Surgery to remove bile duct cancer

Bile duct cancer is also called cholangiocarcinoma. Surgery aims to remove the cancer and some healthy tissue around it. It gives the best chance of a cure.

Unfortunately, surgery isn’t for everyone. Less than 3 out of 10 people (less than 30%) can have surgery to remove bile duct cancer. This is because the cancer has already spread by the time most people are diagnosed. This is called advanced bile duct cancer.

How your surgeon decides

Your surgeon looks at your tests and scan results to see if they can remove (resect) the cancer. If they think they can, the cancer is called resectable.

They also check how well you are overall. This is because surgery to remove bile duct cancer is a major operation. So, you need to be generally fit to have it.

Like all operations, there is a risk of problems after this surgery. Your surgeon will talk to you about:

what the operation involves
what to expect after the operation
the chance of the cancer coming back
the risks and benefits of having the operation
if you are well enough to have the operation

Removing bile duct cancer

The type of surgery you have depends on where the bile duct cancer is. There are 3 main types:

intrahepatic bile duct cancer - starts in the bile ducts in the liver
perihilar bile duct cancer - starts in the bile ducts just outside the liver. This is where the right and left hepatic bile ducts meet
distal bile duct cancer - starts in the bile duct near the pancreas and small bowel (duodenum)

Diagram showing the groups of bile ducts

During the operation, your surgeon removes the cancer and a border of tissue around it. This is called the margin.

It can be difficult for your surgeon to remove a margin without cancer cells in it. This is because the bile ducts are very close to main blood vessels and other organs.

If there are cancer cells in the margin it increases the chance of the cancer coming back.

Before surgery to remove bile duct cancer

If there is a collection of bile in your liver, your surgeon may want to drain it before the operation. This is called biliary drainage. It can make your liver work better. It can also help it grow back if your surgeon needs to remove part of it.

They drain the bile:

by putting a small tube in your bile duct to keep it open - this is called a stent
passing a thin tube called a catheter through your skin and into your liver - a radiologist does this during a procedure called a percutaneous transhepatic cholangiography (PTC)

You don’t normally need biliary drainage for intrahepatic bile duct cancer. But you might need it if the cancer is in the perihilar or distal bile ducts.

Your surgeon will talk to you about how they will drain the bile and the risks and benefits.

Surgery to remove intrahepatic or perihilar bile duct cancer

Your surgeon normally removes the parts of your liver where the cancer is. The operation is called a liver resection or a hepatectomy.

They check how well your liver works before the operation. But having some of your liver removed might sound frightening. You might worry that the remaining part may not work well enough. But your surgeon only needs to leave a third of your liver for it to grow back. And if you don’t have other liver problems it will usually work normally.

If you have a medical condition called cirrhosis Open a glossary item , you might not have enough healthy liver for your body to cope after the operation. Your doctors will talk to you about other treatment options instead of surgery.

Increasing the size of your liver

Your surgeon might ask you to have a procedure called a portal vein embolisation before the operation. They do this if your liver is too small to work properly after surgery. It sends more blood to the part of the liver that isn’t being removed. The extra blood makes it grow. This means it works better.

The portal vein brings blood from your tummy (abdomen) to your liver. In the liver the vein branches in 2. One branch goes to the left side and the other goes to the right. They are called the left and right portal veins.

Diagram showing the liver, its blood supply and the hepatic bile ducts

Having a portal vein embolisation

A radiologist puts a thin tube called a catheter through your skin and into your liver. They inject a dye (contrast medium) down the catheter. This lets them see the portal vein on an x-ray or scan. They can then inject very thin coils, beads or a special liquid into the portal vein on the same side of the liver as the cancer. This stops blood going to that side. More blood then goes to the other side making it grow. This is the part that isn’t going to be removed.

After 4 to 6 weeks your surgeon will check the size of your liver again. If they are happy it has grown enough to work properly, they will arrange the operation.

Liver resection

The liver is split into 8 sections.

Your surgeon might remove a number of them. Which ones and how many depends on:

the size of the cancer
whether the cancer is in the intrahepatic or perihilar bile ducts
whether intrahepatic bile duct cancer is in the left or right hepatic duct

Your surgeon only removes the hepatic bile duct on the same side of your liver as the cancer. This means bile keeps flowing from the hepatic duct on the other side.

Sometimes, they may also need to remove:

the junction where the left and right hepatic bile ducts meet
the bile ducts outside of the liver
your gallbladder

This means there will be no connection between the remaining bile duct in your liver and your duodenum. So, your surgeon will need to reconnect it. This is called a Roux-en-Y hepaticojejunostomy.

If you have intrahepatic bile duct cancer, your surgeon might remove the cancer using keyhole Open a glossary item (laparoscopic) surgery.

Surgery to remove distal bile duct cancer

Your surgeon may do an operation called a pylorus preserving pancreaticoduodenectomy (pank-ree-at-ic-oh dew-oh-den-ek-tom-ee) or PPPD. Or they may do a pancreaticoduodenectomy. This is also called a Whipple’s procedure.

PPPD

Your surgeon normally removes:

the bile ducts outside your liver (extra hepatic bile ducts)
your gallbladder
part of your pancreas and duodenum

Diagram showing the parts of the body removed during a pylorus preserving pancreaticoduodenectomy (PPPD)

After the operation, your stomach, pancreas and the remaining part of your bile duct are joined to your duodenum.

Diagram showing how the pancreas, bile duct and stomach are joined to the bowel after a PPPD operation

Whipple's procedure

As well as your extra hepatic bile ducts, gallbladder and parts of your pancreas and duodenum, your surgeon might also need to remove the lower part of your stomach.

Diagram showing the parts of the body removed for a Whipple operation

The diagram below shows how your surgeon might join your pancreas and your remaining stomach and bile duct after the operation.

Diagram showing how the pancreas, bile duct and stomach are joined to the bowel after a Whipple's operation

Your pancreas is important for digestion of food. It makes:

insulin to control your blood sugar
pancreatic juice – this contains enzymes which help break down food and make it easier for your body to use

The remaining part of your pancreas should continue to make insulin and pancreatic juice after surgery. So, you may not need to take extra insulin or enzymes. Your doctor will monitor your blood sugar and digestion in case this changes.

You will need support with your eating and drinking after these types of surgery. It might take time to return to a normal diet.

Lymph nodes

Cancer can spread to the lymph nodes. These are part of your lymphatic system Open a glossary item . They get rid of damaged cells and waste products. And they contain cells that fight infection.

Your surgeon normally removes a number of nodes near the bile ducts during the operation. This is to check for cancer cells. Which lymph nodes they remove depends on where the bile duct cancer is.

Problems after surgery

Complications after bile duct surgery can be serious. Possible problems include bleeding and liver failure.

Risk of the cancer coming back after surgery

After any cancer surgery there is a risk the cancer may come back. The risk depends on a number of factors including:

the size of the cancer and how far it has grown
where it is in your body
whether your surgeon can remove a clear margin of tissue from around the cancer
whether there are cancer cells in the nearby lymph nodes

Unfortunately, it is common for bile duct cancer to come back after surgery. Your surgeon will talk to you about the risk of it coming back and answer any of your questions.

Treatment to lower the risk of the cancer coming back

After surgery, your doctor might suggest you have treatment to lower the chance of the cancer coming back. This is called adjuvant therapy. You usually have a chemotherapy drug called capecitabine for 6 months after surgery.

If the cancer comes back after surgery

If bile duct cancer comes back after surgery you normally have treatment with chemotherapy, targeted cancer drugs and immunotherapy.

Some targeted and immunotherapy drugs are only used to treat bile duct cancer that has certain gene changes (mutations). Your doctor will test you for these changes. This helps them decide on the best treatment for you.