Management strategies in resection for hilar cholangiocarcinoma.

Between 1960 and 1990, resection was performed in 23 of 122 patients who underwent surgical treatment for hilar cholangiocarcinoma. Local excision of the lesion alone was performed in 10 cases (43%). Hepatic resection for tumor extending to the secondary bile ducts or hepatic parenchyma was performed in 13 cases (57%): extended right hepatectomy (3), right hepatectomy (1), extended left hepatectomy (6), left hepatectomy (2), and left lobectectomy (1). In three other cases, resection by total hepatectomy and liver transplantation was performed, but these were not included in the analysis of results for resection. Significant operative complications occurred in only two cases (8.7%), and the operative mortality rate was zero. In four cases, complete excision of the tumor could not be achieved macroscopically (macroscopic curative resection rate 19/122; 15.6%). In nine cases, the margins of the resected specimens were free from tumor on histologic examination (microscopic curative resection rate, 9/122; 7.4%). In 10 cases, the resection margins were found to contain tumor on histologic examination. The overall survival rate was 87% at 1 year, 63% at 2 years, and 25% at 3 years (median survival, 24 months). The survival and freedom from recurrence rates for patients with free resection margins was superior to that for patients with involved resection margins or residual macroscopic disease. A potentially curative resection, with histologically negative margins and no recurrence to date, was achieved in seven patients using the following procedures: local excision for two type I lesions; left hepatectomy plus excision of segment 1 for two type IIIb lesions and one type IV lesion; right hepatectomy and right hepatectomy plus excision of segment 1 for two type IIIa lesions. These results indicate that improved survival in hilar cholangiocarcinoma can be achieved by resection, with minimal morbidity and zero mortality rates, if histologically free resection margins are obtained. To achieve this, we recommend the following procedures for each type of lesion, based on our experience and on anatomic considerations: local excision for type I; local excision plus resection of segment 1 for type II; local excision, resection of segment 1, and right or left hepatectomy for types IIIa and b; hepatectomy plus liver transplantation for type IV.     

肝门上入路法切除高位胆管癌

目的总结肝门上入路在BismuthⅢ~Ⅳ型胆管癌中临床应用的经验体会。方法回顾性分析2000年7月至2005年10月采用肝门上入路手术切除的20例BismuthⅢ~Ⅳ型胆管癌患者。结果切缘阳性2例。术后近期内并发胸腔积液5例,伤口感染2例,膈下感染1例,胆肠吻合口瘘1例,肝功能衰竭1例。1年生存率为70%(P0=14/20=0.70),2年生存率为50%(P1=7/14=0.50),3年生存率为57%(P2=4/7=0.57)。结论(1)肝门上入路是BismuthⅢ~Ⅳ胆管癌的手术入肝路径。(2)肝正中裂路径由于没有主要的胆管或血管通过,出血少,操作简单,暴露清楚。肝Ⅳ段切除可以完成部分肝门部胆管肿瘤切除。(3)局部扩大的肝切除方法可以最大限度地保存正常肝组织,减少由于肝功能衰竭所导致的各种并发症;尽可能的做到胆管残端病理检查时的R0切除。     

肝细胞癌合并肝门部胆管癌栓与肝门部胆管癌的CT鉴别诊断

目的分析肝细胞癌(HCC)合并肝门部胆管癌栓(HBDTT)的CT影像特征,并探讨其与肝门部胆管癌(hilar CC)的CT鉴别诊断。方法收集中山大学附属第一医院及江门市新会中医院2013年1月至2018年12月经病理证实的HCC伴HBDTT患者42例(HBDTT组)及hilar CC患者51例(hilar CC组),对两组患者的临床资料及CT影像表现进行比较和分析。结果与hilar CC组相比,HBDTT组男性、乙型肝炎病史、上腹部疼痛比例较高,甲胎蛋白(AFP)水平升高更为常见,而hilar CC组CA19-9、癌胚抗原(CEA)升高患者更多(均P<0.05)。两组CT征象在是否同时累及肝实质及胆管、门静脉期“快退”、胆管壁增厚、血管癌栓及脾大等方面差异均有统计学意义(P<0.001),5项征象均具有较高的特异度(82.4%~98.0%),其中前3项诊断敏感度较高(100.0%、92.9%、85.7%)。结论利用CT可以对HCC合并HBDTT与hilar CC作出准确的鉴别诊断。病变同时累及肝实质和肝门部胆管、门静脉期“快退”及胆管壁不增厚是HCC伴HBDTT的特征性征象,结合乙型肝炎病毒感染、AFP水平升高等综合分析对鉴别HCC伴HBDTT与hilar CC有重要作用。     

近端胆管癌的外科治疗

目的 探讨近端胆管癌的外科治疗及疗效。方法 57例近端胆管癌患者中21例行外科手术治疗,36例行非手术外引流治疗。结果21例手术治疗患者中17例存活14月以上,36例行鼻胆管引流或内置管引流术患者均在8月内死亡。结论 外科手术治疗近端胆管癌疗效明显优于鼻胆管引流术（ENBD）或内置管引流术（EHBD）胆管内外引流。     

肝门部胆管癌的外科治疗

目的 探讨肝门部胆管癌各种术式的疗效。方法 回顾性分析经手术和病理证实的肝门部胆管癌35例手术方式和随访结果。结果 手术切除13例（根治性切除9例,姑息性切除4例）,总手术切除率为37．1％,其中1996年以后的23例中切除12例,手术切除率为52．2％;胆管内引流5例;外引流1例;剖腹探查6例。随访23例,随访率65．7％。切除术组13例,存活7－30个月,平均17．5个月,现仍存活4例,生存期分别为12,13,15和21个月;引流组存活2．5－24个月,平均9．2个月,1例已生存13个月;单纯剖腹探查术者多于术后3个月内死亡。结论 根治性切除和扩大手术切除范围是肝门部胆管癌首选的治疗方法。对不能切除者,不应放弃手术探查,应争取行胆管内、外引流术。     

肝门部胆管癌的外科治疗

目的探讨肝门部胆管癌的外科手术治疗的方法及其效果。方法对96例肝门部胆管癌患者外科手术治疗的方法及疗进行回顾性分析。根治性切除术33例,姑息性切除17例,内和外引流46例。结果手术病死率9.4%,各组间差异无统计意义。手术切除率52%,其中根治性切除率34%;根治性切除、姑息性切除、内引流和外引流组术后生存时间为30、17、13、2.9个月。结论根治性切除是肝门部胆管癌有效的治疗手段,对无法行根治性切除者以内引流为首选治疗方法,能提高患者术后生活质量,延长生存期。     

肝门胆管癌的临床诊断

目的：探求实用和有效的诊断肝门胆管癌的方法。方法：对61例肝门胆管癌及50例良性胆道疾病（肝门胆管结石伴肝管狭窄、肝门胆管损伤性狭窄）的临床表现,实验室和影像检查结果比较分析。结果：肝门胆管癌的主要表现为梗阻性黄疸和右上腹痛。肝门胆管癌病人血清CA19－9水平显著高于良性对照组（P＜0．01）。血清CA19－9,CEA诊断肝门胆管癌的敏感性和特异性分别是83．6％,17．4％和68％,100％。B超,电脑彩超,CT,MRI诊断肝门胆管癌的敏感性和特异性分别是70％,97％,71．9％,78．3％和95．7％,100％,90．9％,87．5％。所有46例肝门胆管癌病人行MRC均能明确显示胆管梗阻部位和扩张的肝门胆管树。结论：血清CA19－9有助于肝门胆管癌的诊断。彩超,MRI结合MRC是诊断肝门胆管癌的首选影技术。     

肝门部胆管癌外科治疗25年的历程

1989年,国内首次报道肝门部胆管癌以来,该病的治疗作为跨世纪的热点问题已逐渐深入.但是,存在的争议仍然较多,距最后解决问题仍有差距. 1 命名及范围与分类 习惯上胆道系统分为肝内、外胆管系统,以左、右肝管的汇合点作为分界线.然而,从解剖学上位于肝管汇合以上的胆管,部分仍位于肝实质之外,而临床上又无清楚的划分肝内、外胆管的标志.     

肝门部胆管癌外科治疗25年的历程

Hilar cholangiocarcinoma has received great attention in the past 25 years because of its rising prevalence. However, the results of surgical treatment of hilar cholangiocar-cinoma are still unsatisfactory. A series of studies on cholangio-carcinoma, both clinical and experimental, were conducted in the Research Institute of Hepatobiliary Surgery of PLA. Detailed clinicopathological research revealed the characteristics of nerve involvement and metastasis of bile duct cancer, which may be responsible for the high recurrence after surgical removal. Hepa-titis C virus may be one of the causal factors of bile duct cancer in China. Clinically, of the 402 patients with hilar cholangiocarcinoma, 51. 5% of the resections were found to be R0. The 5-year survival rate was 33. 3% and the morality rate was 0.3%. For those high-risk patients with jaundice, when resec-tion of the hepatic artery was found to be necessary, an arterial-portal venous shunt was constructed with satisfactory results. However, the best approach to treat hilar cholangiocarcinoma still needs further investigation.     

Surgical management of hilar cholangiocarcinoma

OBJECTIVE: To assess the surgical management of hilar cholangiocarcinoma over a time period when liver resection was considered standard management. SUMMARY BACKGROUND DATA: Hilar cholangiocarcinoma remains a difficult challenge for surgeons. An advance in surgical treatment is the addition of liver resection to the procedure. However, liver resection in the setting of liver dysfunction caused by biliary obstruction can be associated with increased mortality. METHODS: Between 1997 and 2004, 80 patients with hilar cholangiocarcinoma having surgery were reviewed. Fifty-three patients had attempted curative resections, 14 patients had palliative bypasses, while 13 patients had findings that precluded any further intervention. Twenty-three patients required portal vein resection and reconstruction to achieve negative margins, 3 of which also required reconstruction of the hepatic artery. RESULTS: Patients undergoing resection had a 9% operative mortality, with morbidity of 40%. Patients who demonstrated lobar hypertrophy preoperatively due to tumor involvement of the contralateral liver or induced with portal vein embolization (PVE) had a significantly lower operative mortality than those patients without hypertrophy. Median overall survival in patients resected was 40 months, with 5-year survival of 35%. Negative margins were achieved in 80% of cases and were associated with improved survival. Five-year survival in patients undergoing resection with negative margins was 45%. CONCLUSION: Combined liver and bile-duct resection can be performed for hilar cholangiocarcinoma with acceptable mortality, though higher than that for liver resections performed for other indications. The use of PVE in cases where hypertrophy of the remnant liver has not occurred preoperatively may reduce the risk of operative mortality.     

肝门部胆管癌的外科诊治进展

胆管癌发病率占人类恶性肿瘤的2%,男性发病略高于女性,约为1.5:1[1].其中58%～75%发生在肝胆管分叉处,称肝门部胆管癌(hilar cholangiocarcinoma),又称Klatskim肿瘤.因其特殊的生长部位和生物学特性,如何早期诊断和处理这一临床病变,成为胆道外科医师面临的严峻挑战.本文就肝门部胆管癌的外科诊治进展作一综述.     

肝门胆管癌的鉴别诊断

目的 提高对肝门胆管癌诊断和鉴别诊断的认识，减少对其误诊误治；方法 对上海中山医院1993年1月至1996年12月收治的33例术前诊断为肝门胆管癌的手术病例进行回顾性分析．根据病理结果，探讨影像学检查、肿瘤相关抗原、组织活检和细胞学检查以及手术探查对肝门胆管癌诊断和鉴别诊断的价值。结果 根据病理结果．33例手术病例中有8例系其他肝门部梗阻性疾病被误诊为肝门胆管癌，误诊率占所有手术的24．2％。这8例被谋诊患者中，包括肝门胆管癌栓3例，特发性良性狭窄2例。咀囊管癌累及肝总管1例，胆囊管残株癌1例，肝外胆管结核1例。结论 虽然有较多的方法可用于肝门胆管癌的鉴别诊断．但临床误诊率仍较高。我们建议对所有肝门胆管癌病人．只要无手术禁忌证，均应积极手术探查。     

Multidisciplinary treatment of hilar cholangiocarcinoma

With advances in surgical techniques, the number of curative resection for hilar cholangiocarcinoma has increased. However, the recurrence rate after curative resection is significantly high. There is no established adjuvant therapy for these patients, although some groups have administered intraarterial infusion of 5-fluorouracil combined with cisplatin. In our institution, postoperative radiation is administered to control remnant tumors at the ductal and surgical margins. Extracorporeal radiation is directed at the surgical margins and intraluminal radiation at the ductal margins. This has improved the cumulative survival rate for cholangiocarcinoma patients who underwent both curative and noncurative resection. The 3-year survival rate of those who underwent curative resection with and without postoperative radiation is 100% and 28.5%, respectively. The longest survival duration among our patients who received intraluminal radiation for positive ductal margins were 55 months. Because the biological behaviour and radiation sensitivity of the tumors differ among individually, these should be determined through molecular biologic studies in the future. Such tailored therapy will require multidisciplinary treatment.     

肝门部胆管癌外科治疗25年的历程

1989年,国内首次报道肝门部胆管癌以来,该病的治疗作为跨世纪的热点问题已逐渐深入.但是,存在的争议仍然较多,距最后解决问题仍有差距. 1 命名及范围与分类 习惯上胆道系统分为肝内、外胆管系统,以左、右肝管的汇合点作为分界线.然而,从解剖学上位于肝管汇合以上的胆管,部分仍位于肝实质之外,而临床上又无清楚的划分肝内、外胆管的标志.     

肝门部胆管癌的手术治疗

目的 总结肝门部胆管癌的手术治疗经验.方法 回顾性分析2007年1月至2011年12月哈尔滨医科大学附属第一医院同一医疗组手术治疗的88例肝门部胆管癌患者的临床资料.所有患者术前经影像学检查确诊,并根据黄疸程度及剩余肝脏体积进行术前辅助治疗,行PTCD 19例、门静脉栓塞4例.基本手术方式为肝门部胆管癌切除+肝十二指肠韧带骨骼化+胆管空肠Roux-en-Y吻合术,并常规放置支撑管引流6个月.计数资料采用x2检验,以Kaplan-Meier法计算生存率,生存分析采用Log-rank检验.结果 88例手术治疗的患者中,58例(含11例PTCD治疗者)行肝门部胆管癌切除术,其中43例(含4例术前门静脉栓塞者)为R0切除,15例为姑息性切除;30例行内和(或)外引流术.联合肝切除22例(包括左半肝切除9例、扩大左半肝切除2例、左半肝联合尾状叶切除7例、右半肝切除4例),联合胰头十二指肠切除7例,联合肝固有动脉切除3例(重建2例),联合门静脉管壁部分切除2例.按改良Bismuth-Corlette分型,88例患者中Ⅰ型17例、Ⅱ型19例、Ⅲa型21例、Ⅲb型20例、Ⅳ型11例.58例肝门部胆管癌切除术患者中,19例出现各种术后并发症,2例术后30 d内死亡.本组共73例患者获得随访,总体1、3、5年生存率分别为68.5％、28.8％、11.0％.37例R0切除患者、14例姑息性切除患者及22例引流患者1年生存率分别为94.6％、78.6％、18.2％;3年生存率分别为43.2％、35.7％、0;5年生存率分别为18.9％、7.1％、0.R0切除患者生存率高于姑息性切除患者(x2=4.77,P＜0.05);姑息性切除患者生存率高于内和(或)外引流患者(x2=13.26,P＜0.05).结论 手术治疗肝门部胆管癌,应力求R0切除,尽量避免单纯性胆汁引流;术前充分而高效的肝功能恢复与储备能确保手术的疗效.     

肝门部胆管癌的手术治疗

近年来,肝门部胆管癌的术前影像学诊断和手术技巧有了很大的进步,肿瘤的切除率有了较大的提高.根治性切除被认为是对肝门部胆管癌患者最有效的处理方式并可带来较好的预后.     

肝门部胆管癌的外科治疗

目的探讨肝门部胆管癌的诊断和外科治疗的效果.方法对46例肝门部胆管癌的临床资料进行回顾性分析.结果本组术前误诊率43.5%(20/46).18例手术切除,总手术切除率39.1%(18/46),其中根治性切除率26.1%(12/46);22例行周围胆管空肠吻合术;6例U管引流术.根治切除、姑息切除、胆管空肠吻合和U管引流组病人的平均生存期分别是(20.32±11.24)月,(18.12±10.43)月,(12.46±8.78)月和(7.32±5.24)月.切除组病人的生存期显著长于姑息性手术组(P<0.01),而且生活质量显著提高.结论临床医生应重视肝门部胆管癌的早期诊断.根治切除术可显著延长患者生存期和改善生存质量.     

肝门部胆管癌的外科治疗

目的 探讨肝门部胆管癌的临床特征、治疗方法对远期生存率的影响.方法 对1995 —2005年收治的98例肝门部胆管癌的临床特点、诊断及随访结果进行回顾性分析,并将手术方式和治疗效果进行对比研究.根据数据类型分别进行x2检验、t检验,生存率计算采用Kaplan-Meier 法,并作log-rank检验.结果 83例施行了外科手术,15例施行保守治疗.83例中行根治性切除术者33例,姑息性切除术者16例,内或外引流术者34例.肝门部胆管癌切除者1、3、5年生存率分别为79％、42％、17％,其中根治性切除1、3、5年生存率分别为88％、54％、24％;姑息性切除1、3年生存率分别为55％、9％,无5年存活者.根治性切除、姑息性切除生存率差异有统计学意义(log-rank test,P＜0.001).结论 根治性切除是提高肝门部胆管癌远期生存率及改善生活质量的有效手段,早期诊断和治疗是提高远期疗效的关键.     

肝门部胆管癌的手术治疗

近年来,肝门部胆管癌的术前影像学诊断和手术技巧有了很大的进步,肿瘤的切除率有了较大的提高.根治性切除被认为是对肝门部胆管癌患者最有效的处理方式并可带来较好的预后.     

Preoperative management of hilar cholangiocarcinoma

From both the therapeutic and diagnostic viewpoints, percutaneous transhepatic biliary drainage (PTBD) is crucial for the preoperative management of hilar cholangiocarcinoma. The direct anterior approach under fluoroscopic guidance is the most advantageous form of PTBD. Despite some advantages, endoscopic retrograde biliary drainage is contraindicated for preoperative biliary decompression. Pertinent multiple catheterizations using PTBD result in an accurate diagnosis of cancer extent, and produce effective relief of jaundice, as well as preventing the development of cholangitis. This, in turn, permits a rational surgical strategy and improved postoperative recovery. Preoperative staging of hilar cholangiocarcinoma is achieved by tube cholangiography through the PTBD catheter and by percutaneous transhepatic cholangioscopy. Angiography and percutaneous transhepatic portography are also recommended to diagneous extramural invasion of cancer. Prevention of posthepatectomy liver failure is the greatest challenge in the treatment of this disease. A multifactorial approach that combines several elements may provide sufficient data for determing the safe limits of surgery and for predicting posthepatectomy liver failure. Preoperative percutaneous transhepatic portal vein embolization (PTPE) is an effective method for preventing this intractable complication.