Surgical Options for Biliary Tumors and Bile Duct Injuries after Gallbladder Surgery
Biliary surgery is most frequently performed for stones, strictures and tumors. The treatment options available at UMC include:
Resection of primary biliary neoplasms (cholangiocarcinoma)
Treatment of bile duct cancer usually requires the removal of the bile duct and possibly portions of the liver, gallbladder, pancreas and small intestine. After resecting the neoplasms, either through open surgery or laparoscopic surgery, the surgeon reconnects the bile ducts to the small intestine for proper biliary drainage.
Biliary Drainage Procedures
Biliary drainage procedures are performed when the bile duct becomes blocked, narrowed or injured. During surgery, continuity of the biliary tree is usually re-established via a hepaticojejunostomy.
Surgical Options for Pancreas Disease
Upon referral of a suspected pancreatic pathology, the UMC hepatobiliary team initiates a pre-operative work up which usually includes an evaluation of the pancreas via Endoscopic Ultrasound. This evaluation helps to determine the location of the pathology in either the head, neck, body or tail of the pancreas.
Subsequent treatment options include:
Pancreaticoduodenectomy (Whipple Procedure)
A pancreaticoduodenectomy, also known as a Whipple procedure, involves the removal of the pancreas head due to a tumor in the pancreas or bile duct.
If a tumor exists in the head of the pancreas, it is usually necessary to remove the pancreas head, duodenum, gallbladder and a portion of the bile duct (Figure 1). Sometimes, part of the stomach
is also removed.
The end of a patient's bile duct and the remaining pancreas are then connected to the small bowel (Figure 2) to ensure flow of bile and enzymes into the intestines.
Distal Pancreatectomy (laparoscopic or open)
Indicated for tumors in the body and tail of the pancreas, a distal pancreatectomy involves the removal of cystic neoplasms either laparoscopically or with open surgery. With both laparoscopic and open distal pancreatectomy procedures, surgeons attempt to preserve the spleen.
With chronic pancreatitis, a dilated pancreatic duct usually reflects obstruction. Procedures to improve ductal drainage include:
- Longitudinal Pancreaticojejunostomy (Puestow Procedure): The pancreatic duct is opened from the tail to the head of the pancreas and attached to the small bowel.
- Distal Pancreaticojejunostomy (Du Val Procedure): The pancreas is divided transversely at the neck, and the body and tail are drained via attachment to the small bowel.
- Sphincteroplasty: When endoscopic sphincterotomy is unsuccessful, surgical sphincteroplasty may be required of the minor or major papilla.
Surgical Options for Liver Cancer
When determining treatment options for tumors of the liver, the UMC hepatobiliary team reviews the results of one's pre-operative evaluation and overall health to recommend appropriate treatment options.
Surgical resection involves the removal of one or more sections of the liver in which a tumor(s) exists. Typically, surgeons can remove up to 70% of a cancerous liver, if there is no or mild fibrosis. It will regenerate in about two to six weeks following surgery. If patients can withstand surgery and have sufficient liver function, resection offers an excellent five-year survival rate of more than 50%. Liver cancer can recur after resection, and close surveillance is required.
For surgical purposes, the liver is divided into eight segments, based on vascular inflow and bile duct drainage. Branches of the hepatic artery and portal vein supply each segment.
During resection, the surgeon first uses ultrasound to determine the tumor’s proximity to hepatic structures. The surgeon’s goal is to remove the tumor(s) and as little liver as possible, while ensuring a margin free of tumor. Using vascular occlusion and isolation techniques that cut off blood flow to the liver during surgery, it is now possible to perform major hepatic resections with minimal blood loss. As with all resections, postoperative complications can occur from the cut edge of the liver. These include bleeding and bile leaks. Most of these complications can be treated nonoperatively.