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

Cholangiocarcinoma. Role of percutaneous transhepatic cholangiography in determination of resectability

Exploratory laparotomy is frequently used to diagnose, treat, or palliate cholangiocarcinoma although surgery is rarely curative. In light of newly developed percutaneous and endoscopic approaches to diagnosis and therapy, we reviewed our experience with 35 cases of cholangiocarcinoma diagnosed and treated at the University of Michigan Medical Center from 1979 to 1984. Percutaneous transhepatic cholangiography (PTCA) was performed in 34 cases of which only four were resectable. All 22 patients who had preoperative cholangiograms suggesting unresectability had confirmation of this at surgery. Surgical palliation was accomplished with a combination of internal and percutaneous drainage in most cases. Angiographic, cytologic, and laboratory data are presented. PTCA accurately predicted unresectability of cholangiocarcinoma and is superior to angiography in this respect. In patients with cholangiocarcinoma, percutaneous and endoscopic approaches offer alternatives to surgery for diagnosis and palliation.

Carcinoma of the extrahepatic bile ducts: a postmortem study of 65 cases and review of the literature

From 1950 to 1982, 65 patients with carcinoma of the extrahepatic bile ducts were autopsied in the Institute of Pathology of the University of Düsseldorf. The average age of men was 64.5 years and that of women was 70 years. The ratio of men to women was 1 to 1.71. The greatest number of tumors was found in the common bile duct (40.1%), followed by the hepatic ducts (29.2%) and the confluence of the common hepatic duct with the cystic duct (27.7%). Adenocarcinomas of various differentiation were found in 96.7% of the cases and anaplastic carcinoma in 3.3%. Metastases were present in 49 cases (75.4%). Cholelithiasis was found in 51% of the cases. The results of the present postmortem study are compared with the literature.

Failure to improve survival by improved diagnostic techniques in patients with malignant jaundice

In a consecutive series of 118 patients with malignant obstructive jaundice at North Tees General Hospital only 70 patients were adjudged fit to undergo surgery. Tumour resection was possible in only four patients. Palliative bypass was performed in 45 patients while 21 patients had no procedure other than an exploratory laparotomy. In contrast to the accuracy of investigation the results of surgery have been poor with considerable mortality (42.8 per cent) and lack of long-term survivors. The results emphasize the role of non-surgical methods for relieving jaundice of malignant aetiology, especially in frail elderly patients and those who have metastases at the time of presentation.

Carcinoma of the proximal extrahepatic biliary tree radiologic assessment and therapeutic alternatives

Preoperative cholangiography and angiography have been used in a series of 37 patients with hilar cholangiocarcinoma investigated over a 17-month period in a single specialist unit. Twelve lesions were judged to be irresectable on the basis of the cholangiographic findings: this was confirmed at laparotomy in nine patients and at autopsy in one. Angiography was performed in 21 patients, and suggested irresectability in eight: this was confirmed by laparotomy in seven. The eighth patient had compression of the left portal vein which had been interpreted as tumor invasion on angiography, and it was possible to perform a curative extended right hepatic lobectomy. Of the 13 potentially resectable patients, three were unfit for major resectional surgery. Five were found to be irresectable at laparotomy because of vena cava involvement in two and distant metastases in three. Five patients underwent resection with histologically clear margins. The combined use of cholangiography and angiography is recommended as a means of selecting appropriate therapy for patients with hilar cholangiocarcinoma.