Unfortunately, up to 50% to 90% of patients with hilar cholangiocarcinoma present with unresectable disease.5 Median survival for patients with unresectable intrahepatic and perihilar tumors is 6 to 7 months and 5 to 8 months, respectively.7 For patients with unresectable disease, the goal is to alleviate symptoms (pruritus and jaundice) and to prevent complications of obstruction (cholangitis and hepatic failure), which are the most common immediate causes of death.6 This is accomplished with drainage of the biliary tree. Drainage may involve ERCP with biliary stent placement; PTC with catheter placement that can be internalized or externalized; and, rarely, operative biliary-enteric bypass. The roles of liver transplantation, radiation therapy, and chemotherapy for patients with cholangiocarcinoma are controversial.7
Routine follow-up of a patient after resection is a first postoperative visit 1 to 2 weeks after surgery, and then every 3 to 6 months for at least 5 years. Follow-up studies are aimed at detecting recurrence and include history and physical examination, as well as liver function tests and imaging studies. Risk factors for recurrence are margin-positive resection, lymph node metastases, and vascular involvement.9 The most likely sites of recurrence of perihilar tumors after resection are within the bile duct, in the regional lymph nodes, or in the liver.6 In these circumstances, treatment is directed at palliation of symptoms as described above. JAAPA
Kathryn Hines works in the Division of Vascular Surgery, Johns Hopkins Hospital, Baltimore, Maryland, and is Director, Advance Surgical Preparedness Program for Physician Assistants, The George Washington University, Washington, DC. Timothy Pawlik is Associate Professor of Surgery and Oncology; Director, Hepatobiliary Surgery Program; and Director, Liver Tumor Center Multidisciplinary Clinic; at Johns Hopkins Hospital, Baltimore, Maryland. The authors have indicated no relationships to disclose relating to the content of this article.
Steve Wilson, PA-C, department editor
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