Surgery for bile duct cancer

Surgery is the main treatment used to treat bile duct cancer. The type of surgery you have depends on whether the tumour can be completely removed with surgery (is resectable) or cannot be completely removed (is unresectable). When planning surgery, your healthcare team will also consider other factors, such as your overall health.

Surgery may be done for different reasons. You may have surgery to:

• completely remove the tumour
• remove as much of the tumour as possible (called debulking) before other treatments
• reduce pain or relieve symptoms or blockages caused by advanced bile duct cancer (palliative surgery)

The surgeon tries to remove the tumour along with a layer of tissue at the edge of the tumour where there are no cancer cells (a negative margin). But most people with bile duct cancer are diagnosed at a late stage when surgery to completely remove the cancer is not possible, for example, if the cancer has spread:

• too far into the liver
• into major blood vessels in the area
• to the lining of the abdominal cavity (peritoneum)
• to organs far from the bile duct (metastatic cancer)

Before surgery, the surgeon will look at the test results to see if the cancer can be removed with surgery. The doctor will also make sure that you are healthy enough to have surgery. Some people with jaundice due to a blockage of the bile duct may have a catheter or stent inserted to drain bile before the surgery that will remove the cancer.

The following types of surgery are used to treat bile duct cancer. You may also have other treatments before or after surgery.

Bile duct resection is surgery to remove a section of the bile duct where there is cancer. The cancer is still in the early stage and is small and only in the bile duct. This surgery may be used when cancer is in the part of the bile duct outside the liver (extrahepatic). A new path for bile is made by connecting the remaining duct opening to the small intestine. Surrounding lymph nodes may be removed to see if they contain cancer.

This surgery is not done often because bile duct cancer is not usually found in the early stage.

In a liver resection (also called a partial hepatectomy), part of the liver is removed with surgery along with an area of healthy liver tissue. It may be used in bile duct cancer that is near the liver (perihilar) or in the liver (intrahepatic).

This surgery is complicated because of the different blood vessels (portal vein and hepatic artery) and hepatic ducts in the liver. The doctor makes a cut in the abdomen (belly). The surgery depends on the size and location of the tumour and how much it has spread to the liver. It also depends on how well the liver is working. A section of the liver or an entire lobe may have to be removed. The surgeon attaches the remaining bile duct to the liver.

A Whipple procedure (pancreaticoduodenectomy) is used to treat extrahepatic distal bile duct cancer. A Whipple procedure removes part of the bile duct and pancreas, the gall bladder and part of the small intestine (duodenum) and stomach as well as the surrounding lymph nodes.

After these organs have been removed, the surgeon connects the remaining bile duct to the small intestine to drain bile from the liver.

During a liver transplant, the liver is removed and replaced with a healthy liver from an organ donor. A liver transplant is not usually an option for most types of bile duct cancer and is not a standard treatment. A liver transplant is not usually done because:

• Intrahepatic bile duct cancer has a high rate ofcoming back after treatment (recurrence).
• It is difficult to find a suitable liver donor.
• There are many risks associated with an organ transplant.

A liver transplant is an option in perihilar cholangiocarcinoma. It may be done in some people when the tumour cannot be completely removed with surgery but has not spread outside the liver.

With a transplant, the entire liver and bile ducts are removed and replaced with those from a donor. The person with cancer is given drugs to help suppress the immune system and make sure the body doesn't reject the transplanted liver. If a transplant is planned, chemoradiation is given before the transplant. Sometimes, it may be given after the person receives the transplant. But if the cancer has spread to other organs, a liver transplant will not be done.

Find out more about liver transplant.

Palliative surgery or procedures are done when bile duct cancer cannot be removed with surgery or is too widespread. These procedures relieve symptoms like jaundice or pain and help prevent infection. Jaundice can occur if the tumour causes a blockage in the bile duct so that the bile cannot flow normally and builds up. Biliary drainage restores the flow of bile and relieves symptoms, but it does not treat the cancer. It can improve your quality of life.

A stent is a small metal or plastic tube that is placed into the bile duct. Most biliary stents are made of expandable wire mesh. The stent helps keep the bile duct open and allows bile to flow into the small intestine.

There are several ways to place a stent into the bile duct:

• The most common way to insert a stent is with an endoscopy. The stent is put into place during an ERCP (endoscopic retrograde cholangiopancreatography).
• Stents may be inserted during a surgical procedure, though this is not as common as with an endoscopy.
• Doctors can also place a stent through the abdomen using an x-ray to guide them during a PTC (percutaneous transhepatic cholangiography). The doctor inserts a needle through the skin into the bile duct and then injects a dye into the bile duct. The dye helps show blockages in the biliary tract so the doctor knows where to place the stent. The doctor then uses a guide wire to insert the stent. Once the doctor places the stent, the needle and guide wire are removed.

Sometimes a tube (catheter) can be used to help drain bile from around a blockage. The catheter drains the bile into a bag outside the body or into the small intestine. The catheter is usually secured to the skin with a stitch (suture). Doctors often insert a biliary catheter in the same way as a stent, using a PTC.

A biliary bypass is an operation that creates a route for bile to bypass the blockage. It changes the flow of bile so it can go around the tumour. Different types of biliary bypass operations may be done depending on where the blockage is.

• A choledochojejunostomy joins the common bile duct to the jejunum of the small intestine.
• A hepaticojejunostomy joins the common hepatic duct to the jejunum.

Doctors may offer a biliary bypass to people with advanced extrahepatic bile duct cancer. It may be used when a stent isn't possible or does not relieve the bile duct blockage.

Side effects can happen with any type of treatment for bile duct cancer, but everyone’s experience is different. Some people have many side effects. Other people have only a few side effects.

Side effects can happen any time during, immediately after or a few days or weeks after surgery. Sometimes late side effects happen months or years after surgery. Most side effects will go away on their own or can be treated, but some may last a long time or become permanent.

Side effects of surgery will depend mainly on the type of surgery and your overall health.

You may have some of the general side effects of surgery, such as pain, nausea, vomiting or infection. Surgery for bile duct cancer may also cause bleeding, lung problems and these other side effects:

A blood clot in the leg is called a deep vein thrombosis (DVT). It can occur right after bile duct surgery because the person is not moving around much. Other factors also contribute to DVT. In the most serious cases, a blood clot can break away and travel to the lungs (called a pulmonary embolus). This causes shortness of breath and affects the ability of the blood to get oxygen from the lungs. Report shortness of breath and any redness, swelling, pain or cramps in the calf of the leg to the doctor or healthcare team.

Diarrhea or more frequent bowel movements can happen in people who have extrahepatic bile duct surgery, especially if bile is redirected to flow directly into the small intestine. Stool also tends to stay in the bowel for less time.

Cholangitis is an inflammation of the bile ducts. It occurs when bile doesn’t drain properly and causes an infection. This can happen when a biliary stent or drainage catheter becomes blocked. Doctors may prescribe antibiotics and replace a blocked biliary stent or catheter.

A bile leak or bile duct injury can happen after extrahepatic bile duct surgery. It can cause pain in the abdomen. The doctor may do an ERCP to find the source of the leak and place a stent to help drain the bile. Surgery is sometimes needed to repair the leak or injury to the bile duct.

An anastomosis is where the remaining bile duct is surgically connected to another structure, such as the small intestine. The stitches holding the 2 ends together may break or come apart and bile may leak out into the abdomen. This is called an anastomotic leak, and the surgeon needs to repair it.

Digestion problems can happen after a Whipple procedure. The pancreas makes digestive enzymes, and removing part of the pancreas can cause a decrease of enzymes. About 1 in 3 people who have had a Whipple procedure need to take enzymes to help them digest food.

After surgery, you may not feel like eating, or you may feel bloated or full faster. It may be easier to eat small meals throughout the day rather than having 3 large meals each day. Snacking between meals can also help the body absorb food and lessen bloating or feeling too full.

Problems with blood sugar levels can happen when part of the pancreas is removed during a Whipple procedure. The pancreas produces insulin, which is needed to control blood sugar. You may develop diabetes if part or all of the pancreas is removed. The chance of developing diabetes is greater if you had blood sugar problems before surgery. The healthcare team will monitor the blood sugar level. Changes in diet and medicines may be needed to control high blood sugar.

Tell your healthcare team if you have these side effects or others you think might be from surgery. The sooner you tell them of any problems, the sooner they can suggest ways to help you deal with them.

Find out more about surgery and side effects of surgery. To make the decisions that are right for you, ask your healthcare team questions about surgery.