الفهرس 
Anatomy of the biliary tractOnly 14 pages are availabe for public view
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Abstract
Cholangiocarcinoma (CCA) is a fatal cancer of the biliary epithelium, arising either within the liver (intrahepatic) or in the extrahepatic bile ducts (extrahepatic). Globally, CCA is the second most common primary hepatic malignancy. (Mcglynn et al, 2006)
Although no clear causal agent for cholangiocarcinoma has been identified, certain pathological conditions that result in either acute or chronic biliary epithelial injury appear to predispose to its development. (Ronald et al, 2000)
Cholangiocarcinomas occur in the hilar region in about 65% of cases, the distal common bile duct in 20%, and-as an intrahepatic lesion in 15%.
(Fevery et al,2007)
Patients with hilar and extrahepatic cholangiocarcinomas usually present with symptoms of biliary obstruction, including painless jaundice, pale stools, dark urine, and pruritis. (Bernard et al, 2008)
Other symptoms that occur in patients with cholangiocarcinomas include malaise, weight loss, and abdominal pain. These non-specific symptoms usually appear after the disease is advanced, but may be the only symptoms in patients with intrahepatic cholangiocarcinomas. Cholangitis is an unusual presentation, hepatomegaly, tumor mass, or dilated gallbladder may be observed at clinical examination. (Khan et al, 2005)
The diagnosis of cholangiocarcinoma remains difficult, despite the multiple diagnostic methods available. Further studies comparing the accuracy of the various imaging methods, especially the new intraductal methods, are needed, and the imaging features of malignancy should be standardized.
(Bernard et al, 2008)
Operative procedure is the most important prognostic factor affecting the operative results of hilar cholangiocarcinoma. For patients with irresectable hilar cholangiocarcinoma, no evidence has shown that the prognosis after treatment of ERBD or EMBE is poorer than that after laparotomy.
(Yi et al ,2004)
The main prognostic factors of intrahepatic cholangiocarcinoma (ICC) are: gross type (size, multifocality, vascular, serosal and biliary involvement), local extent, lymph-node involvement and microscopic and molecular biological patterns. (Guglielmi et al, 2008)
R0 of ICC is the most effective treatment and the only therapy associated with prolonged disease-free survival. Nonetheless, there is currently little agreement on the indications for surgical resection. According to some authors curative resection (R0) of ICC is feasible only in patients with a single lesion, negative lymph nodes and resectable hepatic margins of >1 cm.
(Cherqui et al, 1995)
Curative resection is the only treatment that produces good results in hilar cholangiocarcinoma. Hepatic transplantation has the theoretical premise of increasing surgical radicality and offers a treatment with curative intent for patients who are excluded from surgical treatment due to advanced stages of the disease or the presence of hepatic disease that contraindicates hepatic resection. (Guglielmi et al, 2008)
Studies on transplantation for hilar cholangiocarcinoma are limited and there are no current indications regarding the use of this therapeutic option in clinical practice. Local recurrence is a frequent event after surgical resection for cholangiocarcinoma; to achieve better control radiotherapy has been proposed, alone or associated with chemotherapy. (Chari et al, 2003)
The principal end-point of treatment of cholangiocarcinoma is resection with negative margins. (Chari et al, 2003)
Patients with distal duct carcinoma have the highest rate of curative resection as compared with proximal duct carcinoma. (Nagorney et al, 1993)
The prognosis of patients with distal duct carcinoma is also better than that of patients with proximal duct carcinoma. (Bortolasi et al, 2000)
The role of postoperative radiotherapy is uncertain. However, studies of concurrent chemotherapy and radiotherapy show more promising results. (Mehta et al, 2001)
The definitive therapy for all extrahepatic bile duct carcinomas is complete resection. Overall resectability rates range from 10% to 85%, depending on whether distal cancers are present. Lesions of the lower third of the bile duct have the best rates of resectability by pancreaticoduo-denectomy; middle-third obstructions of the bile duct are almost always due to gallbladder cancer. Hilar CCAs and Klatskin’s tumors are technically more challenging to resect, giving them the lowest rate of resectability among bile duct tumors. (Choi, 2010)