General Surgery
Bile duct resection removes a diseased bile duct and reconnects the bile flow to the bowel. Complete removal offers the only chance of long-term survival from bile duct cancer.
Bile duct cancer, called cholangiocarcinoma, drives most of these operations, with choledochal cysts and damaged ducts behind it. At Nagoya University, 574 resections for cancer at the liver hilum over 34 years saw operative mortality fall to 1.4 percent, and patients with clear margins and clear lymph nodes reached 67 percent five-year survival in the later years. Send your CT, MRI and blood tests, and our liver and bile duct team will tell you whether the tumor can come out completely.
67%
Five-year survival with clear margins and clear lymph nodes, Nagoya, 2001 to 2010
1.4%
Operative mortality in the last five years of 574 resections
41% vs 11%
Deaths after drainage through the skin against endoscopic drainage, DRAINAGE trial
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Review of your scans before you book
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The bile ducts carry bile from the liver to the small bowel. A tumor or narrowing in them blocks the flow, and the skin and eyes turn yellow, the urine darkens and the skin itches.
What a bile duct resection removes
The bile ducts in brief
Small ducts inside the liver join into a right and a left duct, which meet at the hilum, where the liver receives its blood vessels. The common bile duct then runs down behind the duodenum and through the head of the pancreas to empty into the bowel. The position of the disease along this path decides the operation.
Five conditions bring patients to us for bile duct surgery.
- Perihilar cholangiocarcinoma, also called a Klatskin tumor, at the junction of the right and left ducts.
- Distal cholangiocarcinoma, in the lower duct inside the pancreas.
- Gallbladder cancer growing into the bile duct.
- A choledochal cyst, a ballooned bile duct present from birth.
- A benign narrowing, including injury from earlier gallbladder surgery.
Choledochal cysts in adults
A choledochal cyst left in place carries a lifelong risk of cancer in its wall, along with repeated infections and pancreatitis. We remove the whole cyst and gallbladder and join a loop of small bowel to the duct below the liver, an operation called hepaticojejunostomy.
Cancer at the liver hilum
Jarnagin and colleagues at Memorial Sloan-Kettering followed 225 patients with perihilar cancer. Of 80 resections, 78 percent included part of the liver, and every one of the nine patients alive at five years had had a liver resection with clear margins.
Complete resection remains the only therapy that offers the possibility of long-term survival, and hepatic resection is a critical component of the surgical approach.
Memorial Sloan-Kettering study of 225 patients, Annals of Surgery, 2001
Cancer lower in the duct
A tumor in the lower duct sits inside the head of the pancreas, so its removal means a pancreaticoduodenectomy, the Whipple operation, which takes the lower duct, the head of the pancreas, the duodenum and the gallbladder together.
R0 resection remains the best chance for long-term survival, and lymph node status is the most important prognostic factor following R0 resection.
Johns Hopkins series of 564 patients, Annals of Surgery, 2007
Why the liver comes out too
Cancer at the hilum spreads along the ducts into the liver and into the small caudate lobe behind them. Removing the duct alone leaves cancer cells at the margin, so the standard operation takes the right or left half of the liver with the caudate lobe.
Bile duct resection alone
When removing only the duct suffices
A small tumor in the middle of the duct, a choledochal cyst and a benign narrowing need only the duct, with a new bowel connection. In Nagoya, limited resections of the duct alone for perihilar cancer became rare, as surgeons moved to taking part of the liver for clear margins.
Survival after surgery
DeOliveira and colleagues at Johns Hopkins reviewed 564 bile duct cancers operated on over 31 years. Survival after complete removal depended on where the tumor started.
This table scrolls sideways on a narrow screen. Swipe or drag to see every column.
Survival after complete removal of bile duct cancer, by location, 564 patients
| Tumor location |
Median survival |
Five-year survival |
| Inside the liver |
80 months |
63 percent |
| At the hilum |
30 months |
30 percent |
| Lower duct |
25 months |
27 percent |
Survival for R0 and pN0 patients was satisfactory, whereas survival for pN1 patients was still poor, suggesting that establishment of effective adjuvant chemotherapy is needed.
Nagoya series of 574 resections, Annals of Surgery, 2013
The numbers in plain terms
Across all 574 Nagoya patients, 32.5 percent lived five years and 19.9 percent ten years. In the later decade, 67.1 percent of patients with clear margins and clear lymph nodes reached five years, against 22.1 percent when cancer had reached the lymph nodes. Bile duct cancer stays one of the hardest cancers to cure, and we give you these figures before any decision.
Staging before surgery
Three findings decide. The first, how far the cancer runs up the ducts into the liver. The second, whether it has reached the portal vein. The third, whether one half of the liver has shrunk from long blockage. A thin-slice CT, an MRI with MRCP of the ducts and, in selected patients, a PET scan answer all three, and a tumor board of surgeons, radiologists, gastroenterologists and oncologists reads them together before anyone books a flight.
Draining jaundice before surgery
The DRAINAGE trial
Coelen and colleagues randomized 54 patients with resectable perihilar cancer to drainage through an endoscope or through a tube placed via the skin into the liver. The trial stopped early when 11 of 27 patients died after drainage through the skin, against 3 of 27 after endoscopic drainage. Complications from drainage matched, and more than half the endoscopic group needed an added tube through the skin.
1
Imaging and tumor board
CT, MRI and blood tests, with a written plan.
2
Draining the bile
A stent placed through an endoscope into the part of the liver that will stay, when jaundice runs high.
3
Growing the remnant
Blocking the portal vein to the half of the liver that comes out, so the remaining half grows over four to six weeks.
4
Surgery
Once bilirubin has fallen and the remnant has grown enough.
Safety before the operation
The study was prematurely stopped because of higher all-cause mortality in the percutaneous transhepatic biliary drainage group.
Dutch DRAINAGE trial, Lancet Gastroenterology and Hepatology, 2018
Stents and drains
Our page on biliary stenting explains the stent types and how they relieve jaundice, for patients whose tumor cannot come out.
Our approach
We drain only the part of the liver that will remain, by endoscope first, and keep a tube through the skin for when the endoscopic route fails.
The operation
Open surgery, five to ten hours.
Removing the duct and lymph nodes
The surgeon frees the bile duct from the artery and portal vein, removes it with the lymph nodes around it, and sends the cut ends of the duct to the pathologist during surgery to confirm clear margins.
- The bile duct and the gallbladder.
- The lymph nodes along the duct and the hepatic artery.
- The right or left half of the liver with the caudate lobe, for perihilar cancer.
- A segment of the portal vein when the tumor touches it, rejoined during the same operation.
Rejoining the bile flow
A loop of small bowel, called a Roux loop, comes up to the cut ducts of the remaining liver and gets stitched to each one, so bile drains straight into the bowel.
The operation changes with the position of the disease.
This table scrolls sideways on a narrow screen. Swipe or drag to see every column.
Bile duct operations by position of the disease
| Disease |
Operation |
Liver removed |
| Perihilar cancer |
Duct, nodes, half the liver with the caudate lobe |
Yes |
| Lower duct cancer |
Whipple operation |
No |
| Mid-duct tumor or narrowing |
Duct alone with a Roux loop |
No |
| Choledochal cyst |
Cyst and gallbladder with a Roux loop |
No |
Keyhole surgery for bile duct operations
Choledochal cysts in suitable patients come out by keyhole surgery. For bile duct cancer we operate open, since the vessel work and the liver resection need full access and the evidence for keyhole surgery in these cancers stays limited.
Risks, chemotherapy and recovery
Expect complications. Major bile duct surgery carries one of the highest complication rates in abdominal surgery. In the 2001 New York series, 64 percent of patients had a complication and 10 percent died, and in the last five years of the Nagoya series complications still reached 43.1 percent while deaths fell to 1.4 percent. Experience matters. Bile leaks, infection inside the abdomen, bleeding and liver failure after a large resection make up the main risks.
This table scrolls sideways on a narrow screen. Swipe or drag to see every column.
BILCAP, capecitabine tablets against observation after surgery, 447 patients
| Analysis |
Capecitabine |
Observation |
| Median survival, all patients |
51.1 months |
36.4 months, difference short of significance |
| Median survival, patients treated as planned |
53 months |
36 months, significant |
| Severe side effects |
44 percent |
Not measured |
1
Days one to three
Intensive care, then the ward, with drains and liver blood tests every day.
2
Days four to fourteen
Eating again, walking, drains out, and discharge between ten and fourteen days after a perihilar resection.
3
Weeks three to eight
Recovery at home, with the liver regrowing and tiredness easing.
4
Within sixteen weeks
Six months of capecitabine tablets, started once you have recovered.
The stay in Istanbul
Plan three to four weeks in Istanbul for a perihilar resection and two to three weeks for a Whipple or cyst operation. Our surgeon confirms fitness to fly before you leave, and a companion can sleep in your room. Our coordinators speak English, Arabic, French, Russian, Serbian, Romanian and Spanish, and follow-up after you return home runs through them, with the pathology report and the chemotherapy plan sent to your oncologist. The cost depends on the operation, any drainage or vein blocking before surgery and the length of stay, and the estimate after the free review lists each.
Although this study did not meet its primary endpoint of improving overall survival in the intention-to-treat population, the prespecified sensitivity and per-protocol analyses suggest that capecitabine can improve overall survival in patients with resected biliary tract cancer when used as adjuvant chemotherapy following surgery and could be considered as standard of care.
BILCAP trial, Lancet Oncology, 2019
Follow-up
A CT scan and the CA 19-9 blood marker every three to six months for two years, then every six to twelve months, read by our team or by your oncologist at home.
Bile duct resection FAQ
Can bile duct cancer be cured with surgery?
For some patients. Complete removal with clear lymph nodes gave 67 percent five-year survival in the later Nagoya years, and surgery remains the only treatment with that chance.
Will I need part of my liver removed?
For cancer at the hilum, yes, the right or left half with the small caudate lobe behind the ducts, since cancer spreads into them. Lower duct cancer needs a Whipple operation instead.
Do I need a stent before surgery?
When jaundice runs high or before a large liver resection. We prefer an endoscopic stent in the part of the liver that will stay.
How long does recovery take?
Ten to fourteen days in hospital after a perihilar resection, and two to three months to feel fully recovered.
Will I need chemotherapy after bile duct surgery?
We recommend six months of capecitabine tablets after surgery for cancer, based on the BILCAP trial.
References
- Jarnagin WR, Fong Y, DeMatteo RP, et al. Staging, resectability, and outcome in 225 patients with hilar cholangiocarcinoma. Annals of Surgery. 2001;234(4):507-517.
- DeOliveira ML, Cunningham SC, Cameron JL, et al. Cholangiocarcinoma: thirty-one-year experience with 564 patients at a single institution. Annals of Surgery. 2007;245(5):755-762.
- Nagino M, Ebata T, Yokoyama Y, et al. Evolution of surgical treatment for perihilar cholangiocarcinoma: a single-center 34-year review of 574 consecutive resections. Annals of Surgery. 2013;258(1):129-140.
- Primrose JN, Fox RP, Palmer DH, et al. Capecitabine compared with observation in resected biliary tract cancer (BILCAP): a randomised, controlled, multicentre, phase 3 study. Lancet Oncology. 2019;20(5):663-673.
- Coelen RJS, Roos E, Wiggers JK, et al. Endoscopic versus percutaneous biliary drainage in patients with resectable perihilar cholangiocarcinoma: a multicentre, randomised controlled trial. Lancet Gastroenterology and Hepatology. 2018;3(10):681-690.
