Tumors of the biliary tract. bile duct cancer

benign tumors

Pathological anatomy and diagnostics. Of the benign tumors of the gallbladder, adenomas are mainly found. These tumors do not have pronounced specific clinical symptoms. They are usually detected during cholecystectomy and autopsy and often occur in combination with cholelithiasis. They are often localized in the region of the bottom of the gallbladder. On choleiistograms, round-shaped filling defects are revealed. When localized in the neck of the gallbladder, they can interfere with the outflow of bile from it, which contributes to the development of XX.

From benign tumors, papillomas (papillomatosis), fibromas, myomas, and in some cases also neurinomas, leiomyomas and hamartomas are also often found. Pronounced cellular atypism and a tendency to recurrence give grounds to consider these epithelial tumors as precancerous diseases. The clinical interest of such tumors is that they cause obstruction of the biliary tract and lead to breast cancer. Polypoid tumors of the terminal choledochus can block the external opening of the pancreatic duct, which usually leads to the development of CP.

Before surgery, these tumors can only be diagnosed using cholecystography and ultrasound. With cholecystography, unlike gallstones, the position of the filling defect does not change with a change in the position of the patient's body.

Treatment. When benign tumors of the gallbladder are detected, cholecystectomy is indicated, as well as removal of the tumor within healthy tissues.

In case of tumors of the terminal part of the common bile duct, it is sometimes necessary to perform a pankeatoduodenal resection. This intervention is very risky and must be performed according to strict indications (bleeding, malignant degeneration of the tumor, etc.). In all other cases, they are limited to papillectomy or excision of the tumor. If it is impossible to perform the latter, they resort to curettage or electrocoagulation of the tumor. The use of these methods does not exempt from tumor recurrence.

Malignant tumors

Pathological anatomy. Gastrointestinal cancer often (85-90% of cases) develops against the background of long-term HCC. From this point of view, a number of authors consider HCC to be a precancerous disease. Cancer of the gallbladder quickly spreads by lymphatic routes to the perihepatic tissues, which often causes the development of breast cancer. Of the individual types of cancer, adeno-karshshoma and scirrhus are more common (85% of cases), rarely mucous, solid and poorly differentiated cancer. In the early stage of the development of carcinoma of the gallbladder, the process proceeds without any special clinical symptoms or with the characteristic symptoms of CCC, which is caused by a combination of cancer of the gallbladder and cholelithiasis. A cancerous tumor is more often localized in the anteroposterior part of the body of the gallbladder.

Relatively rarely, it is localized in the neck of the gallbladder or on its lower surface. Cancer of the gallbladder shows an excessively malignant course and already at an early stage of development gives metastases to the lymph nodes and into the thickness of the liver parenchyma. Primary tumors located in the bottom of the gallbladder spread faster to the liver. They give metastases primarily to the lymph nodes located in the region of the gate of the liver. Cancer starting from the cervical region of the gallbladder fairly quickly spreads to hepaticocholedochus, as a result of which the outflow of bile through the common gallbladder is blocked and MF, dropsy of the gallbladder, etc. occur.

Clinical picture and diagnosis. Pancreatic cancer has no specific symptoms. In a later period, it is also not possible to identify the symptoms characteristic of this disease, and only when the tumor spreads, both general and local signs are noted. In different stages of the development of cancer of the gallbladder, only symptoms of cholecystitis are expressed. It should be noted that about 1% of operations performed for cholelithiasis, with revision of the biliary tract or GI of the removed gallbladder, are diagnosed as cancer.

Cancer of the gallbladder is characterized by the presence in the right hypochondrium of a dense, bumpy and, as a rule, painless infiltrate. With the localization of the tumor in the neck of the gallbladder, its dropsy occurs. Often, the clinical picture of obstructive cholecystitis joins this, destruction of the gallbladder wall develops, and sometimes its perforation into the free abdominal cavity or into the lumen of neighboring organs (DPC, OK), which causes peritonitis or the occurrence of internal bile duct. In such cases, the patient's body temperature rises and is hectic in nature. A tumor from the cervical region of the gallbladder quickly spreads to the CBD and leads to the development of rapidly progressing mammary glands.

Of the common signs of cancer of the gallbladder, general weakness, loss of appetite and weight loss are often noted. Patients often die from NP. When, with prolonged HCC in a patient of senile age, pain in the right hypochondrium becomes permanent, subfebrile temperature, anorexia, constant weight loss and dyspeptic symptoms appear, then pancreatic cancer should be assumed. In such cases, leukocytosis is detected in the blood, ESR increases. When the CBD is compressed by a tumor or affected lymph nodes, the level of bilirubin, cholesterol, alkaline phosphatase increases in the blood, bile pigments appear in the urine, those. there are all signs of MF.

In the early stage of the disease, a filling defect is noted on cholecystograms. Of the existing methods of instrumental research, laparoscopy is considered more reliable, in which it is possible to examine the gallbladder with a bumpy surface of the tumor on it, growing into the liver, as well as metastases in it. On the scan in the right lobe, a "silent zone" is revealed.

Treatment. Possible treatment of cancer of the gallbladder is only surgical, despite the fact that it is not always possible to perform a radical intervention. From the point of view of the patient's recovery, the chance is very small. If possible, both radical and palliative operations are performed. Often the gallbladder is removed for HCC, and the diagnosis of cancer is made after the GI. In the vast majority of cases, the outcome of surgery is unfavorable. About 10% of patients after surgery live up to 5 years

When confirming the diagnosis of cancer during surgery, extended cholecystectomy is indicated. In this case, a wedge-shaped resection of the liver and removal of the lymph nodes located in the hepatoduodenal ligament are performed. When the tumor grows into the neck of the bladder and hepaticocholedochus, in some cases it will be possible to remove the gallbladder, resect the hepaticocholedochus together with the lymph nodes located in the hepatoduodenal ligament.

When the tumor grows into the liver, segmental resection of the liver or right-sided hemihepatectomy is performed. With common tumors of the gallbladder, the long-term results of radical operations are unfavorable. The average life expectancy after surgery is one year. With the defeat of the high sections of the bile ducts, it is often not possible to perform even a palliative operation. In some cases, it is possible to impose only external drainage of the lobar duct of the liver according to Prader or Smith (Figure 19) or to recanalize the tumor using transhepatic drainage. In some cases, it is possible to perform a palliative operation, the purpose of which is to drain the disintegrated tumor cavity, and if the choledochus is obstructed, drain the intrahepatic ducts (Figure 20).

Figure 19. Transhepatic drainage of hepaticocholedochus: a — according to Prader. b - according to Smith

Figure 20. Hepaticojejunostomy (diagram)

The tumor can be localized in any part of the CBD - from the gate of the liver to the terminal part of it. Distinguish between exophytic and endophytic cancer. In the exophytic form, the tumor grows into the lumen of the duct and quickly obturates it. With endophytic cancer, the duct narrows evenly over a large extent.

Pathological anatomy. In 30% of cases, bile duct cancer occurs in combination with cholecystitis. All parts of the bile ducts are affected by a tumor with almost the same frequency. The lobar ducts of the liver are relatively less affected by primary cancer. The tumor often develops at the confluence of the lobar ducts, in the region of the papilla of Vater, etc.

According to statistical data, in 14% of cases the tumor is localized at the confluence of the lobar ducts, in 24% of cases - at the confluence of the cystic and hepatic ducts, in 36% of cases - in the gallbladder and in 10% - in the region of the papilla of Vater. In other areas, the tumor is rarely localized. With exophytic growth, the tumor on palpation is in the form of a dense node. With an infiltrating tumor, it is in the form of a dense cord or an obturated tube. These tumors grow into the thickness of the submucosal layer and significantly narrow the lumen of the ducts.

In some cases, the tumor is in the form of a massive conglomerate, in which, in addition to the ducts, the surrounding tissues are also involved. Bile duct cancer spreads quite quickly. In 50-75% of operated patients, tumor growth into neighboring tissues and metastases in other organs are detected.

When a tumor affects the lymph nodes located at the gates of the liver, in the paraortal region, it is often impossible to perform a radical operation even with small tumors. The most common metastases are the liver. The vast majority of bile duct tumors are adenocarcinomas. Papillary scirrhus is relatively less common, and differentiated or squamous cell carcinoma is relatively rare.

Clinic and diagnostics. In a relatively early period of the disease, biliary tract cancer leads to the development of breast cancer, which is due to obstruction of the lumen of the bile ducts or their narrowing and impaired outflow of bile into the duodenum. Unlike jaundice that develops with cholelithiasis, with obstruction of the CBD by a tumor, the appearance of jaundice may not be preceded by a pain attack.

With a slow course of the process of narrowing of the bile ducts, often patients are disturbed by skin itching, only after that jaundice appears. In a number of patients, jaundice grows rapidly and is often of an intermittent nature, due to the disintegration of the tumor tissue and the temporary restoration of the patency of the cancer process (weakness, apathy, lack of appetite, weight loss, anemia, etc.). Cholangitis often develops, which significantly aggravates the patient's condition. With localization of a cancerous tumor in the right or left hepatic duct and while maintaining the patency of the CBD, jaundice does not occur, which makes diagnosis difficult.

With a tumor of the common hepatic duct, an enlarged, painless gallbladder is palpated (Courvoisier symptom). The gallbladder can also be palpated with dropsy, which is also due to the blocking of the common gallbladder by the tumor. The place and level of obturation are specified by the condition of the gallbladder using laparoscopy. Identification of an empty gallbladder indicates obstruction of the upper part of the hepatic duct. With a low location of the obstruction of the CBD, the CBD is filled and tense.

To determine the condition of the PP and the level of obstruction of the ducts, laparoscopic cholecystocholangiography and percutaneous hepatocholangiography are performed.

To detect a choledochal tumor and differentiate it from cancer of the OBD, fibroduodenoscopy and ascending cholangiography are performed. The latter helps to determine the degree of prevalence of the tumor, and in case of incomplete obturation - to identify the boundaries of its prevalence, assess the condition of the upper biliary tract and the possibility of surgical treatment.

For the diagnosis of biliary tract cancer, ultrasound, percutaneous transhepatic cholangiography, RPCG, laparoscopic puncture of the gallbladder, and cholangiography are used. Clarification of the morphological diagnosis is possible only during the operation: after choledochotomy, choledochoscopy and tumor GI.

Differential diagnosis is primarily carried out between the cholestatic form of hepatitis, cholelithiasis, pancreatic cancer, liver cancer and gallbladder.

When feeling a dense, elastic, rather mobile and painless formation (Courvoisier's symptom), it becomes clear that we are dealing with saturation of the terminal CBD. In such cases, almost no additional research is required. In cases where these symptoms are absent, it is difficult to diagnose a tumor without the use of special research methods.

Treatment. Treatment of cancer of the extrahepatic bile ducts is only surgical. Radical surgery can be performed only in 10-15% of patients. The earlier the patient undergoes surgery, the greater the likelihood of a radical operation. In the late stage, as a result of MF, irreversible changes can develop in the body. In the presence of cancer of the biliary tract, when the tumor is localized in the distal part, it is possible to perform a pancreatic duodenal resection, since it is rarely possible to perform a radical operation in cancer of the biliary tract. More often, forced intervention is performed to eliminate jaundice and decompress the biliary tract. For this purpose, BDAs are superimposed.

In some cases (prolonged jaundice), pancreatic duodenal resection is considered appropriate to perform in two stages. As the first stage of the operation, laparoscopic cholecystostomy is performed.

With the localization of a cancerous tumor in the middle part of the hepaticocholedochus, it is removed with the whole mass, together with the lymph nodes of the perivesical region and the hepatoduodenal ligament. The hold breath is anastomosed with the duodenum or intestinal loop. In the presence of tumors in the terminal part of the choledochus, CDA or xlecystogastroenteroanastomosis is applied. At low (below PP) localization of the tumor, a hepaticojejunoanastomosis is applied (see Figure 20) or hepaticoduodenoanastomosis. When the tumor is localized in the proximal part, the tumor is recanalized and this part is drained.

When the tumor is localized in the more proximal part of the hepatic duct, internal drainage of the intrahepatic ducts is performed (hepatojejuno- or hepatogastroanastomosis). When the tumor is localized in the region of the liver gate, it is impossible to use the extrahepatic biliary tract for drainage. Only in some cases is it possible to recanalize the bile duct and drain the affected section with rigid drainage. The latter is brought out or introduced into the intestinal lumen. With such localization of the tumor, the intrahepatic bile ducts are usually drained or an anastomosis of the intrahepatic bile ducts with the stomach (Dolioty operation) or TC (Longmeyer operation) is performed (Figure 21).

Figure 21. Cholangiojejunoanastomoses: a — according to Longmeier; b—modification of the Longmeier method

Clinic and diagnostics. Cancer of the extrahepatic biliary tract in the initial stage proceeds without pronounced symptoms, until the development of obstruction and the occurrence of jaundice. In some cases, patients note dull pain in the epigastric and right hypochondrium regions. In the initial period, jaundice is intermittent. This is due to the elimination of perifocal inflammation and spastic contractions. With complete obstruction of the bile duct, jaundice becomes permanent and progresses rapidly.

The skin becomes yellow-green. Depending on the localization, the progression of jaundice occurs at different rates. In the icteric period of the disease, most patients have no pain or they are mild. General phenomena are rapidly growing: intoxication, exhaustion, caused by a violation of the process of bile and PS entering the duodenum. When the tumor is localized in the terminal parts of the common bile duct, the gallbladder performs a certain compensatory function. In this regard, it expands significantly, increases in size, becomes palpable, mobile and painless (Courvoisier symptom).

In such cases, jaundice grows slowly. In the initial stage, thick bile accumulates in the gallbladder, then, as a result of the absorption of bile pigments, the bile becomes discolored (“white bile”). Some authors explain this by a deep violation of liver function. With the localization of the tumor in the upper sections of the bile duct, jaundice develops faster. Here, bile does not pass into the gallbladder, as a result of which it is empty and the symptom of Courvoisier is not noted. When the tumor is localized in the distal part of the RA, the presence of Courvoisier's symptom does not always indicate its obstruction.

With cancer of the papilla of Vater, jaundice is often undulating, which can cause diagnostic errors. In addition to jaundice, patients experience skin itching, weakness, loss of appetite, and weight loss. With such localizations of cancer in the feces, occult blood is often detected (positive Gregersen test), which indicates the disintegration of the tumor. Patients often develop cholangitis, body temperature rises, chills, and profuse sweating are sometimes noted.

At the same time, duodenoscopy and duodenography in the state of duodenal hypotension are of great importance for the diagnosis of cancer of the Vater papilla. Laparoscopy is also used, which makes it possible to see the dilated subcapsular bile ducts and an enlarged gallbladder. Radionuclide study, percutaneous, transhepatic hedecystocholangiography are used. The latter makes it possible not only to identify the cause of jaundice, but also to clarify the place and nature of the obstruction to the outflow of bile.

Treatment. Treatment of cancer of the papilla of Vater is only operative. Often it is possible to perform a radical operation. In the early stage of the disease, when the tumor is 2-2.5 cm in size, not all duodenal elephants are involved in the tumor process, the head of the pancreas does not undergo infiltration, and there are no immediate and distant metastases. At this stage, a palillectomy is performed, after which the CBD and the pancreatic duct are sutured into the duodenum (from the back). When the tumor reaches a significant size with a relatively favorable condition of the patient, pancreatoduodenal resection is performed.

However, often the patient's condition does not allow such an extensive and traumatic operation. In such cases, it is considered possible to remove the tumor along with the Vater papilla (transduodenal papillectomy). In advanced cases, with a serious condition of the patient, palliative surgery, EDA, cholecystojejunostomy, choledochotomy are performed.

With radical operations, the average life expectancy in 5-8% of cases is about 5 years.

Cancer of the extrahepatic bile ducts less common than gallbladder cancer, more common in men, usually over the age of 50. Its combination with calculosis is less common than with gallbladder cancer. The favorite localization of cancer is the ampullar part of the common bile duct, the place of confluence (confluens) of the cystic, common hepatic and common bile ducts. Macroscopically, the tumor is usually small (1.5-2.5 cm), whitish in color, grows into the lumen of the duct and infiltrates its wall. When palpated, it gives the impression of a dense knot or a rigid tube, which is difficult to distinguish from a cicatricial stricture of the duct.

In favor of the latter to some extent they say inflammatory changes in the surrounding tissues, however, in case of doubt, the issue can be resolved only after a histological examination. As a rule, it is an epithelial, more often a cylindric cell carcinoma of a scirrhous or papillary structure. Bile duct cancer develops relatively slowly, metastasizes late, usually to the liver and regional lymph nodes. In the late stage of the disease, tumor growth into neighboring organs and tissues, ascites due to compression of the adjacent portal vein are observed.

Most common and earliest symptom is obstructive jaundice. Once having arisen, as a rule, without a previous attack of pain, it progresses rapidly. The stool becomes discolored, the urine is dark in color, the content of bilirubin in the blood serum reaches 170-340 µmol/l (10-20 mg%) or more. The amount of cholesterol and alkaline phosphatase in the blood serum increases. Jaundice is often accompanied by excruciating itching; sometimes it precedes the onset of jaundice. There is a decrease in the prothrombin index up to 30% and the albumin-globulin ratio (less than one). With cholemia, subcutaneous and intestinal bleeding appears. Emaciation, general weakness, loss of appetite progress, sometimes appearing before the onset of jaundice.

Stomach ache often absent or insignificant, blunt in nature, localized in the right hypochondrium, epigastric region, back. In some cases, cholangitis develops, manifested by chills and high fever.

Liver somewhat enlarged, painful on palpation. Functional liver tests in cancer, in contrast to acute hepatitis, do not change within 2-3 weeks of the disease. With prolonged obstruction of the duct by a tumor, cirrhotic changes develop in the liver: it becomes dense, sometimes bumpy, and increases. If the tumor is localized below (distal to) the confluence of the cystic duct, then developing bile hypertension contributes to the stretching of the gallbladder; in these cases, it is well palpable, tense, but completely painless (Courvoisier symptom). Over time, the overlying bile ducts also expand, containing not bile, but a mucus-like white liquid (“white bile”).

When the tumor is located dropsy or chronic empyema of the gallbladder develops at the confluence of the cystic and common bile ducts. In those cases when the tumor obturates the common hepatic duct, the gallbladder is in a collapsed state, devoid of bile. It should be borne in mind that if one of the lobar hepatic ducts (right or left) is affected, jaundice may be absent even if it is completely occluded by a neoplasm; at the same time, the corresponding lobe of the liver atrophies.

Diagnostics often difficult even during surgery. Clinical manifestations sometimes make it possible to suspect bile duct cancer, for example, the presence of Courvoisier's symptom. Great diagnostic difficulties arise with cholangitis, severe pain syndrome, simulating choledocholithiasis. Conventional methods of radiopaque examination of the biliary tract are ineffective due to the early onset of intense jaundice. The correct diagnosis is facilitated by laparoscopic cholecystocholangiography or laparoscopic cholangiography, as well as percutaneous - transhepatic cholagiography. However, after the latter, it is often necessary to undertake a laparotomy due to the outflow of bile or blood from the puncture hole in the liver, which reduces the value of this study.

Diagnostic doubts during surgery (tumor or scar) can be resolved with an urgent biopsy, but sometimes only a subsequent planned histological examination of serial sections can correctly judge the nature of the lesion of the bile ducts. In the differential diagnosis between cancer of the terminal section of the common bile duct and cancer of the Vater papilla, duct and head of the pancreas, there are usually great difficulties that cannot always be resolved even with pathomorphological examination.

Treatment of malignant tumors bile ducts is only surgical, but the operability of this disease is low. Usually, duct resection is performed, ending with duct suture on the drainage or biliodigestive anastomosis. In case of damage to the terminal section of the common bile duct, pancreatoduodenal resection is performed. From palliative interventions, the imposition of cholecystoduodeno- or cholecystoenteroanastomosis is more often performed. When the tumor is localized in the area of ​​the common hepatic duct, re-aialization and intubation of the duct or external transhepatic drainage are indicated.

Operations such as external or internal are also possible. cholangiostomy with the help of drains (formation of an anastomosis with a viutrihepatic duct located subcapsularly on the lower surface of the liver and sharply expanded as a result of a disturbed outflow of bile). Mortality after radical surgery is about 30%. Palliative operations, eliminating jaundice and intoxication and normalizing the chemistry of digestion, improve the condition of patients, but do not prolong life for a long time.

Malignant tumors of the gallbladder make up about 4% of cancers of the gastrointestinal tract, which are formed from epithelial cells. The mechanism of the development of the disease is not fully understood. In 1% of patients, gallbladder cancer develops as a complication after surgery. In 90% of cases, it can be a consequence of gallstone disease left without due attention. There is also a correlation with the gender of patients - women are 3 times more likely to develop cancer of the gallbladder and bile ducts than men. Up to 80% of tumors of these organs are adenocarcinomas, that is, neoplasms from glandular epithelial cells. They metastasize to neighboring structures - the liver, hepatic, duodenal and pancreatic lymph nodes.

Clinical picture

Like many oncological diseases, cancer of the gallbladder and ducts develops rapidly and aggressively, often when a diagnosis is made, the tumor already metastasizes to neighboring organs. As a rule, it is diagnosed during the preparation of the patient for surgery for cholelithiasis.

The very first clinical symptom is recurrent pain in the right hypochondrium, indigestion, nausea and vomiting. Against the background of tumor growth, ascites and carcinomatosis of the abdominal organs can also develop.

Disease classification

The most widespread is the international classification of oncological diseases TNM, derived from the Latin terms tumor, nodus and metastasis. The first letter describes the size of the tumor and the degree of its germination in healthy tissues, the second - the defeat of the lymph nodes, the third - the presence of metastases. Within each characteristic there is also a separate feature gradation, for example:

• TIS or carcinoma in situ - the tumor does not extend beyond the lesion;
• T1 - the muscular layers and the mucous membrane of the gallbladder are affected;
• T2 - the tumor grows into the perimuscular connective tissue;
• T3 - the neoplasm metastasizes to the visceral peritoneum and regional organs - for example, to the liver;
• T4 - the tumor grows into the liver by more than 2 cm, or spreads to at least two nearby organs: omentum, stomach, duodenum, pancreas, colon, extrahepatic bile ducts;
• N1 - metastasis captures the gate of the liver and lymph nodes of the cystic and common bile ducts;
• N2 - metastases spread to the lymph nodes of the head of the pancreas, portal vein, superior mesenteric and celiac arteries, duodenum.

Treatment tactics and prognosis of survival

Treatment of gallbladder cancer is extremely rare, since the disease is almost impossible to diagnose at an early stage. As a rule, the tumor is detected during diagnostic and therapeutic manipulations indicated for other reasons, for example, during cholecystectomy. If metastasis extends beyond the gallbladder, cholecystectomy is performed. To prevent the development of cancer at the expense of residual diseased epithelial cells, the lobe of the liver and regional lymph nodes are removed.

The chances of a full recovery, however, are low. In advanced cases, the survival prognosis is extremely low, since very often the tumor progresses, growing into the liver. They occur in 70% of operated patients. If the bile duct is blocked by a tumor or inflamed lymph nodes, endoprosthetics (stenting), transhepatic cholangiostomy or hepaticojejunostomy are performed. However, only 10% of patients manage to prolong life by a maximum of 5 years.

Cancer of the common bile duct

Symptoms and diagnosis of the disease

The bile ducts have a small diameter, so even with a minimal tumor size, signs of blockage begin to appear. They are expressed in aching pain in the right hypochondrium, jaundice, lack of appetite, sudden weight loss, skin itching. Laboratory diagnostics reveals the growth of direct and total bilirubin, serum alkaline phosphatase, a slight change in the concentration of serum transaminases. Instrumental studies are also informative - endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography. Both methods also involve the collection of affected tissues for histology.

TNM classification of the disease

In accordance with the international classification of the stages of development of oncological diseases, the following types of cholangiocarcinomas are distinguished:

• TIS or carcinoma in situ - the tumor does not extend beyond the affected organ;
• T1 - a malignant tumor spreads in the muscular-connective layer of the organ or in the subepithelial connective tissue;
• T2 - there is a germination of carcinoma in the perimuscular connective tissue;
• T3 - carcinoma metastasizes to neighboring structures;
• N1 - the tumor metastasizes to the lymph nodes in the hepatoduodenal ligament;
• N2 - metastasis spreads to the lymph nodes near the celiac and mesenteric arteries, the head of the pancreas, duodenum and peripancreatoduodenal lymph nodes.

Tactics of treatment and prognosis of survival in cancer of the common bile duct

Only surgical removal of the tumor can increase the chance of recovery, while its resectability is no more than 10%. For resection of cancer of the distal sections, the so-called Whipple operation is performed - pancreatoduodenal resection, after which the patency of the biliary tract and the gastrointestinal tract is restored. If the neoplasm is localized in the proximal sections, after removal of the tumor, restoration of the common bile flow is required. When removal of the tumor is not possible, tunneling is performed using drainage. On the one hand, it opens into the common bile duct, on the other - into the intrahepatic ducts. External drainage is sometimes used for percutaneous transhepatic cholangiography. After surgery, life expectancy increases by an average of 23 months. Chemotherapy helps to slightly prolong this period.
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- malignant tumor lesion of the bile ducts (common hepatic, cystic or common bile). Cancer of the extrahepatic biliary tract is manifested by jaundice, fever, abdominal pain, pruritus. Diagnosis includes ultrasonography, percutaneous transhepatic cholangiography, retrograde cholangiopancreatography, liver tests, CT, MRI, diagnostic laparoscopy. Radical treatment of extrahepatic duct cancer may include cholecystectomy, duct resection, pancreatoduodenal resection. In inoperable cases, palliative surgery, radiation and chemotherapy are performed.

General information

Treatment of cancer of the extrahepatic biliary tract

The choice of treatment tactics for cancer of the extrahepatic bile ducts is dictated by the localization and stage of the tumor. Unfortunately, the disease is often detected already in advanced stages, which makes radical surgical treatment difficult.

With early detection of cancer of the common bile duct, in the absence of interest of neighboring structures, it is possible to perform resection of the common bile duct, followed by end-to-end suturing or sewing of the proximal part of the common bile duct into the wall of the duodenum or jejunum. In case of damage to the supraduodenal section of the common bile duct, cholecystectomy and resection of the duct are performed. Tumor localization in the distal common bile duct dictates the need to perform

Diagnosis can be aided by investigations such as pneumoperitoneum radiography, intravenous and percutaneous cholangiography, laparoscopy, and selective angiography.

Treatment. The close connection of the lymphatic vessels of the gallbladder and the liver makes simple cholecystectomy for gallbladder cancer unpromising. Therefore, most surgeons under radical surgery mean the removal of the gallbladder with resection

her square lobe or "anterior liver" according to Quino. Although there is an opinion that such operations, while increasing postoperative mortality, do not improve long-term results

(Dony, Deschrey-w, 1969; Loth, Enlhert, 1971), encouraging observations are described when, after a radical operation, a stable recovery was calculated in 15-16 years (S. A. Holdin, 1949; Mitmaker et al., 1964). Such operations are indicated only at an early stage of tumor development, so they are rare. According to Vaittinen (1970), out of 300 interventions for gallbladder cancer performed by him in hospitals in Finland, 31 patients (10%) underwent radical surgery, and 10 have been alive for more than 5 years. The recommendation of A. D. Nikolsky (1968) to supplement cholecystectomy with intraportal administration of antitumor drugs is quite justified.

Palliative operations for gallbladder cancer are aimed at decompressing the liver in case of obstruction of the biliary tract and eliminating the purulent focus in case of gallbladder empyema.

CANCER OF THE EXTRAHEPATIVE BILIC DUCTS

The main bile ducts are not such a rare localization of cancer, as is commonly thought: among malignant tumors of the organs of the biliopancreatoduodenal zone, they occupy the second or third place after pancreatic cancer (A. V. Smirnov, 1968; Porter, 1958; Maki et al., 1966). In MNIOI them. P. A. Herzen observed 465 patients with malignant tumors of the organs of the biliopancreatoduodenal zone, including 75

(16%) with tumors of the extrahepatic bile ducts. According to the ONTS of the USSR Academy of Medical Sciences, the localization of cancer in question was 13%. The average age of patients is 60 years. Men and women are affected with equal frequency.

Pathological anatomy. According to the combined statistics of Sako et al. (1957), out of 570 cases of extrahepatic duct cancer, common bile duct cancer accounts for 35.6%, cancer of the triple duct junction (confluent hepatico-cystico-choledocien by French authors) - 24%, common hepatic duct cancer - 13.9 %, cancer of the right and left hepatic ducts - 8.2%, cancer of the cystic duct - 6%, the share of unclassified tumors -

Macroscopically distinguish between nodular, infiltrative and papillary forms of cancer. According to MNIOI them. P. A. Herzen with an infiltrative form, complete obstruction of the biliary tract occurs later, metastases are more common, and the possibility of performing radical operations is less. The most favorable prognosis for papillary cancer. Microscopic tumors have the structure of adenocarcinoma of varying degrees of differentiation; occasionally squamous cell carcinoma occurs (N. A. Vorotilkin, 1962).

Cancer of the main bile ducts spreads mainly through the lymphatic vessels, most often the liver is affected secondary. Metastases during surgery

are found in 50-71.4% of patients (Kuwayti et al., 1957; Strohl et al., 1963).

Clinic. Jaundice is an obligatory sign of damage to the main bile ducts. In half of the cases, it occurs suddenly. In the rest of the patients, pre-icteric

symptoms are noted on average for 2 "/ 2 months. The longest pre-icteric anamnesis (7 months) is observed in cystic duct cancer, which often occurs with painful attacks under the guise of cholelithiasis. Jaundice is usually intense and persistent (G. I. Seleznev , 1969; A. V. Volsky, 1970). However, when the primary tumor is localized at the site of the triple junction of the ducts or in one of the lobar ducts, as the observations of MNIOI.imp. A. Herzen show, it may have a wavy or recurrent character. the course of obstructive jaundice with the rapid development of symptoms of hepatic decompensation is observed with complete obstruction of the main ducts, causing the gallbladder reservoir to turn off.Given this, it is clinically necessary to distinguish between proximal and distal obstruction of the extrahepatic biliary tract with a border at the level of the triple junction of the ducts.For high tumor stenoses, a significant increase is characteristic liver, and for distal - positive sign of Courvoisier. However, an increase in the gallbladder with obstructive jaundice does not always indicate the level of obstruction, since it can be turned off as a result of blockade of the cystic duct by the tumor.

Cholangitis in duct cancer is observed in 38-55% of patients. At the same time, according to A. I. Krakovsky and R. A. Ni-hinson (1969), fever can occur for G / 2-2 months before the onset of jaundice. Approximately with the same frequency pains are noted. Significant weight loss in duct cancer rarely has time to develop; this symptom is more characteristic of pancreatic cancer.

Diagnostics. Patients with obstructive jaundice caused by cancer are usually mistakenly admitted to infectious diseases hospitals, from where, on average, after 4 weeks they are transferred for surgical treatment (B. A. Korolev et al., 1970; I. B. Rozanov, G. I. Sabelnikova, 1970) . This period is excessively long, if we take into account that, as a rule, several days are enough to exclude parenchymal jaundice. In this case, a comprehensive study of serum enzymes is of great importance. Obstructive jaundice is characterized by hyperbilirubinemia, hypercholesterolemia, hyperphosphatasemia, normal aldolase levels and a moderate increase in aminotransferase activity.

Differential diagnosis of extrahepatic bile duct cancer has to be carried out with other cancer localizations in the organs of the pancreatoduodenal zone, as well as with obstructive jaundice caused by cholelithiasis. Percutaneous cholangiography can help establish the correct diagnosis (Fig. 110). In difficult cases, the diagnosis is specified on the operating table. When examining a patient with obstructive jaundice, one should not forget the words of P. A. Herzen (1935): “Keeping a patient with retention jaundice without surgery for more than 15-21 days is a gross mistake, which is paid for by the huge mortality of patients immediately after surgery ...”

Treatment. For radical treatment of cancer of the distal common bile duct, pancreatoduodenal resection is recognized as the method of choice.

(A. V. Smirnov, 1961; A. A. Shalimov, 1970; Shith, 1966; Maki et al., 1966). I. F. Linchenko (1972) collected in the world literature from 1958 to 1970 information about 209 pancreatoduodenectomy for

Rice. 111. Scheme of resection of the hepato-gastric duct with cholecystectomy (stages 1-3 of the operation).

cancer of this localization with postoperative mortality of 26.9%.

With a tumor lesion of the supraduodenal part of the hepatobiliary duct in a limited area, a more sparing duct resection with cholecystectomy can be performed (I. L. Bregadze, M. I. Izrailev, 1958; V. I. Kizhaev, 1962; A. V. Smirnov, 1969; E. S. Futoryan, B. M. Shubin, 1973; Mighton, 1966; Walters, 1970). These operations are

are found even less frequently than pancreaticoduodenectomy: according to I.F. Linchenko (1972), for 1958-1970. published reports of 56 resections of extrahepatic bile ducts, of which 20 belong to domestic surgeons. 6 similar surgeries were carried out in the Oncological Center of the Academy of Medical Sciences of the USSR.

An economical excision of the ducts with suturing of the ends is not justified, but a wider removal of the tumor with the imposition of a biliodigestive anastomosis is indicated. In MNIOI them.

P. A. Herzen adopted the technique of anastomosis of the stump of the resected duct with the stomach on a controlled transnasal drainage, which provides good decompression of the liver and unloads the sutures of the anastomosis (Fig. 111). According to this technique, 10 operations were performed; 3 patients died from complications.

Tumor growth towards the gates of the liver severely limits the possibilities of radical treatment. According to Kozaka et al. (1967), the operation is feasible when any of the lobar ducts can be mobilized 1 cm above the tumor. In this case, the main duct of the other lobe, if it cannot be used to drain bile, is crossed and tied up within healthy tissues. In some cases, resection of the ducts is combined with the removal of the corresponding

lobe; liver (Haynes et al., 1964; Quatlebaum et al., 1965).

The main type of care for patients with tumor obstruction of the extrahepatic biliary tract is palliative surgery aimed at eliminating jaundice. These operations are especially difficult with high stenoses, when it becomes necessary to remove bile from the intrahepatic ducts. Hepato- and cholangiostomy, proposed at the beginning of the century! (Kehr, 1904; Lohse, 1911,) do not justify themselves, as they are designed for accidental opening of intrahepatic passages, and therefore often fail. The removal of bile from the peripheral ducts, including the subcapsular ones, does not provide sufficient decompression of the liver. Imposition of direct anastomoses with intrahepatic ducts

After resection of a lobe or segment of the liver (Longmire, Doliotti methods), it is traumatic, unbearable for patients with obstructive jaundice caused by cancer.

Topographic and anatomical studies of recent years have made it possible to develop less traumatic approaches to the intrahepatic ducts. Noteworthy is the removal of bile from the right hepatic duct through the back wall of the gallbladder above its neck (Fig. 112). This operation was performed in 20 patients at P.A. Herzen Moscow Research Institute of Surgery; 7 patients died of complications. Of the ducts of the left lobe of the liver, it is quite large and

located is the schrotk of the 3rd segment, access to which without resection of the hepatic parenchyma can be carried out according to the methods proposed by Soupault, Couinaud (1957) and AI Krakovsky (1967).

Rice. 112. Variants (a-c) of cholangiocholecystostomy according to E. S. Futo-ryan and B. M. Shubin.

The experience of 65 operations on the intrahepatic ducts with high tumor stenoses, performed at the MNII them. P. A. Herzen, shows that the operation of choice is recapitalization, which consists in bougienage of the duct, leaving submersible polyethylene drainage in it. Using this method, 25 operations were performed with 6 deaths and an average life expectancy of 11 months. A.V. Volsky (1970) recommends intubating both lobar ducts during re-nalization and performing cholecystectomy; he performed 13 operations; 6 patients died from complications.

CANCER OF THE MAJOR DUODENAL PAPILLA

Cancer of the major duodenal papilla is found in 0.1--1.7% of those who died from malignant tumors (V. V. Vinogradov. 1962; G. I. Rtskhiladze, 1957; V. D. Keleman, G. P. Kovtutsovnch. 1963; Friska, 1971 ). In the group of patients with tumor lesions of the organs of the pacreatoduodenal zone, this localization is not uncommon and occurs in 12-20% of cases (A. A. Shalimov, 1970; V. I. Kochiashvili, 1970; O. S. Shkrobidr., 1973).

Pathological anatomy. Neoplasms of the major duodenal papilla arise from the epithelium of the ducts (common bile, pancreatic, papilla ampulla) or from the epithelium of the duodenal mucosa. The tumor is usually small (from 0.5 to 2-2.5 cm), has the appearance of a rounded or ovoid formation protruding into the lumen of the duodenum (Fig. 113). In most cases, it is exophytic, grows slowly and does not go beyond the papilla for a long time. With infiltrative cancer, the surrounding tissues are quickly involved in the process (duodenum, head of the pancreas,

common bile duct). Microscopically, the tumor is most often an adenocarcinoma.

Metastases are found relatively rarely. 56 patients with cancer of the major duodenal papilla were observed at P. A. Herzen Moscow Research Institute of Cancer Research; metastases were detected in 25%. According to the ONC of the USSR Academy of Medical Sciences, metastases were found in 23 patients out of 81 (28.3%). Similar information is provided by other authors (3. A. Topchiashvili, 1957; V. V. Vinogradov, 1962;

A. A. Shabanov et al., 1970; Nordeck and Bohme, 1969). Metastases affect the regional lymph nodes, then the liver and less often other organs.

Clinic. The symptomatology is similar to that of pancreatic head cancer, but the clinical course differs in features that are of diagnostic significance, and also affect the prognosis and choice of treatment.

Localization of the tumor at the level of the papilla determines the relatively early onset of jaundice. The preicteric period is shorter than in pancreatic cancer. Jaundice in more than half of the patients has a wave-like character.

Tumors of the major duodenal papilla ulcerate rather quickly. This circumstance contributes to the penetration of infection from the duodenum into the bile ducts and pancreatic ducts. Cholangitis occurs more often than in cancer of the head of the pancreas (in 40-50% of cases), manifested by chills, high fever (up to 38-39 ° C), pain in the liver. Infection of the pancreatic duct leads to outbreaks of pancreatitis, which are confirmed by increased urinary diastasis and clinical signs: paroxysmal pain surrounding nature, vomiting, fever and high leukocytosis.

For cancer of the major duodenal papilla, bleeding from the tumor is characteristic. The degree of blood loss is different: from the presence of occult blood in the feces to significant bleeding, accompanied by severe anemia.

Diagnostics. The inflammatory component in cancer of the major duodenal papilla gives rise to serious diagnostic errors. Pain syndrome, fever, undulating jaundice give rise to such diagnoses as cholecystitis, cholangitis, pancreatitis. After the use of antibiotics, inflammation is removed, the condition of some patients improves and they are discharged, mistakenly considering "recovered." Internal bleeding is rarely regarded as a symptom of peptic ulcer disease. after 1-3 months, and sometimes after 1-Y / 2 years. With "oncological alertness of the doctor and a comprehensive assessment of the data of the anamnesis, clinical, radiological

The number of diagnostic errors will be significantly reduced during clinical and endoscopic examinations.

A positive symptom of Courvoisier is detected in 50-75% of "observations. In the remaining patients, the gallbladder cannot be palpated due to a significant increase in the liver or changes in the gallbladder (cholecystitis, cholelithiasis). According to the P.A. Herzen Moscow Research Institute, a combination of cancer major duodenal papilla with cholelithiasis and cholecystitis was 14% in cases.Courvoisier's symptom, as you know, indicates distal obstruction of the biliary tract and is equally characteristic of cancer of the major duodenal papilla, malignant tumors of the head of the pancreas and the distal common bile duct.

The method of hypotonic duodenography contributes to the specification of the topical diagnosis. The diagnostic value of this study is emphasized by many authors (G. I. Varno-

vitsky, Mallet-Gui et al., 1958; L. Berkovits, 1970). In MNIOI them. P. A. Herzen in 70% of patients

in patients with cancer of the major duodenal papilla, the diagnosis was clarified using hypotonic duodenography in the modification of V. N. Kotlyarov (1968). The study is carried out in a gentle way without the use of a probe and is necessarily supplemented by pneumoduodenography (Fig. 114). B. M. Sosina and A. N. Mikhailov (1970) also proposed probeless duodenography using an aeron for hypotension of the duodenum. This method; research can be applied in a polyclinic.

There have been reports of the possibility of early and accurate diagnosis of cancer of the major duodenal papilla using fibroduodenoscopy (A. S. Loginov, Yu. V. Vasiliev, 1972 "Takemoto, Kondo, 1968; Shinya, Wolff, 1971).

Treatment. The history of surgical treatment of cancer of the major duodenal papilla begins in 1898, when Halsted? removed the tumor by circular resection of the duodenum, sutured it end to end and reimplanted the common bile and pancreatic ducts into the intestine. In the same year, Ridel performed transduodenal excision of the major duodenal papilla with resection of the orifices of both ducts and their reimplantation into the posterior wall of the duodenum - this operation was called transduodenal papillectomy.

The attitude to this intervention as a radical operation is the subject of discussion until now. The technical improvement of pancreatoduodenal resection, which began in the 30-40s, and some successes achieved in this area, as well as the desire for maximum radicalism, could not but cause a critical assessment of more eco-

Nominal interventions. Opponents of transduodenal papillectomy appeared, considering it to be oncologically unjustified (V. I. Petrov, 1956; A. V. Smirnov, 1961; I. F. Lin-

Chen-ko, E. M. Gumilevskaya, 1969; A. A. Shalimov, 1970; Koszarski, 1966; Kuhlmager, 1967, etc.).

There is also an opposite point of view. In 1956, B. A. Petrov spoke at a meeting of the Moscow Surgical Society with an urgent recommendation not to do extended, traumatic operations - pancreatoduodenal resections - with limited tumors of the major duodenal papilla, but to perform transduodenal papillectomy. A. V. Gulyaev (1938), S. M. Mikirtumov (1963), A. N. Shabanov et al. (1970), V. V. Vinogradov (1962), D. A. Arapov (1972), Hess (1950) and others are also supporters of this operation.

Relatively early admission of patients, and in connection with this, the small size of the tumor and rare metastasis can provide high resectability in cancer of the large duo-

Dental papilla: 42-89% (V. V. Vinogradov, 1962; A. A. Shalimov, 1970; N. S. Makokha, 1961, etc.). In the ONTS of the USSR Academy of Medical Sciences, the resectability was 42%; in MNIOI them. P. A. Herzen-69%. It is rational to expose the patient to transduodenal papillectomy at the stage of the disease, when the tumor is still a local process.

N. S. Makokha (1961) proposes to produce an economical pancreatoduodenal resection for cancer of the major duodenal papilla; its essence lies in the removal of the tumor along with adjacent tissues in the form of a triangle, the base of which passes through the head of the pancreas, and the apex is located at the outer wall of the duodenum (Fig. 115). This intervention is less traumatic than pancreatoduodenal resection.

E. S. Futoryan and B. M. Shubin (1976) made changes to the generally accepted technique of transduodenal papillectomy aimed at increasing the radicalism of the intervention, as well as improving the immediate and long-term results of treatment. Modified opera-

The solution consists in removing fiber from the nearest metastasis zones, wide excision of the nipple along with a section of the intestinal wall and adjacent pancreatic tissue, resection of the common bile and pancreatic ducts.

Rus. 115. The boundaries of economical pancreatoduodenal resection according to N. S. Makokha.

a - resection of the head of the pancreas with a wedge-shaped excision of the adjacent wall of the descending part of the duodenum; b - anastomosis after economical pancreatoduodenal resection; 1 - liver; 2 - the upper part of the duodenum; 3 - gallbladder; For - vesico-duodenal fistula; 4 - common bile duct; 5

Tumor of the major duodenal papilla; 6-line resection (in the form of a triangle); 7- lower gorichoch-tal part of the duodenum; 8-jejunum; 9-pancreatic duct; 10-voices of the pancreas; 11-transverse colon; 12- mesocolon; 13-suture of the duodenum.

The reconstructive stage consists in ligation of the common bile duct and in the creation of biliodigestive and pancreatodigestive fistulas on controlled transnasal drains that provide temporary external discharge of bile and pancreatic juice (Fig. 116). The experience of 30 transduodenal papillectomies performed by this technique allows us to consider it the operation of choice for limited cancer of the major duodenal papilla.

When the tumor spreads to the surrounding tissues (duodenal wall, pancreatic head), pacreatoduodenal resection should be performed.

Mortality after transduodenal papillectomy is 20-25% (V. V. Vinogradov, 1962; A. A. Shabanoi et al., 1970, etc.), after pancreatoduodenal resection - 30-70% (A. A. Shalimov, 1970; V. I. Kochiashvili, 1970; Bowden, Pack, 1969).

The long-term results of radical operations are relatively satisfactory: the five-year survival rate is 17-30% (A. A. Shalimov, 1970; N. S. Makokha, 1969; Megan-dier et al., 1968, etc.). Cases of long-term cure after transduodenal papillectomy are described. The patient, operated on by Korte, lived for 22 years, operated by A. V. Gulyaev - 19 years. A. N. Shabanov et al. The patient was followed up for 8 years. Of the 30 patients operated on by E. S. Futoryan and B. M. Shubin, 7 people are alive. Follow-up period from 1 year to 11

Rice. 116. Scheme of transduodenal papillectomy.