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Gall Bladder And Biliary Cancers

Gall Bladder And Biliary Cancers

About Gall Bladder and Bile Duct Cancer

Gall bladder cancer is fairly common in India, especially in the Northern parts. When gall bladder cancer is discovered at its earliest stages, the chance for a cure is very good. Unfortunately, most gall bladder cancers are discoveredat a late stage, when the prognosis is often very poor. Hilar cholangiocarcinoma( Klatskin’s tumour) is the cancer involving the confluence of right and left hepatic ducts.

These cancers usually present in the 6th decade of life

Risk factors for gall bladder cancer

  • More in females
  • Gall stones and polyps
  • Abnormal pancreaticobiliary junction
  • Carcinogen exposure

Risk factors for hilar cholangiocarcinoma

  • Primary sclerosing cholangitis
  • Parasitic infection ( clonorchis sinensis & opisthorchisviverreni)
  • Smoking
  • Choledochal cysts

Common Signs and Symptoms

  • Abdominal pain, particularly in the upper right portion of the abdomen
  • Abdominal bloating
  • Yellowing of the skin and whites of the eyes (jaundice)
  • Losing weight without trying
  • Nausea
Gall Bladder And Biliary Cancers

Diagnosis of biliarycancers:

Physical examination: Your doctor will examine your abdomen to look for any lump in the upper abdomen on the right side. Your eyes and skin will be examined to look for signs of jaundice

  • Blood investigations:  Complete blood count, Liver function test, HIV, HBV and HCV testing, coagulation profile, CA19-9, CEA, Serum electrolytes, RFT
  • Radiological imaging  USG Abdomen, Triple phase CT scan of the abdomen, MRCP ,PET-CT scan
  • Biopsy: USG guided biopsy for gall bladder cancers if chemotherapy or radiationis to be started . if resectable, usually no biopsy required

If the patient presents with signs & symptoms of obstructive jaundice patient will be advised to get a ERCP or PTBD done to relieve the jaundice. This facilitates a safer surgery. In cases of advanced disease , a metal stent is placed.

Gall Bladder And Biliary Cancers

Treatment Options

The planning of treatment will depend on the extent and type of cancer, degree of spread and the age and general condition of the patient. Most patients are nutritionally depleted and will need support and advice on diet.

The treatment is usually multimodality and the sequencing is decided based on the stage.

Surgery

Surgery for the gall bladder cancer depends on the stage of the cancer. If the disease is confined to gall bladder then patient will require Radical cholecystectomy with wedge resection of the liver(4b/5 segments) with portal lymphadenectomy with or without bile duct resection Some patients will get diagnosed of gall bladder cancer after undergoing laparoscopic cholecystectomy for the gall stones, this is defined as incidental gall bladder cancer.. such patients are treated with revision radical cholecystectomy (wedge resection of the liver)with portal lymphadenectomy at the earliest for stages T2 and beyond. Some gall bladder cancers may require a major hepatectomy as well. We are one of the few centres in the country who o?er major and aggressive surgical resections for gall bladder cancer with a good success rate.

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Chemotherapy

This is considered in patients with potentially unresectable gall bladder cancer or gall bladder cancer with widespread metastasis . It is also given for patients after surgery in certain cases to redue the risk of recurrence

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Radiation

This modality is used in cases where the margins are positive after surgery or as a neoadjuvant treatment prior to surgery to down stage the disease.

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Treatment options for hilar cholangiocarcinoma

Surgery: Major hepatectomy combined with extra hepatic bile duct resection has increased the long term survival and should be considered standard therapy. In general, Bismuth-Corlette type I radical bile duct excision with hepaticojejunostomy is done. In type II & III lesions typically require an major liver resection with hepaticojejunostomy. If the portal vein is involved the portal vein reconstruction may be required. In a locally advanced hilar cholangiocarcinoma neoadjuvant brachytherapy/chemotherapy may be considered. If the response to chemotherapy is good these patients can be considered for surgery.

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Surgery For Biliary Cancer

RADICAL CHOLECYSTECTOMY – this involves removing the cancerous gall bladder with a 2 cm margin of normal liver tissue.

PORTAL LYMPHADENECTOMY – this is a complete dissection of all the lymph nodes draining the area. It is routinely done in all biliary cancers

CYSTIC DUCT STUMP REVISION - this is done in incidental gall bladder cancers where the revision surgery is being done. This is sent for a frozen section and if positive, a bile duct resection may be performed.

Gall Bladder And Biliary Cancers

RADICAL BILE DUCT RESECTION 

this is a complete removal of the bile duct along with its surrounding tissue for a cancer involving the bile duct or gall bladder involving the duct. The upper cut end is joined with the small intestine loop which is called a HEPATICOJEJUNOSTOMY

RIGHT/ LEFT HEPATECTOMY 

Major liver resection involving removal of the right or left lobe of the liver is done usually for hilar cholangiocarcinomas . this is because the cancer may involve one side of the biliary system.

It is common to also remove the segment 1 or caudate lobe in such cases for a complete clearance of the cancer .

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Related FAQ's
1. Do gallstones cause gallbladder cancer?

Gallstones are one of the risk factors for gallbladder cancer. Quite a few patients with gallbladder cancer have gallstones at the time of diagnosis. A stone size of more than 3cm increases the risk of gall bladder cancer.

2. what is do I expect after a surgery for gall bladder cancer?

Patients who undergo radical cholecystectomy with wedge resection of the liver will have a hospital stay of 4-5 days after surgery. They will be started on orals feeds after 24-48 hrs. If the patient requires a more aggressive surgery in the form of major hepatectomy then the hospital stay could be extended by a few days depending on the recovery.

3. What is ERCP and PTBD?

ERCP (Endoscopic Retrograde Cholangio Pancreaticogram) is a procedure that helps the doctor will introduce an endoscopic tube via the oral cavity and visualize your bile duct. It aids the doctor in taking a biopsy and inserting a stent to reduce jaundice.

PTBD(Percutaneous transhepatic biliary drainage) is a therapeutic procedure that leads to drainage of the obstructed bile duct. PTBD is done under fluoroscopy and ultrasound guidance. It is used in hilar cholangiocarcinoma to reduce jaundice to facilitate surgery.

4. What are the complications of surgery for gall bladder and bile duct cancers?

These are major surgeries and about 10% of patients may have some complications. Some of the complications are Bile leak, abdominal collections, wound infection, pneumonia. Most often complications are managed with the change of antibiotics, drainage of fluid collections. Rarely, some complications may require re-surgery.

5. What is the follow up period after surgery?

In the first year, it's every 3 months. After 1 year it's every 6 months till 5 years.

6. What is the survival rate in gall bladder cancer?

5 year survival rate for resectable node negative disease is around 50% and node positive disease is 25%. Inoperable cases have extremely poor prognosis.

7. What is the survival rate in hilar cholangiocarcinoma?

Survival depends on the stage of cancer at the time of diagnosis. Most of the patients get diagnosed in advanced stages. It also depends on the quality of the surgery.

5-years survival in node-negative disease is 50%. In node-positive disease, its 35% In inoperable cases prognosis is very poor with a 5-years survival rate of less than 5%.

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