Cholangiocarcinoma surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief:  Farima Kahe M.D. [2] Suveenkrishna Pothuru, M.B,B.S. [3]

## Overview

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The mainstay of treatment for cholangiocarcinoma is surgical resection. Surgical resection of tumors with negative margins is the best option for all subtypes of cholangiocarcinoma.

## Surgery

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* Surgical exploration may be needed to obtain a suitable biopsy and to accurately stage a patient with cholangiocarcinoma.
* Laparoscopy can be used for staging purposes and may avoid the need for a more invasive surgical procedure, such as laparotomy.[1][2]
* Routine lymphadenectomy at the time of surgical resection has been recommended to increase the chance of survival. Although it can be omitted in patients with solitary, small peripheral cholangiocarcinoma because of the low risk of metastasis.
* Surgical resection is not recommended for cholangiocarcinomas in patients with primary sclerosing cholangitis because the recurrence rate is very high.

### Intrahepatic cholangiocarcinomas

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* In intrahepatic cholangiocarcinomas, resection has usually been reserved among patients with a solitary tumor and with no underlying hepatic disease.[3]

### Extrahepatic cholangiocarcinomas

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* Resection is an appropriate treatment, depending on the extent in the biliary tree and hepatic vasculature.[4]
* Resection is usually reserved for extrahepatic cholangiocarcinomas which is restricted to one lobe and without metastasis and abnormal liver function.[5]
* Tumor ablation performed percutaneously with sonographic guidance using radiofrequency or microwave energy is usually reserved for nonoperable tumors up to 5 cm in size.

### Biliary Stent

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* Biliary stent is usually reserved for patients with non-operable cholangiocarcinoma.[6]
* It is performed percutaneously.
* Plastic stents require to be changed every 3 months and metal stents could be maintained for longer times.
* Metal stents are preferred rather than plastic stents because of rapid biliary decompression and a low complication rate after insertion.

### Liver Transplant

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* Liver transplantation is usually reserved for patients with cholangiocarcioma with either:[7][8]
* Perihilar cholangiocarcinoma in the early stages, which cannot be removed surgically
* No detected metastase
* Tumors developed in liver with reduced function or underlying a biliary inflammation pathology, such as primary sclerosing cholangitis.

## References

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1. ↑ Weber S, DeMatteo R, Fong Y, Blumgart L, Jarnagin W (2002). "Staging laparoscopy in patients with extrahepatic biliary carcinoma. Analysis of 100 patients". Ann Surg. 235 (3): 392–9. PMID 11882761.CS1 maint: Multiple names: authors list (link)
2. ↑ Callery M, Strasberg S, Doherty G, Soper N, Norton J (1997). "Staging laparoscopy with laparoscopic ultrasonography: optimizing resectability in hepatobiliary and pancreatic malignancy". J Am Coll Surg. 185 (1): 33–9. PMID 9208958.CS1 maint: Multiple names: authors list (link)
3. ↑ Ellis MC, Cassera MA, Vetto JT, Orloff SL, Hansen PD, Billingsley KG (2011). "Surgical treatment of intrahepatic cholangiocarcinoma: outcomes and predictive factors". HPB (Oxford). 13 (1): 59–63. doi:10.1111/j.1477-2574.2010.00242.x. PMC 3019543. PMID 21159105.
4. ↑ Kloek JJ, Ten Kate FJ, Busch OR, Gouma DJ, van Gulik TM (2008). "Surgery for extrahepatic cholangiocarcinoma: predictors of survival". HPB (Oxford). 10 (3): 190–5. doi:10.1080/13651820801992575. PMC 2504374. PMID 18773053.
5. ↑ Jang JY, Kim SW, Park DJ, Ahn YJ, Yoon YS, Choi MG, Suh KS, Lee KU, Park YH (2005). "Actual long-term outcome of extrahepatic bile duct cancer after surgical resection". Ann. Surg. 241 (1): 77–84. PMC 1356849. PMID 15621994.
6. ↑ Lee TH (2013). "Technical tips and issues of biliary stenting, focusing on malignant hilar obstruction". Clin Endosc. 46 (3): 260–6. doi:10.5946/ce.2013.46.3.260. PMC 3678064. PMID 23767037.
7. ↑ Darwish Murad S, Kim WR, Harnois DM, Douglas DD, Burton J, Kulik LM, Botha JF, Mezrich JD, Chapman WC, Schwartz JJ, Hong JC, Emond JC, Jeon H, Rosen CB, Gores GJ, Heimbach JK (2012). "Efficacy of neoadjuvant chemoradiation, followed by liver transplantation, for perihilar cholangiocarcinoma at 12 US centers". Gastroenterology. 143 (1): 88–98.e3, quiz e14. doi:10.1053/j.gastro.2012.04.008. PMC 3846443. PMID 22504095.
8. ↑ Pascher A, Nebrig M, Neuhaus P (2013). "Irreversible liver failure: treatment by transplantation: part 3 of a series on liver cirrhosis". Dtsch Arztebl Int. 110 (10): 167–73. doi:10.3238/arztebl.2013.0167. PMC 3607086. PMID 23533548.

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