High bile duct cancer: incidence and pattern of investigation in the General Hospital setting

Between 1 April 1977 and 30 November 1979, 16 cases of high bile duct carcinoma presented at North Tees District Hospital, giving an incidence of one per 40000 population per annum for Teesside. Results of this prospective study emphasize the potential accuracy of preoperative assessment using techniques which should be available in a district general hospital. Ultrasound revealed the site of obstruction in every patient in whom it was used (n = 13), and often indicated a neoplastic aetiology (n = 10). Percutaneous transhepatic cholangiography (PTC) and endoscopic retrograde cholangiography (ERC) correctly demonstrated the site of obstruction in each patient and suggested a primary bile duct carcinoma in 12 patients. Although intraoperative cholangiography gave additional information in some patients, it was not sufficiently reliable to dispense with either PTC or ERC. Histological proof of a primary bile duct carcinoma was obtained in 15 patients. In the 10 patients without obvious metastatic disease frozen section analysis was positive in 7, but was negative in 3 patients with multiple strictures where malignant cells were relatively infrequent and were found in the perineural lymphatics on paraffin sections. In this difficult group of patients the approach described eliminates the possibility of a false negative laparotomy, enables careful planning of the necessary surgical technique and also the consideration of nonoperative management.