Management of cancer of the bile duct.

Tumors of the bile duct are uncommon. Most patients will present with a syndrome of obstructive jaundice, but in a few patients the tumor can mimic benign disease of the biliary tract. Cholangiography continues to be the basis of diagnosis and gives important information for a decision on therapy. Histologic diagnosis is helpful when available, although frequently difficult to obtain and not always possible. The overall prognosis for these patients remains poor. Currently, a multidisciplinary approach is required to select for each patient the best therapy with the lowest morbidity and mortality. It should include a surgeon, gastrointestinal endoscopist, interventional radiologist, and radiotherapist. The prognosis for a patient appears to be related to the tumor's location, resectability, and, in our experience, differentiation. Therapy should be tailored to each patient based on location of the tumor, extent of the disease, condition of the patient, expertise available in each institution, and morbidity and mortality associated with each procedure. At the Lahey Clinic, the resectability rate for bile duct tumor is currently 25 per cent. Resection is more frequently possible for tumor of the distal bile duct and can result in a five-year survival rate of up to 30 per cent. For patients with unresectable distal tumor at the time of operation, a proximal hepaticojejunostomy is the palliative procedure of choice. If nonresectability of a distal tumor is determined before operation, the decision to proceed with an endoscopic placement of a stent versus surgical hepaticojejunostomy or placement of a T tube needs to be an individual one. Although five-year survival for tumor of the proximal bile duct is anecdotal, those patients who undergo resection have the longest survival and may have better palliation than those who undergo strictly palliative, nonresective procedures. To warrant exploration for resection of tumor of the proximal bile duct, careful patient selection is required, and the morbidity and mortality of operation must be minimized. An increasing role of percutaneous transhepatic techniques of decompression of the biliary tract is expected as they improve and gain wider acceptance. They are the procedures of choice in very high-risk surgical patients or in patients determined before operation to have unresectable disease. Improvement in the survival of patients with cancer of the bile duct probably depends on development of better adjuvant therapy, such as new techniques of radiation therapy and new modalities of chemotherapy, in association with surgery or with a percutaneous or endoscopic intubation technique.