肝门胆管癌的术前可切除性评估

近年来,肝门胆管癌的发病率呈逐年增高的趋势。作为普外科最具挑战性的手术之一,外科手术不仅是肝门胆管癌首选的治疗方法,也是其根治的唯一希望[1]。手术治疗肝门胆管癌应力求R0切除,尽量避免单纯性胆汁引流[2]。然而,目前国内肝门胆管癌的根治性切除率依然较低。     

肝门部胆管癌的术前评估方法选择

本期发表了《"两步评估法"对肝门部胆管癌手术治疗价值初探》一文,对肝门部胆管癌提出了能评估肿瘤可切除性、根治切除率和预后情况的方法。关于肝门部胆管癌,目前越来越受到外科临床医师的重视,主要的原因可能是:①除了手术切除治疗外,肝门部胆管癌尚未有更好的治疗方法;②实验     

肝门胆管癌的可切除性评估

肝门胆管癌（hilar cholangiocarcinoma，HCC）又称近端胆管癌或Klatskin瘤。美国每年新增7500例胆管恶性肿瘤病例，HCC占其中的40％-60％。由于其解剖位置的特殊性，多年来手术切除率一直较低。近20年来，随着科技的发展、观念的改变，手术切除率已有显著提高。本文就HCC的可切除性评估作一综述。     

肝门胆管癌手术中的关键技术

正肝门胆管癌是胆管细胞恶性肿瘤的常见类型,而手术根治是其获得长期生存的唯一机会。但由于肝门区重要结构多、解剖复杂且肿瘤侵袭性强都给肿块的切除以及胆道重建带来了很大的难题。本文旨在按照肝门胆管癌手术中的关键步骤及结合国内外同行的经验来探讨肝门胆管癌的手术技巧。1解剖概要肝门胆管癌主要集中于肝门部即左右肝管交汇处至胆总管这一部,临床上其分型有多种,目前多采用Bismuth分型。肝门处三大管道位置一般是左右     

肝门部胆管癌的分型分期与可切除性评估

肝门部胆管癌是肝外胆道系统的恶性肿瘤.由于肿瘤常侵犯肝门部的肝动脉和门静脉,所以手术切除率较低、预后较差.近年来随着影像学技术的发展,不但肝门部胆管癌的诊断和可切除性评估准确性有了很大的提高,而且还提出了一些新的分型分期方法来对肿瘤进行评估.本文就肝门部胆管癌的分型分期与术前可切除性评估进展作一综述.     

肝门胆管癌的根治性切除

肝门胆管癌的根治性切除孙占祺（北京医科大学第一医院．１０００３４）肝门胆管癌并非罕见，近年来报道有增加趋势。该肿瘤预后差，治疗方法也在不断改进。姑息性引流仅用于确已证实不能手术切除的病例。Ｌａｕｎｏｉｓ于１９７９年成功地切除一组肝门胆管癌，平均获得旧...     

肝门胆管癌手术难点及对策

肝门胆管癌起病隐匿，早期不易诊断，就诊时多半已进入中晚期，且该肿瘤与肝门区重要结构密切相关，常合并神经、淋巴侵犯，因而手术切除相当困难，有时需联合肝叶、半肝、肝门部血管甚至胰头十二指肠切除，手术切 除的扩大化是当前的趋势[1，2]。为提高手术成功率，保证术后顺利恢复，应充分认识肝门胆管癌手术中的难点，并采取相应的对策。第一肝门的显露第一肝门结构复杂，各种管道相互交错。胆道肿瘤的浸润可使肝十二指肠韧带挛缩，病变深入肝门直至肝内，使术中暴露肝门困难，难以解剖肝门部的重要结构。在此情况下如何显露肝门和探查…     

肝门部胆管癌的手术疗效分析

正肝门部胆管癌(Hilar Cholangiocarcinoma)又称Klatskin瘤,是指起源于肝总管、左右一级肝管汇合部的肝外胆管上段的恶性肿瘤,占所有胆管癌的60～70%,预后较差~([1])。中国每年新诊断病例超过15000例~([2])。由于其位置特殊,因此很容易侵犯血管、神经、淋巴结、周围脂肪组织和肝实质。根治性外科手术切除是目前唯一可能治愈该病的方式,手术方式包括肝外胆管切除、肝脏部分切除、肝大部切除加淋巴结清扫甚至联合血管重建等手术方式。     

肝门胆管癌联合切肝的适应证

目的 提高对肝门胆管癌采用合理切肝手术的认识。方法 回顾性总结我院1988年以来的94例肝门胆管癌切除手术病例资料,将其分为切肝组（A组,35例）和非切肝组（B组,59例）对比两组的临床资料。结果 A组根治切除率为68．6％（24／35）,B组为35．6％（21／59）;1、2、3和5年生存率：A组分别为：84．19％,54．32％,39．84％,25．35％;B组为49．50％,20．42％,9．72％,3．24％。结论 肝门胆管癌采用合理的切肝手术,对提高生存率有显著影响。     

Liver transplantation for hilar cholangiocarcinoma

Hilar cholangiocarcinoma was accepted as an indication for liver transplantation at the beginning of the transplantation era. Owing to disappointing long-term results for this indication, and in parallel, encouraging results in patients with benign disease, hilar cholangiocarcinoma has generally not been accepted as an indication for liver transplantation in recent years. To improve results, more aggressive approaches have been used: “abdominal organ cluster transplantation” and “extended bile duct resection”, which lead to increased long-term survival rates. However, with improving results after conventional extrahepatic bile duct resection in combination with partial hepatectomy, extended procedures in combination with liver transplantation never became a real option in the treatment of hilar cholangiocarcinoma. However, new awareness of liver transplantation in the treatment of this cancer has been raised for patients with hilar cholangiocarcinoma in the context of underlying liver diseases such as primary sclerosing cholangitis, which preclude liver resection. Current results show increased survival figures, in particular in well-selected patients with early tumor stages. Further improvements in long-term survival may be reached with new adjuvant and neoadjuvant protocols. Patients with neoadjuvant radiochemotherapy show long-term results similar to those for liver transplantation for other indications. Also, photodynamic therapy and the use of new antiproliferative immunosuppressive agents may be an approach for further improvement of the long-term results. Currently, liver transplantation for the treatment of hilar cholangiocarcinoma should be restricted to centers with experience in the treatment of this cancer and should be taken into consideration in patients with contraindications to liver resection.     

Preoperative assessment of hilar cholangiocarcinoma by multidetector row computed tomography

Background/Purpose Hilar cholangiocarcinoma is the one of the most difficult carcinomas to diagnose because of the localization of the main tumor at the hepatic hilus, and because of the complex anatomy of the biliary, artery, and portal systems. To perform a curative operation, it is important to evaluate the extent of carcinoma and the resectability. Hilar cholangiocarcinoma often extends along the axis of the bile duct. Percutaneous transhepatic cholangiogaraphy (PTC) and/or endoscopic retrograde cholangiography (ERC) are usually performed to diagnose the extent of the hilar cholangiocarcinoma. However, computed tomography (CT) was thought not to be useful because its resolution is poor. Now that multidetector row CT (MDCT) and high-performance imaging systems are available, the diagnostic strategy for hilar cholangiocarcinoma has changed. Methods In this study, we analyzed the preoperative diagnostic imaging of 24 consecutive patients whose hilar cholangiocarcinoma was confirmed by histopathological examination. All patients were submitted to 16-channel MDCT, except for those with an allergy to iodine contrast medium. The data obtained from MDCT were analyzed and checked by both radiologists and surgeons, using multiplanar reconstruction (MPR) images. Results The accuracy of diagnosis of horizontal spreading was 80.9% and that of vertical spreading was 100%. However, the sensitivity for lymph node metastasis was insufficient. Based on the data from MDCT and other examinations, all patients underwent surgery. Curative operation was performed in 15 patients (62.5%). Conclusions Our results indicate that 16-channel MDCT is reliable for the diagnosis of hilar cholangiocarcinoma, especially prior to bile duct drainage. Thus, it is important to perform MDCT when patients with obstructive jaundice are encountered.     

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.     

Preoperative biliary drainage for hilar cholangiocarcinoma

Hilar cholangiocarcinomas grow slowly, and metastases occur late in the natural history. Surgical cure and long-term survival have been demonstrated, when resection margins are clear. Preoperative biliary drainage has been proposed as a way to improve liver function before surgery, and to reduce post-surgical complications. Percutaneous transhepatic biliary drainage (PTBD) with multiple drains was previously the preferred method for the preoperative relief of obstructive jaundice. However, the introduction of percutaneous transhepatic portal vein embolization (PTPE) and wider resection has changed preoperative drainage strategies. Drainage is currently performed only for liver lobes that will remain after resection, and for areas of segmental cholangitis. Endoscopic biliary drainage (EBD) is less invasive than PTBD. Among EBD techniques, endoscopic nasobiliary drainage (ENBD) is preferable to endoscopic biliary stenting (EBS), because secondary cholangitis (due to the retrograde flow of duodenal fluid into the biliary tree) does not occur. ENBD needs to be converted to PTBD in patients with segmental cholangitis, those with a prolonged need for drainage, or when the extent of longitudinal tumor extension is not sufficiently well characterized.     

术前减黄治疗肝门部胆管癌的临床研究

目的 探讨术前减黄治疗肝门部胆管癌的临床价值.方法 选取2005年1月-2015年12月在武汉大学人民医院接受手术治疗的肝门部胆管癌患者52例,按照术前是否行减黄治疗分为两组:减黄组24例,术前行减黄治疗;未减黄组28例,直接行手术治疗.比较两组患者手术时间,术中出血量,住院时间,围手术期肝功能变化情况,术后并发症发病率,肿瘤复发率,1、3、5年生存率等指标.采用SPSS 19.0软件进行统计学分析.对两组患者术后采用电话、门诊检查或住院复查等随访方式,随访时间8 ～ 60个月.结果 减黄组住院时间较未减黄组延长,差异有统计学意义(P＜0.05).两组手术时间、术中出血量、术后复发率、术后并发症发病率(包括胆瘘、出血、发热、胸腔积液、腹腔感染、伤口感染、肺部感染、肝功能衰竭等),差异无统计学意义(P＞0.05).减黄组减黄前丙氨酸氨基转移酶为(98.0±51.7) U/L、天门冬氨酸氨基转移酶为(94.2 ±44.2) U/L、总胆红素为(177.5 ±64.1) μmol/L、直接胆红素为(160.2 ±61.9) μmol/L;减黄后丙氨酸氨基转移酶为(71.2±13.8) U/L、天门冬氨酸氨基转移酶为(60.0±12.1) U/L、总胆红素为(93.5±20.7) μmol/L、直接胆红素为(76.3±18.1) μmol/L,差异有统计学意义(P＜0.05).减黄前后白蛋白差异无统计学意义(P＞0.05).减黄组随访患者21例,未减黄组随访患者25例,其他失访.两组患者术后1、3、5年生存率差异无统计学意义(P＞0.05).结论 术前减黄可在一定程度上改善肝门部胆管癌患者肝功能情况.但对于一般情况较好的患者,术前减黄并不能改善患者的预后,故不推荐常规术前减黄.     

腹腔镜在肝门部胆管癌切除术中的应用

目的探讨腹腔镜肝门部胆管癌切除术的可行性。方法2007年3月至2008年8月完成4例腹腔镜肝门部胆管癌手术,术中解剖肝十二指肠韧带,分离显露出胆总管、肝总动脉、门静脉,低位横断胆总管,将肝十二指肠韧带骨骼化,胆囊自肝床分离,切断显露的左右肝管,远端及近端切缘送冰冻病理,结果回报阴性。从肝固有韧带分离并切除肿瘤、胆囊及淋巴结。在消化道的重建步骤中,先进行左右肝管成型,然后将其与空肠施行Roux-en—Y吻合。总结病例资料及手术录像,进行分析。结果4例手术均在腹腔镜下顺利完成,无中转开腹,胆管切缘阴性,手术时间5．5～8．5h,平均6．4h,术中出血260～850ml,平均440ml,无围手术期并发症及死亡发生。结论由有丰富腹腔镜及肝胆外科经验的外科医师操作,腹腔镜肝门部胆管癌切除术在技术上是可行的。     

肝门部胆管癌细胞系高转移亚系的建立

目的 利用肝门部胆管癌原发病灶建立的细胞系接种裸鼠脾脏，筛选出高转移亚系。方法 将FRH-0201制成细胞悬液，接种7只BALB／C裸鼠脾脏。将转移的肿瘤行组织块培养，筛选出细胞亚系。FRH-A再次接种裸鼠，将转移瘤再次培养，筛选出细胞亚系FRH-B。观察细胞形态学、核型变化、肿瘤标志物、角蛋白染色及细胞生长曲线。结果 FRH-A及FRH-B细胞系为梭形和圆形细胞，生长旺盛。电镜显示典型恶性细胞特征。细胞倍增时间为21．8h，染色体众数19条，主流范围18～44条。细胞上清液CA125显著增高。细胞角蛋白染色阳性。FRH-A细胞再次接种裸小鼠，转移发生率100％，肿瘤生长迅速，转移发生快。结论 FRH-A及FRH-B细胞系来源于FRH-0201的高转移的亚系。     

肝门部胆管癌术中淋巴结清扫的研究现状

淋巴结转移是严重影响肝门部胆管癌(HCCA)患者手术预后的独立因素。淋巴结清扫是肝门胆管癌根治性切除术的重要内容,但关于术中淋巴结清扫的定义、范围及清扫数目仍存在较多争议。针对以上问题近年来国内外有较多研究,也有不少新观点。现有观点认为,术中常规对肝十二指肠韧带内、肝总动脉旁和胰头十二指肠后方的淋巴结(第12、8、13组)进行骨骼化清扫能够为HCCA患者带来明显的生存获益,但术中清扫腹腔干、腹主动脉及下腔静脉等周围淋巴结是否能为患者带来生存获益尚不明确;术中适当增加淋巴结清扫数目,不仅能够明显改善N0期患者的生存预后,还可提高阳性淋巴结的检出率,为疾病的分期获得足够的信息,但过度增加淋巴结清扫数目在实际操作中不仅难以实现,还可能导致术后并发症的发生率增加。因此,肝门部胆管癌术中淋巴结清扫相关问题尚需进一步研究。