Challenges in Surgical Management of Extra-Hepatic Cholangiocarcinoma: A Case Series of 9-Year Experience in Pakistan

Abstract

Background:     Cholangiocarcinoma is rare but with alarmingly increasing incidence worldwide. Managing CCA is still challenging in developed as well as in resource-constraint countries.

Objective: To present single center, 9-year experience with the challenges in surgical management of extra-hepatic cholangiocarcinoma, (ECA) in Pakistan.

Method: Prospective, single-centered case series was conducted in the general surgery department of a tertiary care hospital in Lahore, from November 2005 to May 2014. A total of 34 patients were operated for cholangiocarcinoma (CCA) during the study period and were consecutively enrolled for the study after determining eligibility. Data was analyzed using SPSS version 21.  

Results: Male to female ratio was 1.4:1 and mean age of the group was 53 years. Jaundice (100%) was the predominant symptom followed by pruritus in 94%, weight loss in 53%, pain 44% and fever in 32%. All patients had histologically diagnosed CCA. Incidences of hilar, mid and distal common bile duct (CBD) CCA were 53%, 23.5% and 23.5% respectively. Metastatic disease in lymph nodes were found in 41.2% (n=14) of the patients, 8.8% (n=3) patients had intrahepatic abscesses and 35.3% patients had hepatic metastases with ascites. Distal CCA was treated by pancreaticoduodenectomy or local bile duct excision and bilioenteric anastomosis whereas hilar cholangiocarcinoma was managed by Roux-en-Y hepaticojejunostomy subsequent to cholecystectomy and excision of pericholedochal tissues. Free resection margin were achieved in 58.8% (n=20) Overall mortality was 11.7% (n=4) during hospital stay. 50% of the patients were followed up for a mean period of 10.5 months and remained symptom free with better overall quality of life.

Conclusion:       Current study described higher incidence of hilar CCA with male preponderance. Presentation is usually late and the best treatment offered can be a surgical palliation either R1 or R2 resection. Preoperative stenting makes dissection difficult and increases the risk of postoperative infections and hence overall morbidity and mortality.