联合肝叶和肝门血管切除治疗肝门胆管癌

目的　探讨治疗肝门胆管癌理想的肝叶切除术式 ,以期提高其疗效、降低并发症和病死率。方法　对 16例侵犯肝门血管的肝门胆管癌 ,采用肝I ,IV段连同肝门胆管肿瘤与受侵血管整块切除及肝十二指肠韧带骨骼化淋巴清扫。结果　 15例获手术切除 ,切除率为 93 .8% ,12例获R0 切除。无手术死亡和住院死亡。发生暂时性胆漏 1例 ,腹腔感染 1例 ,并发症发生率为 13 .3 % ,均行非手术治愈。随访病例中位生存期为 2 2个月 ,7例尚存活。结论　合并肝叶、肝门血管切除可提高肝门胆管癌的切除率和生存率 ;肝中叶和肝尾叶是肝门胆管癌手术联合切除的主要部位。肝门受侵血管的切除对提高该病切除率和根治率是有意义的 ,应酌情重建或不重建肝门血管。

The strategies of combind liver and hilar vascular resection for hilar Cholangiocarcinoma

Objective Because of local infiltrated growth and spread,the operative resection of hilar (cholangiocacinoma) is very difficult. Recently,combined extended hepatectomy and vascular resection had been performed for treatment of hilar cholangiocarcinoma and has greatly increased the resection rate and survival rate.However, it is associated with high operative morbidity and mortality. The aim of this study is to explore a reasonable hepatic resection strategy, that is safe and beneficial for the patient. Method Sixteen (consecutive) cases of hilar cholangiocarcinoma with involvement of hilar vessels have been treated in our hospital since 1977. En bloc resection of the hilar tumor that included hepatic segment I,IV and involved blood (vessel), as well as hepato-duodenal ligament skeletonization was performed in 15 patients. Results All 15 cases were successfully operated on with a resection rate of 93.8%, and 12 cases with R_0 resection. The operative mortality and in-hospital mortality rate were 0. Temporary bile leak and abdominal infection (respectively) developed in 1 patienteach,with an overall morbidity of 13.3%,and both were cured by non-(operative) therapy. No case of liver failure occurred. Follow up showed the median survival was 22 months and 7 are still alive. Conclusions (1)The resection rate and survival rate for hilar cholangiocarcinoma could be improved by combination of liver and hilar vascular resection.(2)Hilar cholangiocarcinoma mainly spreads to the medial segment(S4) and caudate(S1), and these segments need to be resected in the combined (operation).(3)Although resection of the middle part of liver takes little more time than hemi-hepatectomy and trisegmentectomy, it could preserve more liver parenchyma and reduce postoperative morbidity (such as liver failure) and mortality rates.(4)The resection of the hilar blood vessel involved by tumor was necessary to improve the resection rate and cure rate. Reconstruction of the blood vessel was made selectively by taking the circumstances into consideration.