What is Surgery for Biliary Diseases and Cancers?
Surgery for Biliary Diseases and Cancers | Bile diseases and cancer surgery is a surgical field that covers targeted surgical interventions in the treatment of diseases and cancers related to the gallbladder and bile ducts. In general, cancers other than gallbladder surgery due to stones (Gallbladder cancer, Cholangiocarcinoma), bile leakage due to bile duct injuries or complications after surgery, bile duct stenosis or tumor-related jaundice, which are complex bile diseases managed by HPB surgeons, bring better results. Experienced HPB surgery centers play an important role, especially in cases of acute cholangitis, also known as inflammatory jaundice, since early and correct intervention saves lives.
What is Bile, What Does It Do?
The liver produces approximately 1 liter of bile per day and this bile is stored in the gallbladder by thickening it in the event of hunger. With meals, especially when food reaches the duodenum, the gallbladder contracts and releases the bile inside it into the intestines so that the food can be digested. Bile contains substances such as various salts, cholesterol and bile dyes and is in balance.
Bile is very important for the digestion and absorption of fats. Bile acids break down fat droplets into smaller particles, allowing digestive enzymes to reach the fats. In this way, fats are more easily absorbed by the body. Bile also plays a role in the absorption of fat-soluble vitamins (A, D, E, K).
Stones, parasites or tumors in the gallbladder or ducts may disrupt this function and require endoscopic or surgical intervention.
The most common disease group related to bile is gallstones
GALLSTONE
What is gallstone?
If the solidified structures in the gallbladder and or bile ducts are larger than 3 mm, they are called gallstones, and if they are smaller than 3 mm, they are called biliary sludge. They are seen quite frequently (10-15%), and although their frequency increases with age, they are a disease that also concerns young people and even children.
Why Do Gallstones Form?
There is a balance between substances such as various salts, cholesterol and bile dyes in bile. If this balance is disrupted for any reason, for example, if the cholesterol content increases or bile salts decrease, a sediment forms in the gallbladder, or if the bile flow slows down due to narrowing of the bile ducts, or if parasites enter the bile and the current situation continues, gallstones form.
Who has more gallstones?
Classically, gallstones are more common in women, over the age of 40, in fair-skinned people, in obese people, and in people with a family history of gallstones. In addition, gallstone formation increases especially in those who lose weight rapidly due to uncontrolled diets, in pregnant women and especially in those who vomit a lot, those who give birth a lot, patients with cirrhosis, those who eat excessively fatty foods, some blood diseases such as sickle cell anemia, those who cannot be fed orally and who require long-term intravenous feeding, and those who use some antibiotics such as ceftriaxone. In pregnant women, hormonal changes and inability to feed due to excessive vomiting increase gallstones and related problems, so my advice to pregnant women is to have dark chocolate with them, if nausea and vomiting occur in the first months, to eat a small amount of chocolate every 4-6 hours and to drink 2-3 cups of coffee a day can reduce the development of gallstones.
Some suggestions to reduce gallstone formation
Instead of Western-style nutrition (high-calorie, fatty meat, eggs, rice/pasta, snacks, pizza, pie, potatoes, cake, high-calorie alcoholic beverages, mayonnaise), following the Mediterranean diet (fish, seafood, plant-based products, fresh fruit, vegetables, olive oil, whole grain bread) reduces gallstone development, and gallbladder surgery is required 13-27% less in those who follow the Mediterranean diet. Regular exercise, not eating fatty foods, not being obese, not gaining or losing weight rapidly, staying away from uncontrolled strict and long-term starvation diets, eating a diet rich in fiber, taking in enough calcium, keeping blood fats within normal limits and drinking 3 cups of coffee a day can contribute to reducing gallstone formation.
What Complaints and Diseases Do Gallstones Cause?
First of all, gallstones may not cause any complaints and may remain silent for a lifetime. We call these asymptomatic stones.
Since gallstones are mobile, they can cause complaints such as Biliary colic (Chronic Cholecystitis with Stones), which is a short-term abdominal pain that is especially seen after meals, and sometimes nausea and vomiting.
It can also cause inflammation of the gallbladder, which is called acute cholecystitis with stones, which causes long-term severe abdominal pain, nausea, vomiting and fever. In fact, if neglected, the inflammation can progress and the gallbladder can rupture, causing abscesses and fatal inflammations called peritonitis in the abdomen.
The most common complaint:
- Abdominal pain
- Nausea
- Vomiting
- Fever
In addition, gallstones can fall into the bile ducts and cause Choledocholithiasis, which can lead to Obstructive jaundice, Pancreatitis (Acute pancreatitis) and Bile duct inflammation (Acute cholangitis). It can also cause inflammation and abscess in the liver (Liver abscess). These conditions are serious diseases that can lead to death.
In which cases should you go to the hospital?
Especially after heavy and fatty meals, those who have pain in the middle and right upper quadrant of the abdomen should think of gallstone disease and consult a doctor. However, if the pain becomes severe and persistent, nausea, vomiting, fever and jaundice are added, the hospital should be consulted urgently.
How is gallstone disease treated, which surgery is performed?
If one of the complaints mentioned above is present, all gallstones should be operated on regardless of their number or size. Today, gallbladder surgeries are performed in the form of Laparoscopic cholecystectomy or Robotic cholecystectomy, feeding and walking are allowed in the 3rd hour after the surgery and our patients are discharged home the next day after staying in bed for 1 night. The pain and return to work period is much shorter than the other surgery, open cholecystectomy. Another important advantage is that it does not leave a visible scar cosmetically.
Is Surgery Necessary for Gallstones? Is there a method to drop or break the stone?
The only valid treatment for gallstones that cause complaints is surgery. As with kidney stones, treatment methods such as breaking or dropping have no place in modern medicine. In gallstones that cause complaints, surgery cannot be deemed unnecessary by looking at the size or number of stones; if there are complaints, all gallstones should be operated on. Delay in treatment can lead to serious consequences such as acute pancreatitis or inflammatory jaundice, acute cholangitis, which can cause 5% death.
Is jaundice caused by gallstones contagious like hepatitis?
When a gallstone falls into the bile duct, bile cannot flow into the duodenum because it will block the duct, and since the gallbladder cannot store all the bile, bile accumulates and mixes with the blood, thus developing the condition we call obstructive jaundice. First, the whites of the eyes turn yellow, then the whole body turns yellow and itching begins. However, since there is no microbial condition like in hepatitis, the disease is not transmitted to those around the patient. There is no transmission to children and spouses through close contact.
How are stones that have fallen into the bile duct treated?
The most preferred method today is ERCP. However, stones can be reached by cutting the abdomen, which we call open surgery, and the stones can be drained or it can be achieved with the laparoscopic method. In fact, in the PTK method, the liver is entered with a needle and then the stones are drained. However, the most promising method is ERCP.
Question: What is ERCP? Which patients require ERCP?
ERCP is required in the presence of stones in the bile duct, in cases of acute inflammation in the bile ducts, in patients who develop jaundice or pancreatitis due to stones, in patients who develop obstructive jaundice due to pancreatic cancer or bile duct cancer. Apart from this, many reasons such as biliary fistulas due to gallbladder surgeries or liver hydatid cyst surgeries, chronic pancreatitis, pancreatic fistulas require ERCP.
Chronic Calculous Cholecystitis, Biliary Colic
What is Biliary Colic?
Two-thirds of gallstone patients are in this group. Intermittent abdominal pain in the right upper quadrant of the abdomen and/or on the stomach, often comes suddenly at night (03:00) or 30-60 minutes after a fatty meal, lasts 10-30 minutes, and can last 5-6 hours. It spreads to the back and between the shoulder blades (scapula).
Why Does Biliary Colic Develop?
The stone in the gallbladder causes the gallbladder duct, which we call the cystic duct, to become blocked intermittently. Due to this blockage, the gallbladder swells (distends) and there is agonizing pain. The pain intervals can range from a few days to a few years.
What Other Complaints Occur?
It is often accompanied by nausea and rarely by vomiting. Physical findings are very limited. When there is pain, there is no finding other than voluntary muscle resistance in the right upper quadrant. Fever, jaundice and chills-shivering do not accompany the pain if there is no acute cholecystitis or cholangitis. In cases of severe pain, MI should be excluded by checking ECG and cardiac enzymes. Laboratory findings are normal in uncomplicated cases. There are 50% atypical complaints: pain unrelated to eating, pain in different localizations. The most common complication of chronic cholecystitis (20%) is acute cholecystitis. Some patients initially have an attack of a. cholecystitis and later develop chronic cholecystitis. In others, symptoms of chronic cholecystitis appear directly.
How is the diagnosis made?
An abdominal ultrasound is sufficient to make the diagnosis in patients with biliary colic.
How is the treatment done?
The gold standard treatment method for all gallstones that cause complaints is Laparoscopic Cholecystectomy. 90% of patients become symptom-free in the long term after surgery.
Asymptomatic (Silent) Gallstones
What does asymptomatic gallstone mean?
Gallstones may not cause any complaints and can remain silent for a lifetime. We call gallstones detected incidentally during routine health checks asymptomatic or silent gallstones. The rate of developing complaints in asymptomatic stones is 2-3% per year. This rate is higher in the elderly. Roughly, the total risk in 5 years is 10%, and the rate of developing symptoms in 20 years is 20-30%. In addition, the rate of developing complications such as pancreatitis (acute pancreatitis) or bile duct stones (choledocholithiasis) in asymptomatic stones is 1-2%. For this reason, we do not recommend surgery, i.e. prophylactic cholecystectomy, for asymptomatic gallstones that do not cause any complaints, except in special cases.
Who is surgery recommended for Silent Gallstones?
In children, in blood diseases that progress with hemolysis such as sickle cell anemia, in cases of non-functioning gallbladder, in gallbladder stones larger than 2.5-3 cm, in cases of what we call porcelain gallbladder (calcification in the gallbladder wall), in patients with diabetes that has been present for a long time and has been followed up uncontrolled, in people who will undergo morbid obesity surgery and in patients who will undergo organ transplantation, surgery (laparoscopic cholecystectomy) may be recommended even if they do not cause any complaints if they have gallbladder stones.
Acute Calculous Cholecystitis, Gallbladder Inflammation
What is Acute Calculous Cholecystitis, How Does It Develop?
It refers to severe abdominal pain, nausea, vomiting and fever due to sudden inflammation in the calculous gallbladder. The initial event in the formation of Acute Calculous Cholecystitis is the blockage of the gallbladder duct, which we call the cystic duct, by the gallstone. After the blockage, inflammation, which we call inflammation, begins in the gallbladder, the bladder swells, its wall thickens and fluid collects around it (acute calculous cholecystitis). In most cases (90%), the stone moves, the blockage opens and the condition improves quickly. In severe cases (5-10%), inflammation progresses and infection is added. Rarely, there is a perforation due to melting in the gallbladder wall. If this perforation is limited to one area in the abdomen, it can lead to abscess, and if it spreads to the entire abdomen without being limited, it can lead to fatal complications called peritonitis. In neglected cases, it can cause liver abscess or closed perforations called cocystoenteric fistula.
What Complaints Does Gallbladder Inflammation with Stones Cause?
Abdominal pain, which often starts after a heavy fatty meal, quickly becomes continuous. It can spread to the waist and the tip of the right shoulder blade. While the pain in biliary colic lasts 3-4 hours and is less severe, the pain in gallbladder inflammation is very severe, lasts a long time (1-3 days) and Nausea-Vomiting is seen in most patients (60-80%). In addition, fever and pulse are increased in physical examination. There is sensitivity in the right upper quadrant of the abdomen (Murphy +) or on the stomach during manual examination. The gallbladder can be felt. Jaundice is seen in one in 10 patients. When blood tests are examined, white blood cells and infection parameters increase. Mild deterioration can be seen in liver tests.
How is Acute Cholecystitis Diagnosed?
In patients suspected of acute calculous cholecystitis, an abdominal ultrasound is sufficient to make the diagnosis.
How is Acute Cholecystitis Treated?
As soon as the diagnosis is made, the patient should be hospitalized and intravenous fluids, appropriate antibiotics and painkillers should be started. In the case of acute calculous cholecystitis, the gold standard treatment method, like all gallstones that cause complaints, is Laparoscopic Cholecystectomy. However, it is recommended to complete the surgical preparations quickly, act early and, if possible, perform the surgery within the first 3-5 days. In case of delay, it may be difficult to complete the surgery closed and it may be necessary to convert to open surgery, although rare.
Patients are discharged with oral antibiotics the next day after the surgery.
Is It Possible to Protect Yourself from Acute Cholecystitis?
Since the majority of acute cholecystitis develops due to gallstones, the main way to protect yourself from gallbladder inflammation is to stay away from a lifestyle that will cause gallstone development. First of all, obesity, fatty and unbalanced nutrition should be prevented, regular physical activity should be done, weight should not be lost or gained rapidly, and the ideal weight should be reached. If blood cholesterol is high, diet and treatment should be taken. In addition, if people with gallstones have digestive complaints, they should undergo surgery before a complication such as acute cholecystitis develops.
Is Surgery Necessary When Acute Cholecystitis Develops?
In cases of acute cholecystitis due to gallstones, yes, surgery is necessary. In patients who apply to the HPB surgeon, if there is no condition preventing surgery, the gallbladder should be removed with a closed surgery without waiting. The earlier the surgery is performed, the faster the patient will recover. If there is a condition preventing surgery, the gallbladder inflammation is dried with effective antibiotics and diet, additional diseases are treated and surgery is performed 4-6 years later under non-urgent conditions.
Does Acute Cholecystitis Go Away On Its Own?
Since the cause of acute cholecystitis is gallbladder stones, it can go away on its own at a low rate. However, attacks continue as long as gallstones are present, and can even cause fatal complications such as acute cholangitis (biliary tract inflammation) and acute pancreatitis. Therefore, the definitive treatment for gallbladder inflammation is laparoscopic cholecystectomy surgery, in which the entire gallbladder is removed together with the stones.
Is Laparoscopic Cholecystectomy Surgery Safe?
Since 1985, laparoscopic cholecystectomy, i.e. closed method gallbladder surgery, has been performed safely and is currently considered the gold standard in the treatment of gallbladder stones.
In the method generally applied, a 10 mm incision is made from the patient’s belly button, a special needle (Veres needle) or a direct 10 mm port is entered and the abdomen is inflated with carbon dioxide gas, then 1 10 mm and 2 5 mm thick additional ports are entered and the abdomen, gallbladder, and liver are observed. With the help of special tools (endo clincher, grasper, hook, dissector, scissors, aspirator), the gallbladder canal and vessels are revealed, clipped, and the gallbladder is separated from the liver by cutting. It is taken out in a special bag (endobag). A final check is made for bleeding and bile leakage and the trocars are removed. The incisions are closed with stitches.
After the surgery, the patient is taken to the ward after recovering in the recovery room, fed with oral water and liquid food after 3 hours, first made to sit, then made to stand up and walk. The patient is sent home the next morning with a fat-restricted diet and painkiller recommendations.
The general advantages of laparoscopic cholecystectomy are known as less surgery site pain, cosmetics, short hospital stay and early return to work.
As an HPB surgeon, my different application is that we enter the abdomen through the navel and a smaller (5 mm) incision in each patient. We infiltrate all port sites with 1-1.5 mL of local anesthetic before the incision. This difference provides both less pain and better cosmetic results.
Do gallstones form during pregnancy?
During pregnancy, the formation of gallstones increases due to hormonal changes in the body, the pressure of the pregnant uterus on the organs, and the change in bile chemistry throughout pregnancy. In addition, excessive vomiting in the first weeks of pregnancy, long hunger, and fluid loss cause the bile to thicken in the bladder and sludge to form.
During pregnancy, the increase in hormones produced in the body can cause the muscles in the gallbladder to relax. This can cause the bile fluid to become more concentrated and increase the risk of stone formation. In addition, the uterus, which grows with the progression of pregnancy, can press on the gallbladder and affect the flow of bile.
Gallstones usually do not cause symptoms during pregnancy or may be overlooked because the symptoms are attributed to pregnancy. Symptoms include abdominal pain, nausea, vomiting, and rarely jaundice may be present because the sludge formed during pregnancy tends to fall into the bile duct.
If gallstones are detected in a pregnant woman, a careful evaluation should usually be made regarding treatment. If the symptoms are mild and there is a short time left until delivery, surgery can be postponed until after delivery with nutritional recommendations. However, if the symptoms are severe or there is a high risk of complications, surgery, namely laparoscopic cholecystectomy, should be performed and the most appropriate time to perform surgery to avoid harming the baby is the 2nd trimester, i.e. between the 3rd and 6th months. However, we have had patients who were extremely symptomatic and had to undergo laparoscopic cholecystectomy in the 7th month.
If you are concerned about gallstones during pregnancy or are experiencing symptoms, it is important to talk to a healthcare professional. Your healthcare professional will evaluate your condition, recommend appropriate treatment options, and guide you regarding the health of you and your baby.
Can Gallstones Cause Death?
Gallstones usually do not cause serious health problems. However, gallstones that cause complaints and are neglected can cause serious complications, which can result in death.
One of the most common complications is inflammation of the gallbladder, called acute cholecystitis. Acute cholecystitis can cause symptoms such as severe abdominal pain, fever, nausea and vomiting. In this case, the patient is stabilized with emergency medical intervention and undergoes surgery at an early stage. Neglected gallbladder inflammation can cause fatal complications such as gallbladder rupture, intra-abdominal abscess or peritonitis.
Stones that fall into the bile ducts can cause acute cholangitis, which is called purulent jaundice and can result in death if not treated with emergency ERCP. Cholangitis manifests itself with jaundice, yellowing of the skin and eyes, darkening of the urine color, lightening of the stool color, abdominal pain and high fever. Treatment is urgent. After starting intravenous antibiotics and performing the necessary tests, if there is a stone or obstruction in the bile duct, bile flow should be provided with ERCP at an early stage.
In addition, another condition that stones falling into the bile ducts can cause is acute pancreatitis. Pancreatitis is inflammation of the pancreas and manifests itself with symptoms such as severe abdominal pain, nausea and vomiting. Pancreatitis is also a life-threatening condition.
However, gallstones are unlikely to cause these serious complications and are generally rare. With early diagnosis and appropriate treatment, most conditions can be controlled. Therefore, it is important for people with gallstones to monitor their symptoms and report any concerns to a healthcare professional immediately.
Do Gallstones Recur or Relapse After Surgery?
In patients who have undergone surgery due to stones and laparoscopic cholecystectomy, there is a very small possibility of new stones forming especially in the bile ducts, and this situation is called “recurrent gallstones”.
The risk of recurrence depends on several factors and each individual’s situation is different. However, the following factors may increase the risk of recurrence:
Gallbladder Remnant: If gallbladder remnant is left unknowingly during surgery (Long Cystic Stump) or if a part of the gallbladder is intentionally left due to a very risky surgery (Partial Cholecystectomy), the remaining tissue may appear as a gallbladder with stones again.
Conditions that increase the formation of new stones in the bile ducts can be listed as bile duct strictures due to partial bile duct injury during surgery, those who have undergone bile duct stone treatment with ERCP before surgery, eating foods containing high cholesterol, obesity, cirrhosis, hemolytic anemia diseases, etc.
In order to reduce the risk of recurrence, it is important to maintain a healthy lifestyle, have a balanced diet and comply with the recommended diet and lifestyle changes. In addition, contacting a healthcare professional when any symptoms or discomfort occur is important for early diagnosis and treatment.
Prof. Dr. Kemal Dolay has both advanced therapeutic knowledge and clinical experience in gallstone diseases. He also offers good medical practices to patients with his experience in stone management, surgeries and more than 7000 ERCPs in complicated bile duct stones.
- Early diagnosis: Early diagnosis of gallstones reduces the risk of complications.
- Individualized treatment: A treatment plan is created considering the patient’s general health status, age, accompanying diseases and lifestyle.
- Patient education: It is important to inform the patient about the disease, to enlighten them about treatment options and to make recommendations on lifestyle changes in patients who do not require surgery.
- Regular follow-up: Regular check-ups are performed in the postoperative period to detect possible complications early.
Gallbladder Cancer
Gallbladder (CC) Cancer is a rare cancer that starts in the gallbladder, but has a poor prognosis due to both late presentation and advanced stage diagnosis and its biological nature. It is mostly seen in the 70s and is 2-3 times more common in women. While CC cancer is detected in 0.4% of cases in autopsy and only 0.2-3% in cholecystectomies, 40%-70% of CC cancers are detected incidentally either during surgery or during pathological examination of gallbladder samples after cholecystectomy. Most CC cancers detected after cholecystectomy are early stage (T1 and 2) and long life is possible with the right treatment.
What are the Risk Factors for Gallbladder Cancer?
Gallstones: Most patients with cancer have gallstones. The risk of cancer increases 10 times in large stones.
Bile polyps: If the true polyp is larger than 1 cm, the risk of cancer increases, if it is larger than 2 cm, the risk is very high.
If there is calcification in the porcelain gallbladder wall, the risk of cancer can increase to 20%
Children and adults with congenital choledochal cysts have a very high risk of cancer, they should undergo surgery before they turn into cancer.
Primary Sclerosis Cholangitis, Congenital bile duct-pancreas anomalies and exposure to carcinogenesis (azotoluene and nitrosamine) increase the risk of cancer.
Salmonella typhoid carriage, Smoking, Obesity and metabolic disorders such as type 2 diabetes are also conditions that increase the risk of cancer.
What Complaints Does Gallbladder Cancer Cause? Does It Cause Symptoms?
Gallbladder cancer does not cause any significant complaints in the early stages, but rather mimics complaints related to gallstones or may occur in the following ways in advanced stages:
Abdominal Pain: The most common symptom of gallbladder cancer is pain felt in the upper right abdomen. The pain is usually located in the bile area and often becomes more severe after meals.
A Bitter Taste in the Mouth or Loss of Appetite: Unlike gallstones, appetite disorders are more common in cancer.
Nausea and Vomiting: Cancer disrupts digestion and causes these symptoms.
Slow Weight Loss: Weight loss is a common symptom in the advanced stages of gallbladder cancer.
Fatigue: The body becomes weak due to cancer, which leads to a general feeling of weakness and fatigue.
Jaundice: It may develop due to the blockage of the bile ducts by SK cancer. In this case, bile cannot pass from the liver to the small intestine and accumulates in the body, causing jaundice in the skin and eyes.
Diagnosis of Gallbladder Cancer
In gallbladder-related complaints, SK cancer is also investigated in addition to gallstones, the following tests can be performed:
Blood tests: Liver enzymes and other tumor markers are checked.
Ultrasound: Used to image the gallbladder and surrounding organs, in SK cancer, the gallbladder wall is seen to be thickened in USG. (sensitivity 70-100%).
Computed tomography (CT) and magnetic resonance imaging (MR): Used for more detailed imaging. It shows the stage of the tumor, liver and lymph involvement, and its relationship with the bile ducts well and provides a guide for treatment.
EUS, PET-CT, ERCP, PTK: These methods can be used for both staging and to eliminate pre-operative problems when necessary.
Biopsy: There is no place for biopsy in operable patients.
Treatment Options for Gallbladder Cancer
Although gallbladder surgery is usually treated with surgery, personalized treatments are planned based on the stage of the disease, its spread, and the patient’s general health. In addition to surgery, chemotherapy, immunotherapy, radiotherapy, and radiologic interventions are also used.
Surgical Treatment
Patients Who Underwent Cholecystectomy: If the pathology results show cancer in patients who have undergone cholecystectomy due to suspicion of gallstones, if the tumor is in the Very Early Stage (T1a tumor: no perimuscular invasion, limited to lamina propria) and the cancer is completely removed, no further treatment is required.
In early-medium stage cancers (T1b-T2), after staging films are taken, the patient must be taken into surgery again and a portion of the liver that comes to the gallbladder bed and the lymph nodes must be removed. In more advanced stage tumors, major liver resection and bile duct resection may be required. However, in such patients, starting with Chemotherapy before surgery may sometimes yield better results.
In patients who have not undergone cholecystectomy, if there is a suspicion of SK cancer, an extended cholecystectomy, that is, surgery that includes the liver tissue and lymph nodes as well as the gallbladder, is performed from the beginning.
Gallbladder Cancer Surgical treatments include:
Gallbladder Surgery (Cholecystectomy): The first treatment step for gallbladder cancer is the complete removal of the gallbladder. This surgery is necessary to completely remove the cancerous condition. If the cancer is in the early stage, only removing the gallbladder (laparotomy or laparoscopic cholecystectomy) may be sufficient.
Partial Hepatectomy: It is the procedure of removing 2 cm of liver tissue from the gallbladder bed, done to leave no tumor inside.
Bile Duct Resection: When SK cancer extends to the bile ducts, the extrahepatic bile ducts, which we call choledochus resection, are also removed together with the lymph nodes in order not to leave a tumor.
Removal of Lymph Nodes, Lymphadenectomy: In order to reveal the lymphatic spread of the cancer and to stage it, a regional lymphadenectomy should be performed around the gallbladder. It also contributes to local control.
Adjacent Organ Resection: If cancer has affected adjacent organs such as the stomach, duodenum and colon, if there is no distant metastasis, the gallbladder, bile ducts and partial liver as well as other organs may be partially removed.
Chemotherapy
Chemotherapy is a treatment used to destroy cancer or prevent its growth. Gallbladder cancer treatment treatment is usually used as an adjuvant (auxiliary) treatment after surgery or as the main treatment option if the cancer has metastasized. Neoadjuvant chemotherapy can also be given before surgery.
Radiation
Radiation therapy is a treatment method that uses high-energy rays (radiation) to destroy cancer. Gallbladder cancer treatment is usually used together with radiotherapy or before or after surgery.
While gallbladder surgery treatment surgical treatment is the most effective option in the early stages of cancer, other treatment methods such as recovery and radiotherapy come into play in advanced disease. The treatment plan of each program is determined by considering the stage of the cancer, its changing condition and general health status. With early diagnosis and appropriate treatment, gallbladder cancer can be treated and the quality of life of patients can be improved.
Who Performs Gallbladder Cancer Surgery?
Surgical procedures performed for gallbladder cancer are comprehensive operations that require very specific knowledge and experience. When it comes to such surgeries, hepatopancreatobiliary (HPB) surgeons perform a treatment that provides better results.
Hepatopancreatobiliary Surgery Specialists
Hepatopancreatobiliary (HPB) surgery is a surgical field that covers surgery related to organs such as the liver, gallbladder, bile ducts and pancreas. If gallbladder cancer also requires additional surgery after cholecystectomy, HPB surgeons are quite competent for both the right decision and complex liver and bile duct surgery
Oncological Gallbladder Cancer Surgery: In gallbladder cancer, a complex radical oncological liver bile duct surgery is required depending on the degree of the tumor. HPB surgeons are surgeons who perform this type of cancer surgery.
New Surgical Techniques and Methods
In recent years, there have been significant developments in surgical techniques in the treatment of biliary diseases and cancers. These innovations ensure that patients recover faster, feel less pain, and have stability in their integrity risks. Especially for complex surgical surgeons such as gallbladder cancer, the treatment process is improved by using advanced methods. Here are some of these innovations:
Laparoscopic Surgery: Treatments planned for gallbladder cancer can also be performed with minimally invasive laparoscopic surgery. It has advantages such as less incision, less pain, short hospital stay, fast recovery, and cosmetic advantages.
Robotic Surgery: Robotic surgery is a method applied in many surgical branches in recent years, as well as in the gallbladder and bile ducts. Robotic systems allow the surgeon to perform the operation in a more precise and controlled manner.
Hybrid Surgical Methods: Hybrid methods applied by combining traditional surgery with minimally invasive methods are widely used in complex cases such as gallbladder cancer. The advantage of hybrid surgery is that larger tumors can be removed with fewer incisions.
Minimally Invasive Endoscopic Methods: The use of endoscopic methods in gallbladder and bile duct cancers is increasing. Endoscopic retrograde cholangiopancreatography (ERCP) and EUS are important techniques used to open obstructions in the bile ducts and to take biopsies when necessary. This method is less invasive compared to surgery and allows patients to recover faster.
Prof. Dr. Kemal DOLAY and His Contributions to Biliary Surgery
Prof. Dr. Kemal DOLAY is an important expert in the field of biliary diseases and cancer surgery and is the pioneer of many innovations in this field. His area of expertise covers the treatment of gallbladder and bile ducts, biliary cancer, obstructions in the bile duct and related surgical treatments. In addition, important treatment methods have been signed in the development and acquisition of minimally invasive methods.
Prof. Dr. DOLAY’s knowledge and experience greatly contribute to both patients and health professionals who will benefit from surgery. He has provided advanced practical training to surgeons who are particularly interested in the biliary tract in many institutions, training and research hospitals and universities and has contributed to their development.
BILE TRACT CANCER, CHOLANGIOCARCINOM
Cholangiocarcinoma (CC) is a rare, difficult and elusive adenocarcinoma originating from the bile duct epithelium. When we look at the anatomy of the bile duct, CC can occur in all bile ducts from the peripheral biliary tree in the liver at the most proximal to the intraduodenal bile duct at the most distal. It is classically divided into three subtypes:
1-Intrahepatic cholangiocarcinoma (IHCC) (20%);
2-Perihilar cholangiocarcinoma (PHCC) (50-60%); Klatskin Tumor
3-Distal cholangiocarcinoma (DCC) (20-30%).
While IHCCs are treated like liver tumors, distal bile duct tumors are treated like pancreatic tumors. The most common of these and the most complex approach is Klatskin tumors.
Perihilar Cholangiocarcinoma (PHCC), Klatskin Tumor
Klatskin tumor is defined as bile duct cancers that involve the hepatic junction or centrally the perihilar region (Figure 1).
PHCC is an aggressive disease with a poor prognosis, most of which is diagnosed at an advanced stage. Treatment of bile duct tumors is a difficult and complex process. The best results are achieved when the treatment is planned and implemented by a multidisciplinary team of experienced physicians (hepatobiliary surgeon, radiology, endoscopist, medical oncologist, etc.). The greatest chance for cure and long-term survival is to achieve a surgical resection with negative surgical margins (R0), that is, without leaving a tumor inside. It is very rare to achieve R0 surgery with only bile duct resection in PHCC. Aggressive surgeries such as extended hepatectomy and pancreaticoduodenectomy, which are technically difficult, have been applied to achieve R0 resection, and over the last two decades, surgical outcomes and survival rates have improved with advances in diagnostic and surgical techniques.
Figure 1. Definition of perihilar cholangiocarcinoma; cancers originating from the bile ducts in the topographic area surrounded by white.
What are the Risk Factors for Cholangiocarcinoma (CC)?
Chronic Inflammation: Although a cause cannot be determined in most cholangiocarcinoma patients, chronic inflammation and compensatory cellular proliferation in the bile ducts are a risk-increasing condition. Some predisposing conditions also increase the risk.
Choledochal cysts: Such congenital conditions increase the risk due to the exposure of the biliary epithelium to toxic pancreatic fluid. The estimated risk of CC in choledochal cysts that are not resected until the age of 20 is accepted as 10-20%.
Recurrent pyogenic cholangitis: The risk of CC also increases in cases of recurrent pyogenic cholangitis characterized by primary bile duct stones.
Chronic ulcerative colitis, choledochal cysts (3-28% lifetime risk) and Caroli disease, papillomatosis, primary sclerosing cholangiocarcinoma (autoimmune, IH-EHSY with multifocal stenosis: annual CC risk 1.5%, 8-20% lifetime risk, especially Klatskin tm: most common risk factor in the West, especially with IBD, the risk increases), Hepatolithiasis, Biliary enteric anastomoses, Genetics (Lynch II syndrome and multiple biliary papillomatosis), Chronic typhoid carriers and in South Asia, parasites such as Clonorchis sinensis and Opisthorchis viverrini also increase the risk. Dietary nitrosamines, Thorotrast, chemicals such as asbestos, oral contraceptives, smoking and Dioxins also increase the risk. Cirrhosis is also an important CC risk factor, increasing the risk by 15 times.
How is Klatskin Tumor Diagnosed?
The diagnosis of PHCC is suggested based on symptoms and findings suggesting a mass in the hepatic hilum or bile duct obstruction, abnormal liver function test results and imaging findings.
What are the Complaints in Klatskin Tumor?
Most patients (90%) present with obstructive jaundice symptoms such as jaundice, tea-colored urine, acholic stools and pruritus. In patients with only right or left-sided bile duct involvement, jaundice may not be present, but these patients have vague abdominal pain. At presentation, 56% of patients have symptoms of malignancy such as weight loss, fatigue and loss of appetite. Severe pain is considered to be an indicator of an advanced stage. 10% of patients may present with cholangitis. In single-lobe SY involvement, patients may present with atrophy on the lesion side in the late stage without jaundice and lobar hypertrophy on the other side in advanced stages, and a mass is palpable in the right upper quadrant in these patients.
Intermittent jaundice may occur in papillary tumors because tumor fragments may break off and act as a valve mechanism, causing intermittent biliary obstruction. In Klatskin tumors, there may be skin findings such as Sweet syndrome, cutaneous prophyria tarda, acanthosis nigricans and erythema multiforme due to paraneoplastic syndrome.
Physical examination generally does not show any features other than jaundice (90%). In cases of long-term bile obstruction and portal vein involvement, liver dysfunction, liver enlargement (25-40%) and portal hypertension symptoms may be seen. A mass (10%) or fever (10%) may also be detected in the right upper quadrant. Since the gallbladder is often decompressed, it is not palpable.
Radiology in Klatskin Tumors
Both diagnosis and staging can be done with US, CT and MRCP. It also determines what kind of surgical plan will be made in operable patients. Bile drainage should be provided with PTC in patients with jaundice and especially if liver resection is planned.
Surgery in Klatskin Tumors
Major liver resection and lymphadenectomy should be performed frequently. The situation that should be considered in surgery is to ensure negative surgical margins.