Cholangiocarcinoma Surgery

Intrahepatic and hilar: two different operations

When surgery is possible

Surgery is considered when the tumor can be removed completely, with clear margins, preserving enough liver, and there are no distant metastases. For an intrahepatic tumor, multiple lesions, regional lymph node involvement and invasion of major vessels are considered unfavorable but not always absolute obstacles — such cases are discussed individually. Large size by itself does not make the tumor inoperable.

For a hilar tumor, enough liver must remain after resection with its own vascular pedicle and a duct to which the bowel can be joined. Vascular involvement is not always an obstacle: sometimes a segment of the portal vein is removed together with the tumor and blood flow is restored.

If the risk of hidden spread is high — a large tumor, multiple lesions, a high CA 19-9 — diagnostic laparoscopy can be performed before a major resection: it detects small peritoneal lesions not visible on CT.

Preparation: drainage and liver volume

Before a major resection with marked jaundice, cholangitis or a small future liver remnant, bile drainage is usually restored first. The drain is placed in the part of the liver that will remain — endoscopically or through a skin puncture. These procedures are performed by endoscopists and interventional radiologists; we organize this stage and decide which duct to drain.

If the future liver remnant is small, portal vein embolization is also performed so that it grows. That is why CT and MRI with MR cholangiography should preferably be done before a drain or stent is placed: a drain distorts the picture, and the extent of the tumor along the ducts becomes harder to assess.

If surgery is not possible right now

The first-line standard for an inoperable tumor in patients in satisfactory general condition is chemotherapy combined with immunotherapy. If molecular testing of the tumor has found a target, the corresponding targeted drugs are used in later lines. For a hilar tumor the most important thing is reliable bile drainage; a metal stent is placed only once inoperability has been confirmed by a surgeon.

Sometimes the tumor shrinks after treatment and the question of resection returns. That is why follow-up imaging during therapy is also reviewed by a surgeon. If you have been told that surgery is impossible, it makes sense to get a surgeon’s second opinion.

How the operation is performed

For an intrahepatic tumor, part of the liver is removed with a margin of healthy tissue — from several segments to the right or left half — together with the regional lymph nodes: of the hepatoduodenal ligament, along the hepatic artery and, for left-sided tumors, of the lesser omentum. When the tumor location and extent of resection allow it, the operation is performed laparoscopically.

For a Klatskin tumor, the extrahepatic bile ducts are removed together with the right or left half of the liver, the caudate lobe and lymph nodes. The duct margins are examined urgently under the microscope during surgery. Bile drainage is restored by joining the liver ducts to a loop of small bowel. Because of the complexity of the reconstruction, this operation is mostly performed as open surgery.

Hospital stay, recovery and further treatment

Recovery follows the enhanced recovery (ERAS) protocol: early mobilization, early eating, controlled pain relief. In the first days liver function, bile drainage and signs of infection are monitored closely. After surgery for a hilar tumor the hospital stay is usually longer than after a standard liver resection.

Adjuvant chemotherapy is usually given after surgery; its regimen and duration are set by the oncologist based on the histopathology report. In the first years CT or MRI and tumor markers are done regularly, every few months, and later less often.

Risks and complications

Risks are what patients ask about least often, although they are the most important thing to discuss before surgery. The main ones are:

• liver failure — with an insufficient remnant volume; this is why volumetry and, if needed, embolization are done before surgery;
• bile leak from the resection surface or the duct-to-bowel anastomosis;
• cholangitis and later narrowing of the duct-to-bowel anastomosis;
• bleeding, infection and general surgical complications, including thrombosis.

The likelihood of each depends on the type of tumor, the extent of resection and the condition of the liver. I will explain the risks in your particular case at the consultation.

What the cost depends on

The cost depends on the extent of liver resection, whether bile duct reconstruction is needed, the approach, preparation for surgery, the number of days in the hospital and the tests. The exact amount is named once the treatment plan has been defined. The payment can be split into parts — installments are available. The in-person consultation is free. More details are on the page “Cost of Surgery: What It Depends On”.

What documents are needed and how to book

• CT and MRI with MR cholangiography discs and reports — especially those done before a drain or stent was placed;
• ERCP, cholangioscopy and percutaneous drainage reports, if performed;
• histopathology, cytology and molecular reports, tissue blocks and slides;
• blood chemistry with bilirubin, CA 19-9 and CEA tumor markers;
• summaries of previous treatment.

Book a consultation by phone or through the form. If you are from another city, send the documents in advance — how to do this is described on the page “Online Oncologist Consultation”.