Neoplastic Lesions of the Extrahepatic Bile Ducts

Cancer of the bile ducts (cholangiocarcinoma) is treated palliatively in 80-90% of cases and resection should only be considered in localised tumours without metastatic spread. When surgical resection is considered the type of procedure will depend on the site of tumour:

• Tumours in the distal common bile duct (i.e., lying behind the duodenum and pancreas) -Whipple's procedure.

• Tumours proximal to this and distal to the confluence of the right and left hepatic ducts -wide excision of the supraduodenal biliary tree, gall bladder and related nodes. A length of jejunum is isolated in a Roux-en-Y loop and an end-to-side hepaticojejunal anastomosis allows biliary drainage.

• Tumours proximal to the hepatic confluence require the above plus a relevant liver resection (see Chapter 9).

Palliation for distal common bile duct tumours is most commonly done by ERCP stenting. Other methods of operative palliation (i.e., "bypass" techniques) are:

• Choledochoduodenostomy - proximal common bile duct is anastomosed to D1.

• Hepaticojejunostomy - can be used in more proximal biliary tumours (i.e., common hepatic duct/proximal common bile duct).

For proximal biliary (hilar) tumours, a segment III hepaticojejunostomy can be used. In this the liver is divided to the left of the falciform ligament until the segment III duct is visualised. An anastomosis is then fashioned between this and a Roux-en-Y loop of jejunum.

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