不同分型的高位胆管癌手术切除方式的选择

１９９１年１月至１９９５年１２月，本院收治高位胆管癌５２例，手术切除１７例，切除率３２．７％。切除组中２例Ｉ型和１例Ⅱ型肿瘤行单纯局部切除，１４例行联合肝叶切除；其中１例Ⅱ型行尾叶切除，１例Ⅱ型和３例ⅢＡ型行肝中叶切除，８例ⅢＢ型行左半肝切除，１例ⅢＡ型行右半肝切除。镜下治愈性切除率为１５．４％（８／５２）。治愈性切除组平均生存期为２１．１月，姑息性切除组则为７．５个月（Ｐ〈０．０５）。切除组手术     

肝门部胆管癌根治性切除手术方式的改进

目的 规范肝门部胆管癌整块或根治性切除术的手术方式,改进和提高其手术治疗效果。方法 总结分析了解放军总医院１９８６年至１９９９年手术治疗的肝门部胆管癌１５７例资料。结果 总手术切除率为６７.５％（１０６／１５７）,根治性切除率为３７.６％（５９／１５７）。近３年对５４例肝门部胆管癌行手术切除,切除率为７４％（４１／５４）,根治性切除率为４３％（２３／５４）;随访年存活率：根治性切除组为５７％（１３／２３）,姑息性切除组为４１％（７／１７）,未切除组为７％（１／１４）。结论 术中病理诊断是选择根治性切除术的重要参考指标。     

肝门部胆管癌103例外科治疗远期疗效的评析

作者回顾总结了１９８６年１月～１９９６年１月十年间行手术治疗的１０３例肝门部胆管癌的临床特征、手术方式和远期生存率等。１０３例肝门胆管癌行手术切除者６６例,非切除者行胆管内外引流者３７例,总手术切除率为６４．１％。手术死亡率２．９％。手术切除组中行根治性切除者３６例,姑息性切除者３０例。根治性切除者１、３、５年的生存率分别为：９６．７％、２３．３％和１３．３％,最长生存者至今已达８年。而姑息性切除者３年生存率仅为３．８％,无５年生存者。作者提出新的肝门部胆管癌的临床分型法。发现肝门部胆管癌的组织类型及分化程度,与肿瘤浸润及转移特征密切相关,分化程度越差其预后亦越差。     

肝切除在肝门部胆管癌手术中的应用和选择

目的 观察肝叶切除在肝门部肝管癌根治术中的疗效并探讨根治性切除术的范围。方法 自１９９５年２月至１９９７年３月手术切除肝门部胆管癌９例,姑息性切除２例,根治性切除７例,８例行各种类型肝切除。结果 姑息性切除１例术后１２个月发生肝内转移,存活１６个月;另１例仍存活,术后２７个月出现阻塞性黄疸。根治性切除１例术后１１ｄ死于肺部感染,其余存活至今。结论 肝切除术肝门部胆管癌根治性切除术中手重要组成部分,     

肝门部胆管癌的外科治疗(附181例报告)

目的　探讨肝门部胆管癌预后与临床病理因素的关系。方法　总结１９７８ 年至１９９７ 年手术治疗１８１ 例肝门部胆管癌的临床病理资料,以１９９１ 年为界分为两个阶段,对比手术切除率及生存期等。结果　１８１ 例中手术切除９７ 例,非切除性胆道内外引流者８４ 例,切除组中根治切除５１ 例,姑息切除４６ 例。根治切除者１、３ 、５ 年生存率分别为９５％ 、２７－５％ 和１７－５％ 。姑息切除者为４８－１％ 、７－４％ 和３－７％ ,非切除性胆道内外引流者１ 年生存率分别为４８％ 、３８－９ ％ ,无２ 年生存者。两阶段对比显示：手术切除率由４０－４％ 提高到６６－３ ％ ,其中根治切除率由１８％ 提高到３８％ 。结论　根治切除是提高肝门部胆管癌远期生存率及改善生活质量的关键,早期肿瘤,分化程度好,无淋巴转移者预后好。     

联合尾叶的规则性肝叶切除术治疗肝门部胆管癌

目的:探讨如何提高肝门部胆管癌根治性切除率和生存率的方法。方法:回顾性分析8年余收治的58例肝门部胆管癌行联合尾叶和规则性肝叶切除术患者的临床资料。结果:肿瘤切除联合行规则性左半肝切除26例，规则性右半肝切除25例，右三肝切除4例，中肝叶切除3例；所有患者同时附加全尾叶切除手术和肝十二指肠韧带淋巴结骨骼化清扫。根治性切除率为72.4 ％(42/58)。1，3年生存率分别为79.5 ％和36.2 ％。有3例现已无瘤存活6年。结论:肿瘤切除联合尾叶的规则性肝叶切除可以提高肝门部胆管癌根治性切除率和术后生存率;熟练掌握手术技巧是关键。     

肝叶切除术在肝门胆管癌手术中应用的价值

目的探讨联合肝叶部分切除在肝门部胆管癌根治术中的应用价值.方法对42例行手术治疗的肝门部胆管癌患者的临床资料进行回顾性分析.结果42例患者中有34例行肿瘤切除术,其中局部切除15例,右半肝切除8例,左半肝切除3例,左半肝切除联合尾叶切除4例,左肝外叶切除联合尾叶切除1例,方叶切除3例,总体手术切除率为81%.其中25例根治性切除,包括8例局部切除,及17例联合肝叶部分切除,根治性切除率为60%.根治性切除组的中位生存期28个月,姑息性手术组的中位生存期14个月,根治性切除术的1年生存率为90%,2年生存率73%,4年生存率28%,姑息性手术1年生存率为57%,2年生存率27%.结论根治性切除的生存率比姑息性手术显著提高,联合肝叶部分切除能明显提高根治性手术的切除率.     

肝门部胆管癌根治性切除中围肝门区手术处理

目的探讨围肝门区手术处理手段在肝门部胆管癌外科治疗中的临床应用。方法回顾性分析我院2002年1月-2007年12月诊治的86例肝门部胆管癌病人的临床资料。其中,实施单纯内引流术38例,姑息性切除术11例,采取联合尾状叶切除、受侵门静脉肝动脉切除重建、肝内胆管断端整形、肝门区淋巴结清扫等技术完成根治性切除37例。结果肝门部胆管癌的根治性切除率由2002年的33．3％,提高到2007年的75．0％。无围手术期死亡发生。结论联合采用尾状叶切除、肝门部胆管断端整形、受侵门静脉切除重建及肝门区淋巴清扫等围肝门区处理手段可提高肝门部胆管癌根治性切除率,降低手术并发症的发生率。     

联合肝叶及肝门部血管切除治疗肝门部胆管癌

目的 探讨联合肝叶及肝门部血管切除在肝门部胆管癌根治术中的应用.方法 回顾性分析解放军总医院肝胆外科2008年1月-2011年12月手术治疗的74例肝门部胆管癌患者的临床资料.74例患者均行手术探查,手术根治性切除33例(44.6％),其中26例联合部分肝切除及血管切除重建;行姑息性切除19例(25.7％);行内引流或外引流术22例(29.7％).结果 联合肝叶及肝门部血管切除的根治性切除组的中位生存时间为27个月,姑息性手术组的中位生存时间为14个月,引流手术组中位生存时间为9个月;根治性切除术的1、2、3年生存率分别为79％、64％、49％;姑息性手术组1、2、3年生存率分别为56％、25％、19％;引流手术组1、2、3年生存率分别为23％、15％、0.结论 根治性切除组的生存率较姑息性手术及引流手术组明显提高,合并肝叶、肝门血管切除可提高肝门胆管癌的手术根治率和生存率;联合肝叶切除有利于肝门胆管癌的根治性切除,提高生存率.     

肝门部电凝锐性解剖在高位胆管癌外科手术中的应用

１９９１年￣１９９５年怍治高位胆管癌病人１４例，采用肝门部电凝锐性解剖的方法，手术切除率达８５．７％，无手术死亡，术后平均存活１４．９个月。１１例获治愈性切除。文章详细介绍了电凝锐性解剖技术在肝门部胆管癌切除时的方法及要点。在临床实践中证实其具有术中出血少、成功率高、耗时少等优点，对提高胆道恶性肿瘤的切除率具有重要意义。     

Indications for combined resection and reconstruction of the hepatic artery in biliary tract carcinoma]

More than 10 years have passed since hepatic artery resection was first performed for the treatment of biliary tract cancer. The safety of this procedure has been established with the introduction of the microsurgery technique. However, the benefits of and indications for this treatment have not yet been clarified. Twenty-three patients underwent vascular resection (portal vein in 7, portal vein + hepatic artery in 9, hepatic artery in 7) among 114 resected patients with biliary tract cancer in our institution. The right hepatic artery was reconstructed by end-to-end anastomosis in most cases. The curative resection rate was 88.9% in hilar bile duct cancer. However, it was less than 50% in other carcinomas. Cumulative 5-year survival rates of vascular resection patients with hilar bile duct cancer, lower bile duct cancer, gallbladder cancer, and cholangiocarcinoma were 14.8%, 25%, 0%, and 0%, respectively. On the other hand, the rates were 38.9%, 0%, 0%, and 0%, in the stage III + IV patients who did not undergo vascular resection. The longest survival period among patients with hilar bile duct cancer and lower bile duct cancer was 85 months and 65 months, respectively, whereas it was 15 months in gallbladder cancer and 20 months in cholangiocarcinoma patients. No hilar bile duct cancer patient who survived for more than 3 years had lymph node metastasis. The longest surviving cholangiocarcinoma patient has received adjuvant chemotherapy consisting of 5-fluorouracil and cisplatin. It is concluded that patients with hilar bile duct cancer are good candidates for vascular resection. Adjuvant chemotherapy should be administered to gallbladder cancer and cholangiocarcinoma patients, because vascular resection alone does not result in prolongation of life in these patients.     

Extensive hilar bile duct resection using a transhepatic approach for patients with hepatic hilar bile duct diseases

BACKGROUND: Extensive hilar bile duct resection beyond the second- or third-order intrahepatic biliary radicals is usually required for patients with hilar cholangiocarcinoma as well as those with benign inflammatory stricture. Most hilar cholangiocarcinoma is resected with combined major hepatectomy to obtain free surgical margins. The purpose of this study was to show the surgical procedure and the usefulness of extensive hilar bile duct resection using a transhepatic approach for patients with hilar bile duct diseases. METHODS: Five patients with hepatic hilar bile duct disease and who were unfit for major hepatectomy for several reasons underwent extensive hilar bile duct resection by way of a transhepatic approach. Four of the patients had hilar bile duct cancer, including 1 with mucous-producing bile duct cancer of low-grade malignancy and 1 with a postsurgical benign bile duct stricture. RESULTS: After extensive hilar bile duct resection, bile duct stumps ranged in number from 3 to 7 mm (mean 4.4). Surgical margins at bile duct stump were free of cancer in all 4 cancer patients. The long-term outcomes were as follows: 3 patients are alive at the time of publication, and 2 patients have died. CONCLUSIONS: A transhepatic approach may be useful when performing extensive hilar bile duct resection bile duct stricture of biliary disease at the hepatic hilus, especially in high-risk patients who are unfit for major hepatectomy as well as in those having benign bile duct stricture and low-grade malignancy.     

Results of surgical resection for patients with hilar bile duct cancer: application of extended hepatectomy after biliary drainage and hemihepatic portal vein embolization

OBJECTIVE: To evaluate the feasibility of an aggressive surgical approach incorporating major hepatic resection after biliary drainage and preoperative portal vein embolization for patients with hilar bile duct cancer. SUMMARY BACKGROUND DATA: Although many surgeons have emphasized the importance of major hepatectomy in terms of curative resection for patients with hilar bile duct cancer, this procedure results in a high incidence of postoperative morbidity and mortality in patients with cholestasis-induced impaired liver function. METHODS: A retrospective cohort study was conducted in 140 patients with hilar bile duct cancer treated from 1990 through 2001. Resectional surgery was performed in 79 patients, 69 of whom underwent major hepatic resection. Thirteen patients underwent concomitant pancreaticoduodenectomy. Preoperative biliary drainage was carried out in all 65 patients who had obstructive jaundice. Portal vein embolization was conducted in 41 of 51 patients undergoing extended right hepatectomy. Short- and long-term outcomes were evaluated. RESULTS: No patient experienced postoperative liver failure (maximum total bilirubin level, 5.4 mg/dL). The in-hospital mortality rate was 1.3% (1 in 79, resulting from cerebral infarction). A histologically negative resection margin was obtained more frequently when the scheduled extended hepatic resection was conducted (75% vs 44%, P = 0.0178). The estimated 5-year survival rate was 40% when histologically negative resection margins were obtained, but only 6% if the margins were positive. Multivariate analysis identified the resection margin and nodal status as independent factors predictive of survival. CONCLUSIONS: Extensive resection, mainly extended right hemihepatectomy, after biliary drainage and preoperative portal vein embolization, when necessary, for patients with hilar bile duct cancer can be performed safely and is more likely to result in histologically negative margins than other resection methods.     

One hundred and eleven liver resections for hilar bile duct cancer

A positive correlation between absence of residual tumor at resection margins and long-term survival in the treatment of hilar bile duct carcinoma has encouraged some surgeons to use a more radical approach, including liver/portal vein resection and combined pancreatoduodenectomy. However, if liver resection is associated with significant morbidity and mortality, it may not produce any overall benefit. This review was undertaken in an attempt to determine whether liver resection is a safe procedure and whether if has any beneficial effect over that of local bile duct excision alone, in terms of achieving curative resection and long-term survival. The records of 151 patients with hilar bile duct carcinoma surgically treated between June 1989 and December 1997 at the Asan Medical Center, Seoul, were retrospectively analyzed. Surgical resection was possible in 128 patients. The remaining 23 patients had surgical palliative drainage. Local bile duct excision alone was performed in 17 patients. Liver resection for tumor extending to secondary bile ducts or hepatic parenchyma was performed in 111 patients; portal vein resection was necessary in 29 of these 111 patients (26.1%) and pancreatoduodenectomy was combined in 18 patients (16.2%). Seven patients died during hospitalization after liver resection, an operative mortality of 6.3%. Margins of bile duct resection were free of tumor on histologic examination in 4 of the 17 local bile duct excisions, but in 86 of the 111 liver resections. The cumulative survival rate after local bile duct excision was 85.7% at 1 year, 42.9% at 2 years, 21.4% at 3 years, and 0% at 4 years. However, the survival rate after liver resection (excluding operative mortality) was 97.1% at 1 year, 72.8% at 2 years, 55.3% at 3 years, and 24.0% at 5 years. Survival and the percentage of patients with tumor-free resection margins after liver resection were superior to those after local bile duct excision. Resection of hilar bile duct carcinoma offers long-term survival only when surgery is aggressive and includes liver resection. Received for publication on July 2, 1998; accepted on July 5, 1998     

Surgical Resection of Hilar Cholangiocarcinoma: Analysis of Survival and Postoperative Complications

Background Surgery is the only potentially curative treatment for hilar bile duct cancer. This study sought to evaluate the efficacy and feasibility of surgical management of hilar bile duct carcinoma, including radical hepatectomy, at a single institution. Methods We performed a retrospective review of 49 consecutive patients who underwent surgery at our hospital between 1990 and 2003. Results Altogether, 44 of 49 patients underwent radical hepatectomy combined with caudate lobectomy and lymphadenectomy. One and four patients underwent partial hepatectomy or bile duct resection, respectively. No patients underwent preoperative portal vein embolization. The 5-year survival rate was 39.7%, with a median survival time of 3.75 years. The postoperative morbidity and mortality rates were 46.8% and 2.0%, respectively. Cox’s proportional hazard model revealed that lymph node status and the residual tumor factor were independent prognostic factors. Multivariate analysis revealed that preoperative hyperbilirubinemia, postoperative complications, and extended surgical procedures were independently associated with postoperative hyperbilirubinemia. After potentially curative resection, 39.4% of patients suffered from disease recurrence. In 60% of the total cases, the sites of recurrence were distant metastases. Conclusion Surgery, including radical hepatectomy combined with caudate lobectomy and lymph node dissection, is a feasible, effective treatment for hilar bile duct cancer.     

肝门部胆管癌的外科治疗

目的　分析一个单位 1986-2 0 0 2年间治疗肝门部胆管癌的经验。方法　回顾 1986-2 0 0 2年在解放军总医院肝胆外科治疗 2 91例肝门部胆管癌的纪录 ,全部治疗均在单一的科室技术领导下进行 ,有一定的连贯性。外科治疗手段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。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 ,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 ,因而根治性切除率只分别为 3 7.6%和 41.2 %。无切除术后 3 0d内死亡。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。结论　肝门部胆管癌是多态性的疾病 ,只是极少数表现为较“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 ,甚至是姑息性切除 ,仍可以达到延长生命和提高生活质量的效果。扩大手术切除和淋巴结清扫范围的治疗作用尚未能确定     

Results of surgical treatments and prognostic factors for hepatic hilar bile duct cancer

Results of surgical treatments for 57 patients who underwent resection for hepatic hilar bile duct cancer between 1984 and 1997 were studied. Bile duct resection was performed in eight patients, and combined resection of bile duct and liver was performed in 49 patients, of whom vascular reconstruction was added in 15 patients and pancreatoduodenectomy (PD) in six patients. All the operations of bile duct resection that were not combined with hepatectomy were non-curative. In the patients who underwent combined resection of the bile duct with liver, outcomes of the patients with well-differentiated adenocarcinoma were better than those with other lower-grade tumors. The factors related to the degree of tumor extension, such as serosal invasion, lymph node metastasis, lymphatic vessel invasion, perineural invasion, venous vessel invasion, and vascular involvement, were other factors which significantly influenced the survival. Curative resection yielded significantly better results than non-curative resection. Of all these variables, good tumor differentiation and vascular involvement were recognized as important prognostic factors by multivariate analysis. Most of the postoperative deaths were encountered in patients who underwent additional operations to hepatectomy, such as vascular reconstruction or PD. Improvement of surgical techniques and perioperative care has yielded better outcomes of vascular reconstruction. However, the application of hepatopancreatoduodenectomy should be limited due to poor outcomes of widespread bile duct cancer of which the histological grade is usually low. Whereas prognosis of bile duct cancer involving the hepatic hilus is mainly determined by the biologic characteristics of the tumor, surgeons should consider the fact that most patients die of local recurrence regardless of the biologic character of the tumor when curative resection is not performed. Received for publication on April 10, 1998; accepted on July 27, 1998     

Role of Hepatectomy in the Treatment of Hilar Bile Duct Carcinoma

Purpose. To clarify the role of hepatic resection in the surgical treatment of hilar bile duct carcinoma.Methods. Between 1980 and 1997, 68 patients underwent surgery for hilar bile duct carcinoma. The patients were divided into a hepatectomy group (n = 40) and a nonhepatectomized group (n = 28) depending on whether they underwent resection of the bile duct confluence in combination with hepatectomy, or alone, respectively. Background data, operative morbidity and mortality, and survival were retrospectively compared between the two groups.Results. There were no significant differences in morbidity and mortality, or in postoperative survival between the two groups (the 5-year survival rates being 20.6% in the hepatectomized group and 7.1% in the nonhepatectomized group; P = 0.0806). However, patients who underwent curative resection had significantly better postoperative survival than those who underwent noncurative resection (P = 0.048). Hepatectomy provided a significantly better cancer-free margin than bile duct resection alone (P = 0.0296).Conclusions. Although a countermeasure must be taken to decrease mortality, the introduction of hepatectomy with bile duct resection would provide a better cancer-free surgical margin than bile duct resection alone for hilar bile duct carcinoma. Curative resection contributed to long-term survival in this series.     

Is parenchyma-preserving hepatectomy a noble option in the surgical treatment for high-risk patients with hilar bile duct cancer?

BACKGROUND: The essential minimum of hepatic segmentectomy combined with caudate lobectomy (parenchyma-preserving hepatectomy) has been recommended particularly for high-risk patients with hilar bile duct cancer to minimize the risk of postoperative liver failure. This quality control study investigated whether parenchyma-preserving hepatectomy is a "noble option" in the surgical treatment of hilar bile duct cancer. PATIENTS AND METHODS: A total of 53 patients with hilar bile duct cancer underwent surgical resection. These patients were retrospectively classified into a major hepatectomy group (major Hx, n=30), a parenchyma-preserving hepatectomy group (preserving Hx, n=11), and a hilar bile duct resection group (HBDR, n=12). A preserving Hx consisted of caudate lobectomy, either alone (n=3), or combined with resection of segment 4 (S4, n=4), or S58 (n=3) or S458 (n=1). The preserving Hx was used for high-risk patients in whom tumor tissue was diagnosed to be Bismuth type I and II by preoperative selective percutaneous transhepatic cholangiography. RESULTS: The mean numbers of hepatico-jejunostomies were 2.8, 4.8, and 4.6 in the respective groups. Mortality rates including hospital death were 13.3%, 0%, and 0% respectively. Morbidity rates were 46.7%, 54.5%, and 33.3%. The preserving Hx group encountered no liver failure (T.Bil>10 mg/dl, encephalopathy) but acquired hyperbilirubinemia (T.Bil>5 mg/dl), pulmonary insufficiency and other complications at the same frequency as in the major Hx group. The survival rates in the three groups were 35.6%, 52.5%, and 48.6% at 3 years and 25.2%, 14.9%, and 24.3% at 5 years respectively. Curability rates (R0 to R1+2) were 76.7%, 54.5% and 50.0%, respectively. Preserving Hx tended to result in higher frequencies of positive transmural margins (e.g., cancer cells remaining around the right hepatic artery or the portal vein). CONCLUSIONS: Preserving hepatectomy for high-risk patients should be limited strictly to patients who do not have tumors which are not invading adjacent organs (e.g., T2) nor a segmental duct and are confined longitudinally to the right or the left.