الفهرس 
Anatomy of Biliary SystemOnly 14 pages are availabe for public view
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Abstract
Cholangiocarcinomas (CCAs) are malignancies of the biliary duct system that may originate in the liver and extrahepatic bile ducts, which terminate at the ampulla of Vater.
CCAs are encountered in 3 geographic regions: intrahepatic, extrahepatic (ie, perihilar), and distal extrahepatic. Perihilar tumors are the most common, and intrahepatic tumors are the least common. Perihilar tumors, also called Klatskin tumors (after Klatskin’s description of them in 1965), occur at the bifurcation of right and left hepatic ducts.
Distal extrahepatic tumors are located from the upper border of the pancreas to the ampulla. More than 95% of these tumors are ductal adenocarcinomas; many patients present with unresectable or metastatic disease.
Cholangiocarcinoma is a tumor that arises from the intrahepatic or extrahepatic biliary epithelium. More than 90% are adenocarcinomas, and the remainders are squamous cell tumors.
The etiology of most bile duct cancers remains undetermined. Long-standing inflammation, as with primary sclerosing cholangitis (PSC) or chronic parasitic infection, has been suggested to play a role by inducing hyperplasia, cellular proliferation, and, ultimately, malignant transformation.
The etiology of most bile duct cancers remains undetermined. Currently, gallstones are not believed to increase the risk of cholangiocarcinoma but there are some risk factors can be accused to cause cholangiocarcinoma as infections, inflammatory bowel diseases, exposure to some chemicals and some congenital anomalies of the biliary tree.
Symptoms may include jaundice, clay-colored stools, bilirubinuria (dark urine), pruritus, weight loss, and abdominal pain.Jaundice is the most common manifestation of bile duct cancer and, in general, is best detected in direct sunlight.
The obstruction and subsequent cholestasis tends to occur early if the tumor is located in the common bile duct or common hepatic duct.
Jaundice often occurs later in perihilar or intrahepatic tumors and is often a marker of advanced disease. Pruritus usually is preceded by jaundice, but itching may be the initial symptom of cholangiocarcinoma, Weight loss is a variable finding and may be present in one third of patients at the time of diagnosis also abdominal pain is relatively common in advanced diseases.
Noninvasive imaging studies like thin-cut helical CT scan and MRI/MRCP of the abdomen usually show only dilated biliary radicals as the primary lesion is frequently not discernible due to its infiltrative nature.
Cholangiography provides anatomical details of the biliary stricture(s) which is required for the diagnosis and management of the cholangiocarcinoma.
Cholangiography can be obtained using MRCP as mentioned above, ercutaneously, and most importantly endoscopically via endoscopic retrograde cholangio-pancreaticography (ERCP).
Resectable intrahepatic cholangiocarcinomas are treated using standard liver resections, and distal cholangiocarcinomas are treated by ancreatico-duodenectomy.
The following focuses on our surgical approach to esectable perihilar cholangiocarcinomas.
Laparoscopic pancreatic surgery represents one of the most advanced applications for laparoscopic surgery currently in use.
In the past, minimally invasive techniques were only used for diagnostic laparoscopy, staging of pancreatic cancer, and palliative procedures for unresectable pancreatic cancer.
With new advances in technology and instrumentation, some sophisticated procedures are currently available, such as the Whipple procedure, one of the most sophisticated applications of minimally invasive surgery.
The primary aim of palliation in a patient with unresectable cholangiocarcinoma is to relieve the obstructive cholestasis and its associated morbidities like pruritus, cholangitis and pain.
Therefore, the essence of an ideal palliation includes improved quality of life via minimal invasiveness, low-procedural related complications, few hospital days or clinic visits, and low cost.