Generally, only jaundice which causes symptoms is treated. Itching which is not relieved by antihistamines and socially unacceptable jaundice are indications for treatment. Patients with long-lasting jaundice should receive potassium to reduce the risk for bleeding disturbances. This should be administered parentally due to poor intestinal uptake.
Drainage of the bile ducts with a stent using endoscopy is the primary option. Compared to open surgery, this procedure has low acute morbidity, but cholangitis and recurrence of jaundice is more common than after surgical anastomosis. The total morbidity throughout the entire disease period should therefore not be underestimated. Plastic endo-prostheses are usually changed after 3 months due to deposition of bile salts, which can obstruct the stent and cause recurrence of jaundice. An alternative is to install a self-expanding metal stent for patients with a longer survival.
Percutaneous transhepatic drainage
Percutaneous transhepatic drainage combined with external/internal transhepatic drainage is reserved for patients where the endoscopic technique is unsuccessful. PTC treatment is painful for the patient and is often carried out under sedation and analgesia, or possibly under general anesthesia. In addition, there is a risk for both bleeding and sepsis. This technique should therefore be secondary to the ERCP technique.
Surgical enterobiliar anastomosis has a higher treatment mortality and morbidity than an endoscopic tent but usually remains open for the patient`s remaining survival time. A cholecystojejunostomy can be performed if the cystic duct is well expanded and opens sufficiently into the bile duct with a safe distance from the tumor. A choledochal duodenostomy gives successful results if the tumor does not grow too high into the hepatoduodenal ligament. Alternatively, an anastomosis can be made between the common hepatic duct and either the duodenum or a jejunal Roux loop.
Exploration is not recommended if only installing an enterbiliary anastomosis. In these cases, endoscopic or percutaneous drainage should be performed instead. If a non-resectable tumor is found by laparotomy, surgical by-pass is recommended as routine treatment.