Surgical possibilities for bile duct cancer: standard surgical treatment

There is no consensus on the surgical treatment of bile duct cancer, which varies from total nihilism to an extremely aggressive resectional policy. This paper describes the adoption of a 'middle road' approach to these difficult cancers, and suggests that selective use of stenting, bypass and resection with judicious application of adjunctive chemotherapy is an appropriate attitude until controlled studies of the alternatives are available. The main aims of treatment are (a) relief of obstructive jaundice, (b) prevention and treatment of future recurrent obstruction and cholangitis, and (c) eradication of tumour when possible. Local resection carries a low morbidity and mortality and is always a reasonable option in patients fit for surgery, but the relative value of non-radical resection and stenting with chemotherapy remains to be determined. Extended resections, including major hepatectomy and radical lymph node dissection, are only justified when the intent is curative, and some patients may not be suitable for such extensive surgery. In patients who are explored and determined to be unsuitable for major resection, surgical bypass is an option, but there is little evidence that this produces better palliation or quality of survival than optimal percutaneous or endoscopic stenting. Of 76 patients referred to the author over 7 years, 27 (35%) underwent surgical resection, and 23 (30%) had no operation. In patients followed up for more than 1 year, median survival following curative resection (9 patients) was 26 months, and after palliative resection (15 patients) it was 11 months. Median survivals after palliative biliary-enteric bypass (11), exploration alone (9), or no operation (20) were 2, 4, and 5 months respectively. A cautious and selective approach to surgery for these tumours is advocated.