Newer techniques in the diagnosis and treatment of proximal bile duct carcinoma--an analysis of 41 consecutive patients.

The clinical course of 41 consecutive patients with primary bile duct carcinoma at or near the liver hilum was analysed to determine whether the outcome was improved by newer techniques of diagnosis and treatment. The age range was wide, with one third under 50 years. The only aetiological factor identified was long-standing ulcerative colitis (present in 9.8 per cent of patients). In one third of patients initial symptoms were misleading. The tumour had been missed in 11 (61 per cent) of 18 patients undergoing an exploratory laparotomy at other hospitals, despite operative cholangiography. None had pre-operative percutaneous cholangiography which was shown to be the best investigatory technique, giving the correct diagnosis in all cases in whom it was performed. Greyscale ultrasonography was useful and endoscopic retrograde cholangiography less so. Median survival in those treated by surgical T- or U-tube drainage (21 patients) or bypass (three) was nine months from diagnosis, as opposed to three months in the 36.5 per cent of patients in whom biliary drainage was not obtained. Radiotherapy, including insertion of a radioactive iridium wire through the tumour via a T- or U-tube, or percutaneously, was performed in nine patients and improved the duration of survival compared with tube drainage alone. The new percutaneous techniques offer a useful alternative to surgery for palliative drainage and radiotherapy.