Treatment of cholangiocarcinoma

Treatment of cholangiocarcinoma operative

With the localization of cholangiocarcinoma in the distal hotel of the biliary system, it can be excised; the survival rate for 1 year is about 70%. With more proximal location, tumor removal is combined with liver resection up to lobectomy; while excision of bifurcation of the common bile duct and superimpose bilateral hepatitis yunoanastomoz.

Some authors favor the removal of the caudate lobe, since the 2-3 bile ducts of this lobe flow into the hepatic ducts immediately near the site of their fusion, and therefore the probability of their destruction by the tumor is high.

The share of resectable cholangiocarcinomas in specialized centers increased from 5-20% in the 1970s to 40% or more in the 90s. This is due to earlier diagnosis and referral of patients to such centers, more accurate and complete preoperative examination and more radical surgery. The complexity of the operation is due to the need to remove the tumor within the healthy tissue. The average survival after extended resection with cholangiocarcinoma of the liver gates is 2-3 years; a fairly good quality of life is achieved during most of this period. With local resection of tumors of types I and II according to Bismut, perioperative lethality does not exceed 5%. With lesions of type III, liver resection is necessary, accompanied by a higher mortality and frequency of complications.

Liver transplantation with cholangiocarcinoma is ineffective, since in most cases relapses develop in the early postoperative period.

The palliative surgical interventions include the formation of an anastomosis of the jejunum with the duct of the third segment of the left lobe, which is usually available, despite the lesion of the larynx of the liver with a tumor. In 75% of cases, jaundice can be eliminated for a period of at least 3 months. If there is no possibility of superposition of an anastomosis with a duct of the III segment (atrophy, metastases), a right-sided intrahepatic anastomosis with a duct of the V segment is applied.

X-ray and endoscopic palliative methods of treatment of cholangiocarcinoma

Before surgery and with unresectable tumors, jaundice and pruritus can be eliminated by endoscopic or percutaneous stent placement.

With an unsuccessful attempt at endoscopic stenting, it is combined with a percutaneous one, which makes it possible to achieve success in almost 90% of cases. The most frequent early complication is cholangitis (7%). Mortality within 30 days ranges from 10 to 28%, depending on the size of the tumor in the portal of the liver; Survival is an average of 20 weeks.

Percutaneous transhepatic stenting is also effective, but is accompanied by a higher risk of complications, including bleeding and bile flow. The stents and the metal mesh after placement through the catheter 5 or 7 F are straightened to a diameter of 1 cm; they cost more than plastic, but with periampulastic strictures their patency lasts longer. These stents can be used with strictures in the area of the gate. The first studies showed that in this case they also have approximately the same advantages over plastic stents, but when installed from a surgeon more experience is required.

A comparative evaluation of surgical and non-surgical palliative interventions was not conducted. Both approaches have advantages and disadvantages. Non-surgical methods should be used in a high-risk group when the expected survival rate is low.

Drainage of the biliary tract can be combined with internal radiotherapy using conductors with iridium-192 or radium needles. The effectiveness of this method of treatment is not proven. The use of cytotoxic drugs is ineffective. Remote radiation therapy, according to retrospective studies, has some efficacy that has not been confirmed in randomized trials. Symptomatic therapy is aimed at correcting chronic cholestasis.

Prognosis of cholangiocarcinoma

The prognosis is determined by the localization of the tumor. In the distal location of the tumor more resectable than with localization in the gates of the liver.

The prognosis for more differentiated tumors is better than for undifferentiated tumors. The most favorable prognosis for polypoid cancer.

Survival within 1 year without resection is 50%, within 2 years - 20%, 3 years - 10%. From these data it is clear that some tumors grow slowly and metastasize at later stages. Jaundice can be surgically removed by either endoscopic or percutaneous stenting. The threat to life is due not so much to the degree of malignancy of the tumor, as to its localization, which can make the tumor unresectable. After excision of the tumor, the average life expectancy of patients increases, which makes it necessary to perform a thorough examination for surgical intervention.