Find out about surgery to completely remove bile duct cancer (cholangiocarcinoma) and some of the possible complications.
About surgery to remove bile duct cancer
Surgery gives the best chance of curing someone with bile duct cancer. If your surgeon thinks they can remove it all they call this a resectable cancer. Fewer than a third of people have resectable bile duct cancer when they are diagnosed.
Having an operation to completely remove bile duct cancer is major surgery. Only surgeons with specialist knowledge and experience should do this type of operation. You need to be generally fit to have the operation. It isn’t suitable for everyone.
Unfortunately it is common for bile duct cancer to come back even after surgery. And there is a risk of problems after this major operation. Your surgeon will talk to you in detail about what the operation involves, the risk of the cancer coming back, and what the possible complications are.
Surgery to remove bile duct cancers in the liver
If your cancer is in the bile ducts in your liver (intrahepatic bile duct cancer), your surgeon may be able to remove it and some of the surrounding liver tissue. This operation is called a resection or a hepatectomy.
Sometimes the surgeon needs to remove one of the lobes of the liver. This operation is called a lobectomy. The liver is made up of 2 main lobes. The lobes are divided into segments.
Many people have concerns about surgery that includes removing part of the liver. They may worry that their liver may not work well enough if some of it is removed. But if you have no underlying medical problems with your liver (such as cirrhosis) it is possible for the liver to grow and work normally.
Surgery to remove perihilar bile duct cancers
Perihilar cancers start in the area where the right and left hepatic ducts join together just outside the liver.
The type of surgery you have depends on the position of the cancer and how big it is. The surgeon usually removes:
- the bile duct containing the tumour and the common bile duct
- part of the liver
- the gallbladder
- the nearby lymph nodes
Your surgeon may also need to remove part of your pancreas and small bowel (duodenum).
Your surgeon will try to reduce the chance of the cancer coming back by removing the tumour and also a border of tissue around it that does not contain any cancer cells. They call this a clear margin.
To get a clear margin you may need to have part of your liver removed, as well as other organs close to the bile duct. The amount your surgeon needs to remove depends on where the cancer is in the bile duct and how large it is
Surgery to remove distal bile duct cancers
Distal bile duct cancers start in the common bile duct near the pancreas.
Surgery to remove distal bile duct cancer includes removing the cancer and the bile duct along with nearby lymph nodes.
Most people also need to have part of their pancreas and small bowel (duodenum) removed. Doctors call this operation a pancreaticoduodenectomy [(pank-ree-at-ic-oh dew-oh-den-ek-tom-ee)].
The surgeon takes away a border of healthy tissue around the tumour. This lowers the risk of cancer cells being left behind. If there are no cancer cells in the border of tissue, they call it a clear margin.
Rarely, people with distal bile duct cancers also need to have part of their liver removed.
Portal vein embolisation before surgery
Portal vein embolisation (PVE) means blocking off part of the blood flow to the area of liver that has the cancer. The aim of PVE is to increase the size of the healthy part of the liver by allowing it to grow. The liver is the only body organ that is able to grow back.
Surgery to remove a cancer may leave only a small amount of healthy liver and this increases the risk of liver failure. Having PVE before surgery allows the healthy liver to grow and so reduces the risk of your liver failing after the operation.
Your doctors might suggest that you have PVE if you have an early stage intrahepatic or perihilar bile duct cancer.
How you have PVE
You have this procedure in the x-ray department. It usually takes between 1 to 2 hours.
First you have an injection to make you sleepy (sedation). Your doctor injects a local anaesthetic into the right side of your tummy (abdomen) to numb the area. They then put a needle into your side and use dye and an x-ray machine to find the right vein.
Your doctor injects a special glue into the vein. The glue blocks the blood supply to that part of the liver.
You stay in hospital overnight. The main side effects are:
- bleeding – your nurses will check you regularly
You usually have to wait about a month after PVE before you have surgery. You usually have a scan first to measure your liver and check the PVE has worked.
Risk of cancer coming back after surgery
After any cancer surgery there is a risk that the cancer may come back. The risk of this happening depends on a number of factors including:
- the size of your cancer and how far it has grown (the cancer stage)
- where it is in the body
- whether the surgeon can remove a clear margin of tissue from all around the cancer
- whether there are cancer cells in the nearby lymph nodes
A clear margin is a border of tissue around the cancer that does not contain any cancer cells. It can be difficult for the surgeon to remove a clear margin around bile duct cancers because of the position of the bile ducts and their closeness to other organs. This increases the risk of the cancer coming back.
Your surgeon will talk to you about the risk of the cancer coming back, and help answer any of your questions about the operation.
A complication is anything that happens after surgery that makes your recovery more difficult. Chest infections and blood clots are possible complications after any surgery.
All operations to completely remove bile duct cancer are major surgery. The aim is to try to cure your cancer. So you and your doctor may feel it is worth taking some of these risks.
Make sure that you discuss the possible complications with your surgeon and have an opportunity to ask questions. Your family may also need to talk things through with your surgeon so that they can fully understand your situation.
Complications are more likely with bigger operations. About up to two thirds of people have some kind of complication after surgery for bile duct cancer.
Complications can be very serious. But they are becoming less common as surgeons get better at deciding who is likely to make a good recovery. But even so, some people who have the most major surgery for bile duct cancer may die as a result of complications after their operation.
Discussing the risks with your surgeon will help you to decide about whether to have surgery or not.
The most common complications are:
A leak can happen from around the join where tissues are stitched back together. It can cause a collection of bile or digestive juices. This can happen in up to 20 out of 100 people (20%) after bile duct cancer surgery.
Your doctor usually puts in a drainage tube until the leak stops. They usually do this during a procedure called an ERCP.
A fistula literally means an opening. An abnormal connection or path develops between two areas of the body.
A fistula may develop from the bile duct or pancreas after bile duct cancer surgery. This means bile or digestive juices can leak into surrounding tissues, which is very painful.
If you get a fistula, your doctor puts in a tube to drain it. You also have medicines to control swelling (inflammation). The tube stays in until the fistula dries up. The fistula then heals on its own. Sometimes the surgeon has to operate again to repair the leak.
Some people develop liver failure after surgery. The risk is higher if you have had liver problems before. So before you have surgery, you have tests to check how well your liver is working and to check for other liver conditions such as cirrhosis.
Internal infections can develop if there is a build up of fluid or blood after your surgery.
Your nurse will give you antibiotics through your drip if you develop an infection. Your doctor will drain abscesses or any fluid that has collected internally. They put in a needle to suck out the fluid. Or you have a drainage tube put in. Your doctor will use x-ray or ultrasound to make sure the needle or tube is in the right place.
You may have bleeding straight after your operation if a blood vessel is not tied off completely. You can also have bleeding if your blood is not clotting properly. Bleeding in the few days following surgery can happen because of infection.
The treatment you need depends on what is causing the bleeding. You may need a blood transfusion.
Chest infections are a common complication of many operations. Infections happen when you can’t move around as much as usual. The physiotherapists and nurses will help you to get up and move around as soon as possible to help reduce the chance of a chest infection.
Chest infections can also happen if you can’t breathe deeply enough after your surgery. Phlegm (pronounced flem) that you would normally cough up stays in your lungs and can become infected. You can help to prevent chest infections by doing deep breathing exercises.
Below is a short video showing breathing and circulation exercises after surgery. Click on the arrow to watch it.
these exercises help prevent you
developing a chest infection or blood
clots in your legs after surgery
these problems are more likely when
you're not moving around as you would
you can do these breathing exercises
while sitting up in a chair or bed or
was lying down relax your shoulders and
upper chest take a slow deep comfortable
breath in and hold for a couple of
seconds then slowly breathe out repeat
this three times you can start these
breathing exercises as soon as you come
round from the anesthetic you should try
to do them every hour when awake until
you are fully mobile if you need to
cough support your wound with your arms
a pillow or a rolled up towel if you're
struggling to clear any phlegm try a
this is where you breathe out in a short
sharp manner as if you're trying to
steam up a mirror
you should move about as soon as
possible after operation but why you
were not as mobile try to keep your legs
moving to encourage better circulation
you can do these exercises in a bed or
in a chair one foot at a time
point your toes away from you then pull
your toes towards your chin try to do 10
of these on both feet at least two or
three times an hour
the next exercise is circling your
ankles one-at-a-time circular ankles
clockwise and then anti-clockwise repeat
this 10 times with each ankle two or
three times an hour
You have heart tests before your surgery to make sure your heart is able to cope with the operation. But bile duct operations can increase the strain on your heart. Some people develop heart problems after surgery that they did not have before.