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.     

Portal vein resection and reconstruction prior to hepatic dissection during right hepatectomy and caudate lobectomy for hepatobiliary cancer

BACKGROUND: Hepatobiliary cancer invading the hilar bile duct often involves the portal bifurcation. Portal vein resection and reconstruction is usually performed after completion of the hepatectomy. This retrospective study assessed the safety and usefulness of portal vein reconstruction prior to hepatic dissection in right hepatectomy and caudate lobectomy plus biliary reconstruction, one of the common procedures for radical resection. METHODS: Clinical characteristics and perioperative results were compared in patients who underwent right hepatectomy and caudate lobectomy plus biliary reconstruction with (ten patients) and without (11 patients) portal reconstruction from September 1998 to March 2002. RESULTS: All ten portal vein reconstructions were completed successfully before hepatic dissection; the portal cross-clamp time ranged from 15 to 41 (median 22) min. Blood loss, blood transfusion during the operation, postoperative liver function, morbidity and length of hospital stay were similar in the two groups. No patient suffered postoperative hepatic failure or death. CONCLUSION: This study demonstrates that portal vein reconstruction does not increase the morbidity or mortality associated with right hepatectomy and caudate lobectomy with biliary reconstruction. This approach facilitates portal vein reconstruction for no-touch resection of hepatobiliary cancer invading the hilar bile duct.     

肝移植术后并发症的介入治疗

目的评价肝移植术后多种并发症的介入治疗。方法回顾性的分析肝移植术后出现各种并发症并进行介入治疗的82例患者,胆管病变62例;肝动脉病变8例;下腔静脉病变13例;肝静脉狭窄7例;门静脉病变9例。胆管并发症采用经T管置入引流管、经皮肝穿刺胆管行胆汁引流或球囊扩张术。球囊扩张成形术或(和)金属支架植入术处理血管狭窄的患者;局部溶栓治疗用于术后血管内血栓形成的病例。结果在胆管并发症患者中,41例经T管置入引流管,34例行经皮穿刺胆汁引流(PTBD),球囊扩张胆道成形术9例。3例肝动脉狭窄的患者接受了球囊扩张成形术或支架植入术,1例肝动脉形成血栓者行插管溶栓,效果良好。9例下腔静脉狭窄患者行支架植入术,1例接受了球囊扩张成形术。5例肝静脉狭窄患者接受了球囊扩张成形术或支架治疗。门静脉狭窄患者中6例接受支架治疗,1例门脉血栓形成行局部溶栓,治疗不满意。结论介入治疗是处理肝移植术后胆管和血管并发症不可或缺的临床治疗方法。     

Hilar cholangiocarcinoma

Surgical resection has been reported to be only hope for cure for the patients with hilar cholangiocarcinoma. Therefore, first of all, radical surgical resection should be considered to be a therapeutic option for hilar cholangiocarcinoma as much as possible. In preoperative staging for hilar cholangiocarcinoma, various extensive patterns of cancer such as the involvements of bile duct, portal vein, hepatic artery and lymph node etc, should be evaluated in each patient. As most patients are associated with obstructive jaundice at presentation, liver function has to be evaluated by appropriate tests for deciding the suitable surgical procedure. When the future remnant liver volume is less than 40% or severe liver functional damage exists or greater surgical stress is expected, preoperative portal vein embolization might have to be selected. On the other hand, if hilar cholangiocarcinoma involves limited region of the hilar bile duct confluence, parenchyma preserving hepatectomy such as S1 resection and S1 + S4 resection should be selected for avoiding the occurrence of liver failure. Combined portal vein resection should be done for the case of the cancer involvement of the portal vein without hesitation to improve the prognosis. However, hepatic artery resection and reconstruction in the involved case should be carefully performed only in severely selected cases. By using several useful pre-operative and intra-operative therapeutic modalities, hilar cholangiocarcinoma should be surgically resected with curative intent and without increasing surgical morbidity and mortality rates.     

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.     

Adenomyoma of the Common Hepatic Duct Mimicking Bile Duct Cancer: Report of a Case

We report an unusual case of adenomyoma of the common hepatic duct mimicking bile duct cancer. A 50-year-old woman was referred to our hospital for the investigation of general fatigue. Laboratory data showed abnormal liver test results and computed tomography showed a mass lesion in the hepatic hilum and dilatation of the intrahepatic bile ducts. These findings led to a preoperative diagnosis of hilar bile duct carcinoma, and we performed a left lobectomy with resection of the extrahepatic bile duct. Macroscopically, an elevated lesion was found in the common hepatic duct, which was confirmed histologically to be an adenomyoma. Bile duct strictures are rarely caused by benign tumors of the biliary tract, such as adenomyoma. Surgical resection of the bile duct should be considered for all bile duct strictures because it is often difficult to differentiate malignant from benign lesions in this location preoperatively, and malignant cells may be present in the lesion.     

Anatomy of the hepatic hilar area: the plate system

To surgically manage hilar bile duct carcinoma successfully, it is important to be familiar with the principal anatomical variations of the biliary and vascular components of the plate system in the hepatic hilar area, because all the variations in the bile ducts and vessels occur in the plate system. The plate system consists of bile ducts and blood vessels surrounded by a sheath. There are three plates in the hilar area: the hilar plate, the cystic plate, and the umbilical plate. The bile duct and blood vessel branches penetrate the plate system and form Glisson's capsule in all segments of the liver, except for the medial segment. The right hepatic duct is usually (in 53%–72% of individuals) formed by the union of the anterior segmental duct and the posterior segmental duct in the hilar area. However, three other variations have been found in which these segmental ducts do not form the right hepatic duct. Few anatomical variations have been identified in the left hepatic duct, but confusion arises because of the variations in the medial segment ducts (B4) which join the left hepatic duct at different sites. In 35.5% of individuals they join the hepatic duct in the vicinity of the hilar confluence (type I B4 anatomy), and in 64.5% of individuals they join the left hepatic duct some distance away from the confluence (type II B4 anatomy). Because B4 is very close to the hilar confluence in type I, hilar bile duct carcinoma can easily invade B4 and, for that reason, for curative resection of hilar bile duct carcinoma, resection of S4a (the inferior part of the medial segment) should be considered along with the resection of extrahepatic bile duct and caudate lobe. Variations in the portal vein and hepatic artery are found in 16%–26% and 31%–33% of individuals, respectively. Because a considerable number of anatomical variations in the bile ducts and vessels persist in the hilar area, and the reported proportions of the different variations vary, it is necessary to have a good knowledge of the plate system and the variations in the bile ducts and blood vessels in the hilar area to perform safe and curative surgery for hilar bile duct carcinoma. Received: June 3, 2000 / Accepted: July 20, 2000     

Use of the hilar plate looping technique for bile duct dissection in living donor liver transplantation significantly reduces recipient biliary complications

Biliary complications remain a major cause of morbidity after liver transplantation, especially in living donor liver transplantation (LDLT). Maintaining adequate blood supply to the bile duct is important for the prevention of biliary complications. The objective of this study was to analyze the effects of different techniques for bile duct anastomosis on posttransplantation biliary complications. From August 2005 to August 2008, 121 liver transplantations were performed at our center. Among the total 121 liver transplant recipients, 68 patients underwent a LDLT using a right lobe graft and were enrolled in this study. We used classic dissection for the first 38 recipients and the hilar plate looping technique for the next 30 patients. The hilar plate looping technique involves the looping of the complete hilar plate and Glissonian sheath around the hepatic duct after full dissection of the right hepatic artery and portal vein. Biliary complications were defined as bilomas or strictures that developed within 6 months after transplantation and required surgical or radiological intervention. There were no significant demographic differences between the 2 groups. The incidence of complications was 15 (39.5%) for classic dissection and 3 (18.8%) for hilar plate looping. Furthermore, there were no biliary strictures in the hilar plate looping group, and there was a significant difference in the complication rate between the 2 groups (P = .011). In conclusion, the hilar plate looping technique during LDLT significantly reduces recipient biliary complications.     

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.     

Ⅲ型肝门部胆管癌的外科治疗（附35例分析）

目的总结Ⅲ型肝门部胆管癌的手术经验。方法回顾性分析我院1999年1月至2006年12月，行手术切除的35例Ⅲ型肝门部胆管癌的临床资料。Ⅲa型16例，行肝门部胆管切除8例，行联合右半肝＋右侧尾状叶切除7例，行联合右半肝＋尾状叶切除、门静脉分叉部切除主干左支吻合1例。Ⅲb型19例，行肝门部胆管切除8例，行联合左半肝＋左侧尾状叶切除9例，行联合左半肝＋尾状叶切除、门静脉分叉部切除主干右支吻合1例．行联合左半肝＋尾状叶切除、门静脉分叉部切除主干右支吻合、肝固有动脉分叉部切除主干右支吻合1例。结果本组32例获得随访，随访时间18～113个月。肝门部胆管切除病例术后病理根治性切除率为37．5％，联合肝叶切除病例术后病理根治性切除率73．7％，3例联合肝叶切除＋血管切除病例均获术后病理根治性切除。肝门部胆管切除术后并发症发生率为31．3％，联合肝叶切除组术后并发症发生率为31．6％。3例联合肝叶切除＋血管切除病例术后均无胆肠吻合口漏、肝断面坏死、胆漏等严重并发症。结论联合肝叶切除，必要时行受累分叉部血管切除重建，有益于提高Ⅲ型肝门部胆管癌的根治性切除率，且不增加术后并发症的发生率。     

Surgical anatomy of the bile ducts at the hepatic hilum as applied to living donor liver transplantation

OBJECTIVE: To evaluate anatomic variations of the biliary tree as applied to living donor liver transplantation. SUMMARY BACKGROUND DATA: Anatomic variability is the rule rather than the exception in liver surgery. However, few studies have focused on the anatomic variations of the biliary tree in living donor liver transplantation in relation to biliary reconstruction. METHODS: From November 1992 to June 2002, 165 patients underwent major hepatectomy with extrahepatic bile duct resection; right-sided hepatectomy in 110 patients and left-sided hepatectomy in 55. Confluence patterns of the intrahepatic bile ducts at the hepatic hilum in the surgical specimens were studied. RESULTS: Confluence patterns of the right intrahepatic bile ducts were classified into 7 types. The right hepatic duct was absent in 4 of the 7 types and in 29 (26%) of the 110 livers. Confluence patterns of the left intrahepatic bile ducts were classified into 4 types. The left hepatic duct was absent in 1 of the 4 types and in 1 (2%) of the 55 livers. CONCLUSIONS: In harvesting the right liver from a donor without a right hepatic duct, 2 or more bile duct stumps will be present in the plane of transection in the graft in 3 patterns based on their relation to the portal vein. Accurate knowledge of the variations in the hepatic confluence is essential for successful living donor liver transplantation.     

Extended liver resection for hilar cholangiocarcinoma

Liver resection for hilar cholangiocarcinoma should be designed for individual patients, based on both precise diagnosis of cancer extent and accurate evaluation of hepatic functional reserve. Therefore we have developed various types of hepatic segmentectomy. Combined caudate lobectomy is essential in every patient with separated hepatic confluence. So-called extensive hepatectomy, resection of 50% or more of the hepatic mass, includes right lobectomy and right or left trisegmentectomy. Right lobectomy with caudate lobectomy is indicated when the progression of cancer is predominant in the right anterior and posterior segmental bile ducts. The plane of liver transection is along the Cantlie line, and the left hepatic duct is divided just at the right side of the umbilical portion of the left portal vein. Right trisegmentectomy with caudate lobectomy is performed in carcinoma which involves the right hepatic ducts in continuity with the left medial segmental bile duct. The umbilical portion of the left portal vein is freed from the umbilical plate by dividing the small portal branches arising from the cranial side of the umbilical portion. Then the left lateral segmental bile ducts are exposed and divided at the left side of the umbilical portion of the left portal vein. Left trisegmentectomy with caudate lobectomy is suitable for carcinoma which involves the left intrahepatic bile duct in continuity with the right anterior segmental bile duct. Liver transection is advanced along the right portal fissure. The right posterior segmental bile duct is usually divided distal to the confluence of the inferior and superior branches.     

仅保留门静脉血供的肝门部胆管癌根治术

目的 探讨仅保留门静脉血供的肝门部胆管癌根治术的适应证和方法,以进一步提高肝门胆管癌的治疗效果.方法 对2006年7月至2007年12月收治的6例肝门部胆管癌,均采取左半肝切除、肝外胆管切除、肝动脉切除、右肝管空肠吻合术. 结果6例均顺利恢复,术后发生胆漏1例、无肝功能衰竭及围手术期死亡病例;术后随访10～23个月,均存活.结论 仅保留门静脉血供的肝门部胆管癌根治术在严格掌握适应证的前提下是可行的,可提高肝门部胆管癌的根治切除率,改善患者预后.     

Highly anatomically systematized hepatic resection with Glissonean sheath code transection at the hepatic hilus

We have developed a new method of hepatic resection, in which the cancer-bearing Glissonean code (G-code) branches are served using a hilar approach for an anatomically systematized resection. Since the hepatic artery, portal vein and bile duct are surrounded by connective tissue, the portal triad can be treated as a fibroid code both outside and inside the liver. Compared to the ramification pattern of the hepatic artery, portal vein and bile duct, that of the G-code is simpler. In all our surgical procedures of hepatic resections, the cancer bearing G-code branch is selectively cut using a hilar approach before the dissection of the parenchyma of the liver. We have experienced 168 cases of several types of hepatic resection for hepatocellular carcinoma. Only in three cases was it impossible to accomplish the transection of some third branches using a hilar approach.     

Combined vascular resection in operative resection for hilar cholangiocarcinoma: does it work or not?

BACKGROUND: It is still not clear how combined vascular resection affects the outcome of patients with hilar cholangiocarcinoma. Our aim was to evaluate implications of combined vascular resection in patients with hilar cholangiocarcinoma by analyzing the outcomes of all patients who underwent operative resection. METHODS: A total of 161 of 228 consecutive patients with hilar cholangiocarcinoma underwent bile duct resection with various types of hepatectomy (88%) and pancreaticoduodenectomy (4%). Combined vascular resection was carried out in 43 patients. Thirty-four patients had portal vein resection alone, 7 patients had both portal vein and hepatic artery resection, and 2 patients had right hepatic artery resection only. The outcomes were compared between the 3 groups: the portal vein resection alone (34), hepatic artery resection (9), and non-vascular resection (118). RESULTS: Histologically-positive tumor invasion to the portal vein beyond the adventitia was present in 80% of 44 patients undergoing combined portal vein resection. Operative mortality occurred in 11 (7%) patients. The survival rates of the non-vascular resection group were better than that of the portal vein resection alone and the hepatic artery resection groups: 1, 3, and 5 years after curative resection, 72%, 52%, and 41% versus 47%, 31%, and 25% (P < .05), and 17%, 0%, and 0% (P < .0001), respectively. Multivariate analysis showed 4 independent prognostic factors of adverse effect on survival after operation; operative curability, lymph node metastases, portal vein resection, and hepatic artery resection. CONCLUSIONS: Although both portal vein and hepatic artery resection are independent poor prognostic factors after curative operative resection of locally advanced hilar cholangiocarcinoma, portal vein resection is acceptable from an operative risk perspective and might improve the prognosis in the selected patients, however, combined hepatic artery resection can not be justified.     

Portal vein resection for hilar cholangiocarcinoma

Hilar cholangiocarcinoma remains a difficult challenge for the surgeon. Achieving negative surgical margins when resecting this relatively uncommon tumor is technically demanding as a result of the close proximity of the bile duct bifurcation to the vascular inflow of the liver. A recent advance in surgical treatment is the addition of portal vein resection to the procedure. Resection of the portal vein increases the number of patients offered a potentially curative approach but is technically more difficult and may increase the risk of the procedure. This study reviews the results of portal vein resection for hilar cholangiocarcinoma. Between 1998 and 2005, 60 patients underwent potentially curative resections of hilar cholangiocarcinoma. Mean patient age was 64 +/- 12 years (range, 24-85 years). Liver resections performed along with biliary resection included 49 trisegmentectomies (37 right, 12 left) and 10 lobectomies (8 left, 2 right). One patient had only the bile duct resected. Four patients also had simultaneous pancreaticoduodenectomy performed. Twenty-six patients required portal vein resection and reconstruction to achieve negative margins, 3 of which also required reconstruction of the hepatic artery. Operative mortality was 8 per cent with an overall complication rate of 40 per cent. Patients who underwent portal vein resection had an operative mortality of 4 per cent, which was not different from the 12 per cent mortality in patients who did not undergo portal vein resection (P = 0.39). There was no difference in actuarial patient survival between patients who underwent portal vein resection and those who did not (5-year survival 39 per cent vs. 41 per cent, P = not significant). Negative margins were achieved in 80 per cent of cases and were associated with improved survival (P < 0.01). Five-year actuarial survival in patients undergoing resection with negative margins was 45 per cent. There was no difference in margin status or long-term survival between those patients who underwent portal vein resection and those who did not. Only negative margin status was associated with improved survival by multivariate analysis. Portal vein resection for hilar cholangiocarcinoma is safe and allows a chance for long-term survival in otherwise unresectable patients.     

Xanthogranulomatous Inflammatory Strictures of Extrahepatic Biliary Tract: Presentation and Surgical Management

Background Xanthogranulomatous cholecystitis (XGC) is a benign, invasive variant of chronic cholecystitis. Invasion of common bile duct (CBD), termed as xanthogranulomatous choledochitis, may mimic malignancy. We describe clinico-pathological features and management of xanthogranulomatous inflammatory biliary strictures. Methods A review of a prospectively maintained database for XGC was performed. Results Out of 6,150 cholecystectomies performed, 620 patients had XGC (10% incidence). Four patients had biliary strictures with xanthogranulomatous choledochitis on final histology. All four patients presented with jaundice and history of cholangitis. Ultrasonography revealed gallstones and thick-walled gallbladder in all. Two patients had hilar strictures: one had mid-CBD stricture and one had a lower-CBD stricture with a dilated pancreatic duct. In all four patients, preoperative diagnosis of malignancy was entertained. Three patients underwent resection—CBD excision for mid-CBD stricture, pancreaticoduodenectomy for lower-end stricture, and right hepatectomy for hilar stricture with atrophy-hypertrophy complex. One patient with unresectable hilar stricture underwent hepaticojejunostomy. Conclusion Xanthogranulomatous choledochitis may be considered as one of the differential diagnosis in patients with biliary stricture especially in a geographical area with a high incidence of XGC, when a patient harbors gall stones and had thick-walled gall bladder on imaging. This stricture can be found anywhere in the biliary tree from hepatic hilum to the lower end. However, preoperative imaging and cytology are unreliable both in confirming the diagnosis or ruling out malignancy. Therefore, resection of the stricture should be attempted wherever feasible.     

High hilar dissection: new technique to reduce biliary complication in living donor liver transplantation.

Biliary complications after living donor liver transplantation (LDLT) continue to be problematic. For reducing the biliary complications, the authors applied an intrahepatic Glissonian approach to the recipient hepatectomy. We called this Glissonian dissection technique at the high hilar level high hilar dissection (HHD). In this study, we introduced this HHD technique and evaluated its outcome in 31 recipients of a living donor liver transplant (LDLT). With total occlusion of hepatoduodenal ligament Glissonia pedicles were divided at the intrahepatic level at the third level of pedicles or beyond. After portal vein and hepatic artery were isolated from the hepatoduodenal ligament, unused bile ducts and bleeding were controlled with continuous suture of the hilar plate. Single duct anastomosis was performed in about 21 and dual duct anastomosis in 10 recipients. Bile leakage of the biliary anastomosis did not occur. There were 6 biliary complications in five patients; 2 bile leaks from the cut liver surface and 4 biliary strictures of which one of unknown etiology. In none of the patients with biliary complications, conversion to a hepaticojejunostomy was necessary. This new HHD technique during recipient hepatectomy may contribute to reduce the biliary complications in duct-to-duct anastomosis by allowing a tension free anastomosis and preserving adequate blood supply to the bile duct. Moreover, it facilitates multiple ductal anastomoses without difficult surgical manipulation.     

Unusual causes of benign biliary strictures with cholangiographic features of cholangiocarcinoma

Focal strictures occurring at the hepatic duct confluence, or within the common hepatic duct or common bile duct in patients without a history of prior surgery in that region or stone disease, are usually thought to represent cholangiocarcinoma until proved otherwise. However, not uncommonly, patients undergo surgical exploration for a preoperative diagnosis of cholangiocarcinoma, based on the cholangiographic appearance of the lesion, only to find histologically that the stricture was benign in nature. Despite sophisticated radiographic, endoscopic, and histologic studies, it is often impossible before laparotomy to distinguish malignant from benign strictures when they have the characteristic radiographic appearance of cholangiocarcinoma. Even at the risk of overtreating some benign cases, most agree that aggressive surgical resection is the treatment of choice, given the serious consequences resulting from a failure to diagnose and adequately treat cholangiocarcinoma. Four patients who presented to our institution between February 1991 and June 2000 underwent laparotomy for a preoperative diagnosis of biliary tract malignancy based on clinical presentation and cholangiographic findings. The final pathology report in all patients showed marked fibrosis and inflammation of the biliary duct without evidence of malignancy. A review of the patient data and the relevant literature identified benign causes of focal extrahepatic biliary strictures associated with concomitant disease processes in two of the four patients. We present these cases and discuss the benign etiologies with emphasis on the role of surgery in both diagnosis and treatment.     

选择性胆管外引流在肝门部胆管癌根治性切除术中的应用

目的 观察选择性胆管外引流在肝门部胆管癌根治性切除术中的价值.方法 总结2000年1月至2008年1月收治的118例肝门部胆管癌的临床资料.结果 选择性胆管外引流后行手术治疗25例,其中右肝管引流12例,左肝管引流10例,左肝外叶胆管引流1例,右后叶胆管引流2例;腹腔广泛种植转移1例,左或右半肝及尾状叶切除22例,扩大左肝切除1例,扩大右肝切除1例;术后胆漏3例,肺部及腹腔感染各1例,围手术期肝功能衰竭死亡1例;其余24例病人术后随访3个月至5年,平均23个月,其中最长的1例已存活4年4个月.结论 选择性胆管外引流可以达到与全肝胆道外引流相似的改善肝功的目的 ,同时选择性胆管外引流也可以较安全的在肝门部胆管癌根治术予以应用.