Surgical treatment for carcinoma of the extrahepatic bile duct

Abstract

Forty-eight patients with primary bile duct carcinoma are reviewed; there were 31 men and 17 women, aged from 39 to 79 yr. Preoperative diagnosis was made in 46 patients by means of percutaneous transhepatic cholangiogram (PTC), endoscopic retrograde cholangiopancreaticogram, selective celiac angiogram and cytologic examination of the bile. PTC was performed in 44 patients and the findings were divided into six groups based on the shape of stenosis or obstruction of the lesion. The tumor was most frequently resected in patients with either U-shaped or papillary-shaped form. Cytologic examination of the bile revealed positive results for carcinoma in 24 out of 34 patients in whom the bile was obtained preoperatively by PTC. Surgical treatment was performed in 23 patients with radical excision of the tumors, in 21 with external drainage, in two with internal drainage and in two with laparotomy only. Operative mortality rate in the resectable group was 17.8% (4 of 23 patients) and 44% in the unresectable group. With regard to methods of treatment and prognosis of the lesion, the patients were divided roughly into three groups depending upon the site of the tumor in the extrahepatic ductal system; upper group: tumor arising at or near the confluence of the hepatic ducts; middle group: tumor from the common hepatic duct down to the upper border of the pancreas; lower group: tumor in the intrapancreatic portion of the common bile duct. Out of the 21 patients in the upper group, only five underwent radical excision. Left hepatic lobectomy was required in one patient or resection of the right branch of the portal vein in another. Intestinal continuity was reconstructed in four out of the five patients with anastomosis of either right or left hepatic duct to the P loop of the defunctionalized jejunum associated with ligation of the right or left hepatic duct. Operative death of resectable cases in this group was 20% (one of five patients). Of the 21 patients in the middle group, seven were treated by local excision and end-to-end anastomosis of proximal common hepatic duct to the intestine or to the distal common bile duct without mortality, five underwent pancreatoduodenectomy with two operative deaths and nine were treated palliatively. The six patients in the lower group were treated by pancreatoduodenectomy; one patient died one month postoperatively. The survival period in the upper group was less than 18 months except one who is living two months after resection of the tumor at the time of this report Of the 12 patients in the middle group, eight lived for less than 13 months and four are living at the postoperatively period from 3 to 16 months. Of the six patients in the lower group, four died within 15 months after operation and two are living each at one year and nine months, and six years postoperatively. The 25 patients who underwent palliative operation regardless the site of the tumor died within 16 months after operation; the average survival period was 3.3 months.