Surgery

Bile Duct Cancers

Surgical removal of intra-hepatic cholangiocarcinoma depends on whether the portion of the liver containing the tumor can be completely removed, and whether the patient can tolerate this major procedure given their other medical conditions (age, heart and lung disease etc.). The tumor must be contained within either the right or left lobe of the liver and not in both lobes or outside the liver. Sometimes a tumor that spreads to the lymph nodes can be removed by surgery, but the cancer has a high chance of returning and patient survival is not as long.

Determining surgical candidacy is more complicated for extra-hepatic cholangiocarcinomas. Cancers in the distal bile duct (the part closest to the small intestine) are treated like pancreatic cancer, by an extensive Whipple procedure that removes part of the pancreas, the distal bile duct, part of the stomach and the duodenum. For common bile duct cholangiocarcinomas, all of the extra-hepatic bile ducts and the lymph nodes need to be removed. Most extra-hepatic cholangiocarcinomas involve the liver hilum which includes the hepatic duct and the left and right branches of hepatic duct. These are also called the Klastskin tumors.

Hepatocellular Carcinoma

In some cases, hepatocellular carcinoma that is confined to the liver is amenable to surgical removal (resection). Patients with hepatocellular carcinoma will often have disease of the liver such as cirrhosis. Cirrhosis creates challenges for successful surgery for several reasons. While a normal liver can “regenerate” or grow back after a portion of it has been removed, cirrhotic livers are unhealthy and do not regenerate as well, or in some cases, at all. In addition, some patients with cirrhosis have elevated blood pressures within the liver, known as portal hypertension. This can lead to excessive bleeding during surgery that cannot be controlled. And finally, livers with more advanced cirrhosis do not make blood clotting factors as well as normal livers do, and a shortage of clotting factors also contributes to excessive bleeding.

As a result, very careful testing by an experienced liver surgeon is necessary to determine whether or not a liver tumor can be surgically removed. Patients with multiple tumors, or tumors that invade into major blood vessels such as the portal veins, are generally not good candidates for surgery. The location of a liver tumor must be such that removal of the tumor leaves behind enough healthy liver, called the future liver remnant. In some cases, a surgeon will choose a strategy in which the blood supply to one side of the liver is blocked off several weeks prior to surgery. This is done to stimulate growth (liver regeneration) on the other side of the liver prior to resection. The procedure to block off the blood vessel – portal vein embolization (PVE) -- does not require an operation, and is performed by an interventional radiologist.

Liver resections are technically complex operations, and should be performed by a surgeon who has specialized training in this field. Liver resections generally take several hours, and most patients are hospitalized for 5 - 10 days, and in some cases, much longer. In rare instances, a liver tumor can be removed by laparoscopic surgery, in which fiberoptic instruments are placed through the abdominal wall to avoid a large incision.

Surgical removal of a liver tumor has the potential to cure patients, but only in situations in which the tumor has not already spread to other sites. Unfortunately, there is not any type of test that can ensure the absence of tumor spread to other sites, except for the test of time. After recovery from a liver resection, patients will undergo surveillance scans at regular intervals to look for evidence of tumor spread.

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Hepatocellular carcinoma articles

Bile duct cancer and cholangiocarcinoma

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Surgery

Hepatocellular Carcinoma