Bile duct resection

What is bile duct resection?

Bile duct resection is an operation to remove bile duct cancer, also called cholangiocarcinoma, by taking out the affected section of duct along with a border of healthy tissue around it. Depending on where the cancer is, your surgeon may also need to remove nearby organs, or parts of them, to reach all the affected tissue.

What conditions does it treat?

This surgery treats bile duct cancer that hasn't spread beyond the bile ducts, or has only grown just outside them, sometimes described as 'resectable' cancer. There are 3 main types, based on where the cancer starts:

• Intrahepatic bile duct cancer, which starts in the bile ducts inside the liver.
• Perihilar bile duct cancer, which starts just outside the liver, where the left and right hepatic bile ducts meet.
• Distal bile duct cancer, which starts near the pancreas and small bowel (duodenum).

Unfortunately, most people with bile duct cancer cannot have this surgery, because the cancer has often spread by the time it's diagnosed.

What are the benefits of having bile duct resection?

For people whose cancer can be fully removed with a clear margin of healthy tissue around it, surgery offers the chance of a cure. It's the only treatment for bile duct cancer that can achieve this, which is why specialist centres will always check carefully whether it's possible in your case.

Are there different types of surgical approaches?

The operation depends on exactly where the cancer is:

• For intrahepatic bile duct cancer, your surgeon removes the affected part of your liver, called a liver resection or hepatectomy; your surgeon only needs to leave around a third of your liver behind for it to grow back and work normally, and smaller, more superficial lesions can sometimes be removed using keyhole surgery.
• For perihilar bile duct cancer, your surgeon removes the bile ducts, gallbladder and the part of the liver closest to the bile ducts, sometimes along with part of the pancreas and small bowel; a rare, very early cancer may only need the bile ducts and nearby lymph nodes removed.
• For distal bile duct cancer, your surgeon removes the bile ducts, gallbladder, part of the pancreas and the first part of the small bowel (duodenum); this is called a pylorus-preserving pancreatoduodenectomy (PPPD), or, if the lower part of the stomach is also removed, a pancreatoduodenectomy, also known as a Whipple's procedure.

If removing the necessary amount of liver would leave too little behind to work safely, techniques to grow the remaining liver first may be used, such as portal vein embolisation, which redirects blood flow to the part that will stay, or, less commonly, selective internal radiation therapy (SIRT).

What happens before the operation?

You'll have a pre-assessment and a number of tests to check you're fit enough for what is a major operation, and to help you prepare. Your surgeon uses your scan results, alongside how well you are overall, to decide whether the cancer can be fully removed.

If bile is building up in your liver, it may be drained beforehand, either using a small stent placed in the bile duct or a thin tube passed through the skin into the liver (a procedure called Percutaneous Transhepatic Biliary Drainage (PTBD). This is usually only needed for perihilar or distal bile duct cancer, not intrahepatic.

If your remaining liver would otherwise be too small, you may have a procedure such as portal vein embolisation first, with a follow-up scan around 4 to 6 weeks later to confirm it's grown enough for surgery to proceed safely. You may also have a staging laparoscopy, a keyhole look inside your abdomen to check the cancer hasn't spread further than earlier scans suggested, or a liver biopsy under local anaesthetic to assess your liver's condition.

What happens during the procedure?

While the exact organs involved depend on where your cancer is (as covered above), the operation generally follows this pattern:

1. Your surgeon removes the section of bile duct containing the cancer, along with a border of healthy tissue around it, aiming to leave no cancer cells behind.
2. Nearby lymph nodes are removed too, so they can be checked for cancer cells.
3. Depending on where the cancer is, other organs or parts of them may be removed at the same time, such as part of your liver, your gallbladder, part of your pancreas, or part of your small bowel.
4. Your surgeon reconnects the remaining organs so that bile, and where relevant, food and pancreatic juices, can continue to flow into your small bowel.

What does recovery look like?

After surgery, you'll have some tubes and drains in place, and some people need a short stay in a high-dependency or intensive care unit before moving to a general ward. Staff will help you get up and about and let you know when you can eat and drink again. Most people stay in hospital for around 1 to 2 weeks after bile duct cancer surgery, extending to about 3 weeks for the biggest operations involving the pancreas.

Before you leave the hospital, your nurse will go through any new medicines and what to expect at home. It's common to feel very tired for several weeks, and sometimes months, so it's worth arranging help for the first stretch. If part of your pancreas was removed, you may need enzyme replacement capsules with meals, usually long-term, and occasionally temporary insulin injections; a dietitian can support you with any changes to your appetite or digestion.

Many people are offered chemotherapy afterwards, usually tablets of a drug called capecitabine for about 6 months, taken for 2 weeks followed by a week off in each 3-week cycle, to lower the chance of the cancer coming back. You'll have regular follow-up appointments and scans, and can contact your specialist team about any new symptoms between visits rather than waiting.

What are the risks and complications?

• infection
• blood clots
• bleeding
• a bile leak
• liver failure
• reduced insulin or digestive enzyme production if part of the pancreas is removed, sometimes needing lifelong replacement treatment
• cancer cells remaining at the edge of the tissue removed (the margin), which raises the chance of the cancer coming back
• it's common for bile duct cancer to return even after surgery, so your surgeon will discuss this risk with you individually.