an 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. You may need:

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

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

Procedures: You may need:

• Laparoscopy: Small incisions (cuts) are made in your belly. The surgeon will place a laparoscope (thin, lighted tube with tools on the end of it) into your belly to take a biopsy.
• Percutaneous transhepatic cholangiography (PTC): A needle is used under X-ray guidance (with dye) to look at your liver and bile ducts. Biopsies may be taken. A stent may be placed if there is a blockage in the duct.
• Endoscopic retrograde cholangiopancreatography (ERCP): A lighted tube with a camera (endoscope) is placed through your mouth and into your small intestine under X-ray guidance (with dye) to look at your 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 your tissue, lymph, and blood systems. Cholangiocarcinoma is given a stage from 1 to 4. The stage is based on how much cancer there is, how far it has spread, and which treatment may work best.

Surgery can sometimes be used to treat cholangiocarcinoma. When planning treatment for cholangiocarcinoma, the tumors are described as resectable (localized) or unresectable. If the cancer is localized, you might 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 cancers that are within the bile duct only, a part or all of the bile duct may be removed. 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. Part of the pancreas and small intestine may also be removed. Some patients may even have a liver transplant.
• Whipple procedure: The head (and sometimes the body) of the pancreas, the gallbladder, bile duct, and part of the stomach (pylorus) and small intestine (duodenum) is removed. Nearby lymph nodes are also removed.
• Biliary bypass: If the tumor is blocking your bile duct, 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 tell you if your tumor is resectable (can be removed with surgery) or unresectable (cannot be removed with surgery).

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, to not remember it, and to help with pain. Reactions can include wheezing, rash, swelling and low blood pressure).
• Bleeding.
• Blood clots.
• Infection.
• Pneumonia (infection in the lungs).
• Bile leaking into the abdomen (belly).
• Liver failure.
• Problems with nutrition.

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 cholangiocarcinoma surgery depends on the procedure you had. 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 okay 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 drainage of lymphatic fluid. Try to do deep breathing and relaxation exercises a few times a day in the first week, or when you feel like 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.