*Core reference pages for biliary tract cancers, benign biliary disease, biliary obstruction, and operative biliary strategy.* --- ### Overview Biliary disease is best approached by **anatomic location**, **benign vs malignant etiology**, and **operative implications**. For HPB practice, the key questions are: - Is this benign, malignant, or indeterminate? - Where is the dominant biliary pathology? - Is biliary drainage needed? - Is an oncologic resection possible? - Is biliary reconstruction required? --- ### Cholangiocarcinoma Cholangiocarcinoma is most useful clinically when divided by anatomic location. | Disease | Location | Typical operation | |---|---|---| | [[Intrahepatic cholangiocarcinoma]] | Peripheral intrahepatic bile ducts | Hepatectomy + portal lymphadenectomy | | [[Perihilar cholangiocarcinoma]] | Hepatic duct confluence | Major hepatectomy + caudate + bile duct resection | | [[Distal cholangiocarcinoma]] | Distal extrahepatic bile duct | Pancreaticoduodenectomy | Key pages: - [[Intrahepatic cholangiocarcinoma]] - [[Perihilar cholangiocarcinoma]] - [[Distal cholangiocarcinoma]] - [[Blumgart classification]] - [[Biliary tract cancer resectability]] --- ### Gallbladder cancer Gallbladder cancer ranges from incidental early-stage disease to locally advanced cancer requiring major HPB resection. | Scenario | Typical question | |---|---| | Incidental gallbladder cancer | Is completion radical cholecystectomy needed? | | Suspected primary gallbladder cancer | Is upfront oncologic resection appropriate? | | Locally advanced disease | Is there liver, bile duct, vascular, nodal, or peritoneal involvement? | | Gallbladder polyp | Is cholecystectomy indicated? | Key pages: - [[Gallbladder cancer]] - [[Incidental gallbladder cancer]] - [[Radical cholecystectomy]] - [[Gallbladder polyp]] --- ### Ampullary cancer Ampullary cancer sits at the intersection of biliary, pancreatic, duodenal, and endoscopic disease. Key questions: - Is this ampullary, distal bile duct, pancreatic, or duodenal cancer? - Is the lesion endoscopically resectable or surgically managed? - Is pancreaticoduodenectomy indicated? - Is histology intestinal or pancreatobiliary subtype? Key pages: - [[Ampullary cancer]] - [[Pancreaticoduodenectomy]] - [[Distal cholangiocarcinoma]] --- ### Benign biliary disease Benign biliary disease is common, but HPB relevance usually comes from complexity, recurrence, failed endoscopy, altered anatomy, or concern for malignancy. Key pages: - [[Choledocholithiasis]] - [[Mirizzi syndrome]] - [[Biliary stricture]] - [[Primary sclerosing cholangitis]] - [[IgG4-related sclerosing cholangitis]] - [[Choledochal cyst]] - [[Recurrent pyogenic cholangitis]] --- ### Biliary stricture A biliary stricture should be approached as malignant until proven otherwise when unexplained, progressive, proximal, or associated with a mass, vascular involvement, weight loss, or elevated CA 19-9. Common categories: | Category | Examples | |---|---| | Malignant | Cholangiocarcinoma, pancreatic cancer, gallbladder cancer, metastatic nodes | | Iatrogenic | Post-cholecystectomy, post-transplant, post-hepatectomy | | Inflammatory | PSC, IgG4 disease, chronic pancreatitis | | Ischemic | Hepatic artery injury, transplant-related | | Stone-related | Mirizzi syndrome, chronic choledocholithiasis | Key pages: - [[Biliary stricture]] - [[Indeterminate biliary stricture]] - [[Primary sclerosing cholangitis]] - [[IgG4-related sclerosing cholangitis]] - [[Cholangiocarcinoma]] --- ### Bile duct injury The first repair is often the best chance for durable biliary reconstruction. Core principles: - Control sepsis. - Drain bile collections. - Define anatomy. - Avoid repeated blind attempts at repair. - Refer early for complex injury. - Reconstruct with Roux-en-Y hepaticojejunostomy when appropriate. Key pages: - [[Bile duct injury]] - [[Postoperative bile leak]] - [[Biliary reconstruction]] - [[Hepaticojejunostomy]] --- ### Biliary drainage Biliary drainage is selective, not automatic. Common indications include: - Cholangitis - Severe symptomatic jaundice - Delay to definitive therapy - Need for neoadjuvant therapy - Planned major hepatectomy with jaundiced future liver remnant - Segmental cholangitis or undrained functional liver Key pages: - [[Biliary drainage]] - [[ERCP]] - [[PTBD]] - [[Preoperative biliary drainage]] - [[Biliary drainage before hepatectomy]] --- ### Operative biliary strategy Key operative reference pages: - [[Biliary reconstruction]] - [[Hepaticojejunostomy]] - [[Bile leak assessment]] - [[Intraoperative cholangiogram]] - [[Hilar plate lowering]] - [[Caudate lobectomy]] - [[Portal lymphadenectomy]] - [[Vascular resection in hilar cholangiocarcinoma]] --- ### Systemic therapy and trials Core biliary tract cancer treatment pages: - [[Biliary tract cancer systemic therapy]] - [[Biliary tract cancer molecular profiling]] - [[Adjuvant therapy for biliary tract cancer]] Landmark trials: - [[BILCAP]] - [[SWOG 0809]] - [[ABC-02]] - [[TOPAZ-1]] - [[KEYNOTE-966]] - [[SWOG 1815]] --- ### Imaging and staging Imaging strategy depends on disease location and planned operation. Key pages - [[CT for HPB surgery]] - [[MRI for HPB surgery]] - [[MRCP]] - [[Diagnostic laparoscopy]] - [[Biliary tract cancer resectability]] --- ### Quick links Malignant: - [[Intrahepatic cholangiocarcinoma]] - [[Perihilar cholangiocarcinoma]] - [[Distal cholangiocarcinoma]] - [[Gallbladder cancer]] - [[Ampullary cancer]] Benign / inflammatory: - [[Choledocholithiasis]] - [[Mirizzi syndrome]] - [[Biliary stricture]] - [[Primary sclerosing cholangitis]] - [[IgG4-related sclerosing cholangitis]] - [[Choledochal cyst]] - [[Bile duct injury]] Operative: - [[Biliary reconstruction]] - [[Hepaticojejunostomy]] - [[Bile leak assessment]] - [[Biliary drainage]] - [[Caudate lobectomy]] - [[Portal lymphadenectomy]] ---