Management of hilar bile duct carcinoma.

BACKGROUND/AIMS: Hilar cholangiocarcinoma is a rare tumor with a dismal prognosis. Because proximal bile duct cancers are uncommon, outcomes related to various therapeutic interventions are not well defined. METHODOLOGY: Between 1985 and 1997, 55 patients with bile duct cancers involving the proximal third of the extrahepatic bile ducts were seen. The management of patients with resectable and unresectable disease was retrospectively reviewed. All but four patients were followed until the time of death. RESULTS: Forty patients underwent laparotomy following preoperative assessment of extent of disease and 19 patients (35%) ultimately underwent resection with curative intent. Survival was significantly longer in patients who underwent resection (2-year survival 47% vs. 18%; P = 0.027). Of those patients whose disease was resected, 11 patients received adjuvant radiotherapy. Survival for this group was not significantly different from that seen in patients who did not receive adjuvant radiotherapy. Similarly, in patients with unresectable disease, administration of radiotherapy was not associated with an improved outcome. CONCLUSIONS: Locoregional extent of disease is the greatest problem in cases of proximal bile duct cancers. Resection provides the best hope for long-term survival, but new adjuvant strategies are needed.

A subcutaneous or subfascial jejunostomy is beneficial in the surgical management of extrahepatic bile duct cancers.

BACKGROUND: Extrahepatic bile duct cancers are rare tumors with a dismal prognosis. Even after a resection, obstructive cholestasis and other biliary complications are the rule. To facilitate retrograde access to the biliary tree for treatment of such biliary complications, a modified Roux-en-Y hepaticojejunostomy is constructed such that the afferent limb is brought up as a subcutaneous or subfascial jejunostomy (SJ). The safety and utility of construction of an SJ was evaluated in patients with extrahepatic cholangiocarcinoma. METHODS: From 1985 to 1997, 24 patients with extrahepatic bile duct cancers received an SJ as part of their management. Demographic data, operative data, tumor characteristics, and postoperative courses were retrospectively reviewed. All but 3 patients were followed to the time of death. RESULTS: The average age of the patients was 62 +/- 9 years. The tumor was resected in 17 patients. Major complications occurred in 5 patients (21%). There was 1 operative death (4%). None of the complications could be attributed to construction of the SJ, although 1 patient had a soft tissue infection at the site of the percutaneous access of the SJ. Frequent dilatations of biliary strictures were required in 5 patients, and 1 patient eventually required insertion of an internal biliary stent. These procedures could all be accomplished through the SJ. CONCLUSIONS: The SJ is a technically simple and safe addition to the management of resectable and unresectable extrahepatic bile duct cancers, particularly proximal lesions. The procedure facilitates brachytherapy if indicated, and it allows convenient management of postoperative biliary complications, including recurrent strictures.