Treatment:
       For both carcinoma of the gallbladder and bile duct, the only hope for cure lies with surgical resection of the tumor and all involved structures. Unfortunately, the cancer has usually spread too far when the diagnosis is made. Seventy-five percent of patients with carcinoma of the gallbladder and 90% of those with carcinoma of the bile duct are diagnosed too late for surgical cure.

Thus, in the treatment of these cancers, the first question to answer is if the tumor may be safely resected with reasonable benefit to the patient. Resection may be impossible if the cancer involves certain blood vessels or has spread widely. Sometimes further invasive testing with laparoscopy is required. Laparoscopy is a surgical procedure that allows the surgeon to directly assess the tumor and nearby lymph nodes without making a large incision in the abdomen. If the tumor is resectable, and the patient is healthy enough to tolerate the operation, the specific type of surgery performed depends on the location of the tumor.

Surgical options for carcinoma of the gallbladder:

• Early Stage I cancers involving only the innermost layer of the gallbladder wall can be cured by simple removal of the gallbladder. Cancers at this stage are sometimes found incidentally when the gallbladder is removed in the treatment of gallstones or cholecystitis. The majority of patients have good survival rates

• Late Stage I cancers, which involve the outer muscular layers of the gallbladder wall, are generally treated in the same way as Stage II or III cancers. Removal of the gallbladder is not sufficient for these stages. The surgeon also removes nearby lymph nodes as well as a portion of the adjacent liver. Survival rates for these patients are considerably worse than for those with early Stage I disease

• Patients with early Stage IV disease may benefit from very extensive surgical resection, but the issue is controversial. Late Stage IV cancer has spread too extensively to allow complete excision. Surgery is not an option for these patients.

Residual cancer may remain even if curative resection of gallbladder cancer is attempted. There is some evidence that radiation may improve survival in these patients. However, this evidence is derived from small trials. The use of radiation in the treatment of gallbladder cancer requires further investigation. Chemotherapy has not been proven to be very effective. When utilized, it is usually given in combination with radiation.

Surgical options for carcinoma of the bile duct:

• For tumors within the liver or high up in the biliary tract, resection of part of the liver may be required

• Tumors in the middle portion of the biliary tract can be removed alone

• Tumors of the lower end of the biliary tract may require extensive resection of part of the pancreas, small intestine, and stomach to ensure complete resection

• Unfortunately, sometimes the cancer appears resectable by all the radiological and invasive tests, but is found to be unresectable during surgery. In this scenario, a bypass operation can relieve the biliary tract obstruction, but does not remove the tumor itself. This does not produce a cure but it can offer a better quality of life for the patient

Radiation can be applied in several modes for the treatment of carcinoma of the bile duct. Radiation before surgery can shrink the size of the bile duct tumor in order to aid resection. Radiation after surgical resection has improved survival in some trials. Brachytherapy is a technique in which small seeds of radioactive agents are placed in the tumor during surgery, allowing concentrated doses of radiation to be delivered to the tumor while sparing nearby tissue. This technique is sometimes combined with postoperative radiation. In some patients who cannot undergo surgery, radiation alone may also lengthen survival. As in carcinoma of the gallbladder, chemotherapy is usually given in combination with radiation.

When long-term survival is not likely due to advanced carcinoma of the gallbladder or bile duct, the focus of therapy shifts to improving quality of life. Jaundice and blockage of the stomach are two problems faced by patients with extensive disease. These can be treated with surgery, or alternatively, by special interventional techniques employed by the gastroenterologist or radiologist. A stent can be placed across partially obstructed bile ducts in order to re-establish the flow of bile and relieve jaundice. A small feeding tube can be placed in the small intestine to allow feeding when the stomach is blocked.