原发性肝癌合并胆管癌栓的外科治疗

目的:提高对原发性肝癌合并胆管癌栓的认识,探讨其诊断、治疗方法及疗效. 方法: 回顾性分析我院1998年1月至2004年1月间收治的42例原发性肝癌合并胆管癌栓的临床资料,施行根治性手术26例,其中18例肝叶切除 胆总管切开取栓、 T管引流术; 8例肿瘤局部切除 胆总管切开取栓、 T管引流术;姑息性手术16例, 其中6例胆总管切开取栓、T管引流术,10例胆总管切开取栓、 T管引流术 患侧肝动脉结扎术(其中4例 门静脉DDS泵置入术).均获得病理诊断,肝细胞癌32例(76.2%).结果: 根治性手术及姑息性手术1年、3年、5年生存率分别为65.4%(17/26),42.3%(11/26),15.4%(4/26)及18.8%(3/16)、6.3%(1/16),0(0/16);总的1年、3年、5年生存率分别为47.6%(20/42),28.6%(12/42),9.5%(4/42). 结论: 外科治疗明显改善患者生活质量,提高了生存时间,而根治性手术是原发性肝癌合并胆管癌栓的积极有效方法.     

原发性肝癌并胆管癌栓的临床诊治分析：附19例报告

目的：探讨原发性肝癌合并胆管癌栓的诊断方法和治疗方式的选择。方法：回顾性分析我院2003年1月至2011年12月收治的19例原发性肝癌合并胆管癌栓的诊断方法、误诊原因及综合治疗效果。应用B超、CT、MRCP和PTC等检查以及术中探查等明确诊断。治疗方式为肝癌切除术＋胆管取栓术,仅行胆管切开取癌栓术及胆管支架置入引流术。结果：19例中7例行手术切除肿瘤＋胆管取癌栓,6例行单纯胆管切开取癌栓,6例仅行胆管支架植入引流术。术后随访至今,其中肿瘤切除＋胆管取癌栓患者平均生存时间超过3年,最长生存时间已超过5年,行胆管切开取癌栓平均生存时间18个月。非手术治疗组仅行胆管支架植入引流术的6例患者生存时间1~13月,平均5.6个月。结论：手术治疗方式是影响肝细胞癌合并胆管癌栓术后预后首要因素。早期诊断、积极切除肿瘤并清除胆管癌栓,术后配合TACE术等综合治疗,是改善预后的有效治疗方法。     

原发性肝癌伴胆管癌栓的外科治疗方式

目的 探讨伴胆管癌栓的原发性肝癌(HCC)外科治疗方式的选择。 方法 回顾性分析1994～2001年15例HCC伴胆管癌栓的外科治疗情况。 结果 肝癌切除加胆管癌栓清除术7例,肝癌切除加肝外胆管切除术4例,单纯胆总管切开取栓术3例,背驮式肝移植1例。术后1年生存率为73.3％,3年生存率为40％,其中有2例生存已超过5年。 结论 原发性肝癌伴胆管癌栓行外科治疗是一种积极有效的治疗方法。复发后的再次手术可取得较好疗效。肝移植作为一种崭新的手术方式值得探讨。     

原发性肝癌并胆管癌栓的手术治疗 (附10例报告)

目的总结原发性肝癌并胆管癌栓的手术原则及手术方式.方法本组10例,在切除原发灶基础上,根据癌灶的部位及浸润情况,采用不同的手术方法.结果通过手术改善了患者的临床症状、延长生存期,提高了生活质量.结论切除原发灶、消除癌栓、疏通胆道及解除梗阻为原发性肝癌并胆管癌栓的手术原则.肝癌切除加胆管癌栓清除,癌栓胆管切除及胆管空肠吻合或胆总管切开取栓术为其有效的手术方式.     

肝细胞癌合并胆管癌栓50例临床诊治分析

目的 探讨肝细胞癌合并胆管癌栓的临床特点和手术治疗效果.方法 回顾性分析我院1998年至2006年50例肝细胞癌合并胆管癌栓的临床特点和手术治疗效果,应用B超、CT、MRCP和AFP等检查以及术中探查等明确诊断,治疗方式为肝癌切除术并胆管癌栓切除、胆管切开取癌栓及胆管支架置入引流术.结果 50例中行根治手术治疗46例,其中肝癌切除术并胆管癌栓切除26例,肝癌切除术并胆管切开取癌栓20例,胆管支架置入引流术4例.全组并发症发生率为26.0%(13/50),术后围手术期死亡率为12.0%(6/50),术后1、2、3年生存率分别为59.1%(26/44)、29.5%(13/44)、20,5%(9/44),最长生存121月,平均19.6月.单因素分析显示影响生存期的因素是AFP定量、肿瘤大小、手术方式及癌栓部位等.多因素分析显示影响生存期的独立因素是手术方式.结论 手术治疗方式是影响肝细胞癌合并胆管癌栓术后预后最重要的因素,积极行手术治疗是延长患者生存期的有效手段.     

原发性肝癌并胆栓的诊治体会：—附12例分析

目的：提出外科手术治疗原发性肝癌合并胆管癌栓的方法，全组病例肝癌切除后，自肝断面胆管残端清除癌栓，胆总管切开取出癌栓，结果：随访6－12个月，健在7例、死亡3例，结论肝癌切除加胆管癌栓清除术对伴发胆管癌栓的原发性肝癌是一种积极有效的方法。     

原发性肝癌并胆栓的诊治体会——附12例分析

目的　提出外科手术治疗原发性肝癌合并胆管癌栓的方法。方法　全组病例肝癌切除后 ,自肝断面胆管残端清除癌栓 ,胆总管切开取出癌栓。结果　随访 6～ 12个月 ,健在 7例 ,死亡 3例。结论　肝癌切除加胆管癌栓清除术对伴发胆管癌栓的原发性肝癌是一种积极有效的方法。     

25例巨块型原发性肝癌切除体会

目的：探讨巨块型肝癌手术切除的可行性及技术要点.方法：回顾性分析2007年-2012年手术切除的25例巨块型原发性肝癌病例特点、手术方法及预后情况.结果：6例行肝左外叶切除,2例行左半肝切除,3例行肝中叶切除,4例行右半肝切除术,10例行肝叶不规则切除术.手术切除率100％.其中,门静脉切开取栓、门静脉化疗泵植入5例,胆总管切开取栓、胆总管T管引流1例.术中根据肿瘤部位选择性阻断肝脏血流.平均手术时间280±125min,术中出血720±260ml,无手术死亡.术后21例有不同程度腹水,胸腔积液12例,肺不张4例,乳糜漏1例,肝功能衰竭1例.无住院死亡病例.术后随访1年生存率59.6％,3年生存率29.8％,5年生存率19.5％.结论：在严格把握手术适应证前提下,选择合适的肝脏血流阻断方法及断肝方法,保证余肝体积,巨块型原发性肝癌的手术治疗是可行的.     

含羟基喜树碱方案经肝动脉灌注检索治疗原发性肝癌38例

目的：观察羟基喜树碱（HCPT）联合方案经肝动脉灌注栓塞治疗手术无法切除的原发性肝癌的效果。方法：按Seldinger法经皮股动脉穿刺插管或手术置入肝动脉植入式药泵后，给予HCPT＋5－Fu MMC 碘化油行化疗栓塞治疗38例原发性肝癌。结果：有效率（CR＋PR）42．1％（16／38），半年生存率为84．2％，1年生存率为52．6％，毒副作用以消化道反应和骨髓抑制、发热为主。结论：含HCPT方案经肝动脉灌注栓塞化疗对中晚期原发性肝癌疗效确切，副反应轻。     

肝外胆管癌的外科治疗与预后关系临床探讨

作者对55例肝外胆管癌的治疗方法与预后的关系进行临床探讨。按Longmire分型，上段、中段、下段胆管癌分别占43．6％、21．8％、346％；有42例得到病理诊断。手术切除11例（26．2％），“减黄”手术30例（胆肠内引流14例，外引流16例），单纯剖腹，PTCD、非手术保守治疗分别为1、6、7例。随访1～62个月，随访率87．3％。平均生存时间10．8±9．7个月；手术切除组生存时间最长（21．4±16．7个月，P＜0．01），生存率最高（P＜005）；胆肠内引流组的生存时间（12．2±6．8个月）和生存率亦明显高于其它各组（P＜0．05）。因此，对有条件的肝外胆管癌，应争取早期作根治性切除＋胆管空肠吻合，并酌情切除受累肝脏；即使无根治条件，亦应尽可能作胆肠内引流。     

原发性肝细胞癌合并胆管癌栓的诊断与治疗

目的：探讨原发性肝细胞癌合并胆管癌栓的诊断与治疗效果.方法：回顾性分析我院49例原发性肝细胞癌合并胆管癌栓的临床特点、诊断和治疗.彩超、CT、MRI等影像学检查是重要的术前诊断措施.24例行根治性切除,25例行姑息性引流或探查手术.结果：MRI具有更高的术前胆管癌栓检出阳性率.围手术期死亡3例,死亡原因为肝功能衰竭2例,肝肾综合征1例.手术并发症14例,经综合治疗后痊愈.42例获得随访,其中根治手术组20例,姑息治疗组22例,随访时间3月-60月.根治手术后1、2、5年累积生存率分别为65.0%,40.0%,12.9%,中位生存时间为21个月;姑息治疗后1、2、5年生存率分别为40.9%、27.3%、0%,中位生存时间为12个月,两组之间1、2、5年累积生存率和中位生存时间差异有统计学意义（P＜0.05）.随访期内死亡的主要原因是肿瘤复发转移.结论：早期诊断、积极采取手术为主的综合治疗是延长原发性肝细胞癌合并胆管癌栓患者生存期的有效手段.     

Surgery for hilar cholangiocarcinoma; a 10 year experience of a tertiary referral centre in the UK.

OBJECTIVE: To review the outcome of patients operated for hilar cholangiocarcinoma and analyse prognostic variables. PATIENTS AND METHODS: A prospectively collected database on patients with hilar cholangiocarcinoma, between 1992 and 2003, and relevant clinical notes were reviewed retrospectively. A total of 174 patients, 96 male, median age 63 years (27-86), were referred. Jaundice was the initial presentation in 167. RESULTS: ERCP was the initial interventional investigation at the referring centre in 150, of which only 30 were stented successfully. PTC and decompression was carried out on 120. In 17, combined PTC and ERCP were required for placement of stents. Seventy-two underwent laparotomy at which 27 had locally advanced disease. Forty-five had potentially curative resections. Extra hepatic bile duct resection was done in 14 patients of which four were R0 resections. Thirty-one had bile duct resection including partial hepatectomy with 19 R0 resections (P=0.042). Post-operative complications developed in 19 patients, and there were 4 30 day mortalities [hepatic insufficiency:/sepsis (n=3), thrombosis of the reconstructed portal vein (n=1)]. Among the patients with R0 resections, the cumulative survival rates at 1, 3, and 5 year; was 83, 58, 41%, respectively, and in those with R1 resections were 71, 24, 24%, respectively, (P=0.021). Overall survival was shorter in patients with positive perineural invasion (P=0.066: NS). There was no significant difference in survival between the node positive and negative group. Median survival of patients who underwent liver resection was longer than those with bile duct resection only (30 vs 24 months P=0.43: NS). CONCLUSIONS: ERCP was associated with a high failure rate in achieving pre-operative biliary decompression which was subsequently achieved by PTC. Clear histological margins were associated with improved survival and were better achieved by liver resection as compared to extra hepatic bile duct resection. Positive level I lymph nodes did not adversely impact survival.     

经导管~(192)Ir近距离放射治疗局部晚期肝门部胆管癌

目的：观察局部晚期肝门部胆管癌姑息性引流术后１９２Ｉｒ腔内放疗的疗效。方法：先行手术探查尽可能刮除肿瘤并放置Ｕ型管引流，术后再经导管腔内放疗。参考点距离放射源中心轴１０ｍｍ，总量２４～３０Ｇｙ／３次。３例配合肝动脉区域性灌注化疗，１例配合外照射ＤＴ４５Ｇｙ／４．５周。结果：生存期６～２６个月，中位生存期１１．５月。１５例死亡，１例目前存活８个月。全组１年生存率３７．５％，２年生存率６．０％，结论：局部晚期肝门部胆管癌姑息性引流术后腔内放疗可提高生存期及生活质量     

Surgical strategy for bile duct cancer: Advances and current limitations

The aim of this review is to describe recent advances and topics in the surgical management of bile duct cancer. Radical resection with a microscopically negative margin (R0) is the only way to cure cholangiocarcinoma and is associated with marked survival advantages compared to margin-positive resections. Complete resection of the tumor is the surgeon's ultimate aim, and several advances in the surgical treatment for bile duct cancer have been made within the last two decades. Multidetector row computed tomography has emerged as an indispensable diagnostic modality for the precise preoperative evaluation of bile duct cancer, in terms of both longitudinal and vertical tumor invasion. Many meticulous operative procedures have been established, especially extended hepatectomy for hilar cholangiocarcinoma, to achieve a negative resection margin, which is the only prognostic factor under the control of the surgeon. A complete caudate lobectomy and resection of the inferior part of Couinaud's segment IV coupled with right or left hemihepatectomy has become the standard surgical procedure for hilar cholangiocarcinoma, and pylorus-preserving pancreaticoduodenectomy is the first choice for distal bile duct cancer. Limited resection for middle bile duct cancer is indicated for only strictly selected cases. Preoperative treatments including biliary drainage and portal vein embolization are also indicated for only selected patients, especially jaundiced patients anticipating major hepatectomy. Liver transplantation seems ideal for complete resection of bile duct cancer, but the high recurrence rate and decreased patient survival after liver transplant preclude it from being considered standard treatment. Adjuvant chemotherapy and radiotherapy have a potentially crucial role in prolonging survival and controlling local recurrence, but no definite regimen has been established to date. Further evidence is needed to fully define the role of liver transplantation and adjuvant chemo-radiotherapy.     

Prevention of implantation metastases after resection of proximal bile duct tumours with pre-operative low dose radiation therapy.

AIMS: Pre-operative endoscopic retrograde cholangiopancreatography (ERCP) with biliary drainage is associated with a greater risk of implantation metastases after resection of proximal bile duct tumours. In a previous study among patients who had undergone biliary drainage before resection, eight patients (20%) developed implantation metastases, within 1 year following resection. The aim of this analysis was to evaluate the results of pre-operative irradiation with regard to a possible reduction of implantation metastases. METHODS: Twenty-one patients with proximal bile duct tumours who had undergone resection following pre-operative irradiation were retrospectively analysed. Pre-operative radiation therapy consisted of three fractions of 3.5 Gy external beam irradiation of the hilar area. RESULTS: Pre-operative biliary drainage was performed in 19 patients (90%). All patients received pre-operative radiotherapy during which no complications were noted. None of the patients developed implantation metastases within a follow-up time of 2 to 79 months. CONCLUSION: The results of this study suggest that pre-operative radiotherapy in patients with a resectable proximal bile duct tumour who have undergone pre-operative drainage, decreases the risk of implantation metastases. To be certain about the role of pre-operative radiotherapy, a randomized study is required. Until then, we advocate standard low dose radiotherapy preceding resection in all patients with lesions suggestive of a proximal bile duct tumour who have undergone biliary drainage.     

外科治疗肝门部胆管癌68例临床分析

目的：探讨提高肝门部胆管癌尤其是肝门部血管受肿瘤侵犯病例的外科治疗方法。方法：回顾性分析我院1986年1月～2004年12月收治手术的肝门部胆管癌68例。结果：按Bismuth-Corlette分型法：Ⅰ型7例,Ⅱ型15例,ⅢA型19例,ⅢB型12例,Ⅳ型15例（包括不能分型3例）。26例（38.24%）确诊前曾有胆囊结石和/或肝内外胆管结石手术史,或同时合并有胆石症。B超、CT和MRCP的确诊率分别为71.43%、84.00%和91.43%。手术方式：根治性切除24例,姑息性切除14例,胆道引流30例。术后1、2、3年生存率：根治性切除组分别为85.0%（17/20）、60.0%（12/20）和25.0%（5/20）,其中3例生存时间超过5年;姑息性切除组分别为58.3%（7/12）、25.0%（3/12）和0,两组之间的3年生存率比较有显著性差异（P〈0.05）;胆道引流组1、2、3年生存率分别为21.4%（6/28）、10.7%（3/28）和0。结论：积极提高手术切除率是改善肝门部胆管癌预后的惟一有效方法;肝十二指肠韧带骨髂化、肝部分切除可提高根治性切除率。姑息性切除、胆道引流有助于改善患者生活质量,延长生存。     

肝门部胆管癌的外科治疗:291例回顾

目的 分析一个单位1986年-2002年间治疗肝门部胆管癌291例的经验。方法 回顾1986年-2002年在解放军总医院肝胆外科治疗291例肝门部胆管癌的纪录,病例分为2组:Ⅰ组:1986年1月-1999年1月,共157例;Ⅱ组为1999年2月-2002年6月,共134例。外科治疗手段包括根治性切除术、姑息性切除术或内、外胆道引流术,主要是依据手术中所发现的病理情况决定。根治性切除术的标准是指切除的边缘病理上未发现残留癌细胞者。根治性切除率在两组分别为37.6％和41.2％。无切除术后30天内死亡。随访结果是通过信件、电话及门诊获得,随访率为88.8％。结果 在我国,肝外胆管癌是并非少见的疾病,近年来手术治疗的病例数有增多倾向。然而,由于肿瘤居于肝门部胆管的深在位置,所以根治性切除手术有困难,甚至联合肝切除亦难以达到根治目的,因而在两组病例中,根治性切除率分别仅为37.6％和41.2％。在第Ⅰ组中,有4例病人于切除术后长期无瘤生存,5年以上生存率为13.3％;另有2例病人亦生存达5年以上,但癌复发,现仍在接受进一步治疗。在第Ⅱ组中尚未有5年生存者,3年生存率为13.6％。结论 肝门部胆管癌是多态性的疾病,只有极少数表现为较“良性”的倾向,而绝大多数则于手术切除后易于复发,虽然手术似乎是已达治愈性。切除性治疗,甚至是姑息性切     

Surgical treatment of cancer of the biliary tract and gall bladder

With the advances in various kinds of diagnostic methods and improvement of operative technique, operations for cancer in biliary tract have recently increased, however, the prognosis has been unsatisfied. During the past 25 years, 495 cases with carcinoma of biliary tract (ca of gall bladder 175 cases, ca of bile duct 201, and ca of papilla vater 105) were operated. The resectability rate was 66% (62% in gall bladder, 62% in bile duct, 84% in papilla vater). Among the lesions in bile duct, the resectable rate in lower bile duct was better than the other site in bile duct. The late results in ca of bile duct, especially in the lesion of upper bile duct were still poor, however, the 5-years survival rate in ca of gallbladder or papilla vater carcinoma was 61% or 56%, respectively. For the further improvement of the surgical results, the sufficient resection of the intrahepatic bile duct in ca of bile duct should be performed, and in gall bladder carcinoma when tumor extends into the neck of gall bladder, bile duct should be resected. In advanced carcinoma, the appropriate hepatectomy or bile duct resection should be considered in proportion to the operative influence and the extension of the tumor.     

肝细胞癌合并胆管癌的临床分型以及手术方式选择对疾病预后的影响

目的 探讨肝细胞癌合并胆管癌的临床特征分型及手术治疗方式选择对远期效果的影响.方法 回顾性分析100例肝细胞癌合并胆管癌患者的就诊资料、肿瘤临床分型及手术方式、生存资料,手术方式有胆管切开取癌栓、肝癌切除并胆管癌切除、胆管支架置入引流等,分析不同手术方式对远期预后的影响.结果 100例确诊并进行根治手术治疗的患者有92例,其中肝细胞癌切除并胆管切口取癌栓的有38例,肝细胞癌切除并胆管癌切除的有48例,胆管支架植入引流的有6例,术后围手术期死亡的患者有9例,25例出现围手术并发症,术后1年、2年、3年的生存率分别为63.0％、25.0％、19.6％,生存期平均为(20.6 ±10.6)个月.通过单因素分析结果显示肝细胞癌合并胆管癌生存期与临床分型及手术方式选择有关.多因素分析结果显示手术方式的选择为影响生存期的独立因素.结论 手术方式的选择是影响肝细胞癌合并胆管癌治疗效果的重要因素.若能早期发现病灶并选择合理的手术方式进行根治,对于延长患者生存期具有重要的意义.