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.     

Major liver resection for hilar cholangiocarcinoma.

Between 1968 and 1984 liver resection with curative attempt was performed in 22 patients with hilar cholangiocarcinoma. Right lobectomy was performed in 4 patients, extended right lobectomy in 7, left lobectomy in 8, and excision of the median segment segment of the left lobe (segment IV) in 3. Bilio-enteric continuity was restored by hepatocholedochostomy in 17 patients and hepatojejunostomy in 4. (One patient had external transhepatic catheter drainage and no internal bile drainage.) Operative mortality rate was 27% and caused by excessive intraoperative bleeding, sepsis, or liver insufficiency. Postoperative complications occurred in 57% of patients surviving the operation and were due mainly to leakage from the hepatocholedochostomy. Median survival was 6 months, and one third of the patients survived 1 year. Three patients survived 10 years and were among the four patients in whom a tumor-free resection margin was obtained (one of them died in the postoperative phase). It is concluded that resection of hilar cholangiocarcinoma may give long-term survival if a free resection margin is obtained. The importance of a free resection margin indicates that surgery should be aggressive and include liver resection.     

Extent of liver resection for hilar cholangiocarcinoma

Background:

The extent of liver resection for hilar cholangiocarcinoma (HC) remains controversial despite extensive studies. The aim of this study was to determine the safety and efficacy of minor and major hepatectomy, selected by predetermined criteria in patients with HC.

Methods:

From 2000 to 2007, 187 patients with HC were studied prospectively; 138 patients underwent resection with curative intent. Minor hepatectomy was performed in 93 patients with Bismuth–Corlette type I, II or III HC without hepatic arterial or portal venous invasion, and major hepatectomy in 45 patients with type III HC with hepatic arterial or portal venous invasion, or type IV HC.

Results:

Overall mortality and morbidity rates were 0 and 29·7 per cent respectively, and the bile leak rate was 1·4 per cent. Actuarial 1‐, 3‐ and 5‐year survival rates were 87, 54 and 34 per cent respectively in the minor liver resection group, and 80, 42 and 27 per cent for major resection (P = 0·300).

Conclusion:

Minor liver resection for HC, selected by predetermined criteria, had good results. Major liver resection, which had a higher operative morbidity rate than minor resection, should be reserved for Bismuth–Corlette type III HC with vascular invasion, or type IV HC. Copyright © 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Surgical resection for hilar cholangiocarcinoma

A retrospective analysis of 62 patients who underwent resection for hilar cholangiocarcinoma performed between 1981–1994 was undertaken. Type I lesions and patients whose operations were performed less than 24 months prior to analysis were excluded, leaving a study cohort of 48 patients (27 male: 21 female, median age 66 years, range 23–86 years). Median post-operative stay was 20 days (8–60) with peri-operative mortality of 10.4%. Histopathological grading of paraffin sections of excised tumours was made, using standard criteria, into poor, moderate, and well differentiated lesions, and the three sub-groups were separately analysed. Patients with poorly differentiated lesions (n=16) had a median survival of 7 months (range 0–24), with 1-and 2-year survival of 19% and 0%, respectively. The median survival of patients with moderately differentiated tumours (n=20) was 27 months (range 0–84), with 1-, 2-, 3-, and 5-year survival of 70%, 55%, 35%, and 22%, respectively. Those with well differentiated carcinomas (n=12) fared better, with a median survival of 62 months (range 16–120) and 1-, 2-, 3-, and 5-year survival of 100%, 66%, 66%, and 58%, respectively. Differences in survival were highly significant atP<0.0001. Patients with poorly differentiated tumours would be best served by non-surgical intervention if this differentiation could be reliably made pre-operatively. Conversely, those with more favourable histological grading are potentially curable by an aggressive radical resection.     

Aggressive surgical resection for hilar cholangiocarcinoma

BACKGROUND: Surgical treatment of hilar cholangiocarcinoma remains a great challenge to surgeons because of its low resectability, poor survival, and high operative mortality and morbidity. METHODS: The medical and pathological records of 36 patients with a preoperative diagnosis of 'resectable' hilar cholangiocarcinoma operated on by us between January 1998 and December 2002 were studied. The clinical presentations, operative records, and pathology results were retrospectively reviewed. RESULTS: Twenty-six patients (72%) underwent resection with curative intent. Apart from resection of the extrahepatic biliary tree and porta hepatis lymph node dissection, 85% received concomitant en-bloc liver resection and 4% received ex situ liver resection and auto-transplantation. The margin of resection was negative (R0 resection) in 73% of patients, and microscopically positive (R1 resection) in the remaining 27%. The 30-day hospital mortality was 7.6%. Of the patients, 42% had major postoperative complications. The median survival was 20 months, with the longest survival 75 months. The 1-, 3- and 5-year actuarial overall survival rate after resection with curative intent was 77%, 31%, and 12%, respectively. The 1-, 3-, and 5-year actuarial overall survival after R0 resection was 84%, 42%, and 16%, respectively. Tumour recurrence occurred in 58% of patients. CONCLUSIONS: Aggressive surgery increases the resectability of hilar cholangiocarcinoma. R0 resection provides the only chance of long-term survival of these patients.     

手术切除治疗肝门部胆管癌

目的 总结肝门部胆管癌手术治疗的经验.方法 回顾性分析本院9年因肝门部胆管癌行手术切除的83例病人的临床资料和随访结果.结果 83例手术切除病人中行根治性切除（R0）31例,非根治切除52例（R1,R2）,术后出现并发症29例,死亡5例.根治性切除组中位生存期21.5个月,1、3、5年生存率分别为79.6%,43.3%和25.9%,明显优于非根治性切除组（P＜0.05），近5年本院根治性切除率达44.8%,中位生存期18.7个月,疗效明显提高（P＜0.05），结论 加强围手术期处理、术中行切缘冰冻病理检查、联合肝切除等可提高肝门部胆管癌根治性切除率、减少并发症和死亡率;根治性切除可更好延长病人生存期,使手术治疗肝门部胆管癌获得良好的疗效.     

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.     

肝门部胆管癌切除的影响因素探讨

目的探讨影响肝门部胆管癌切除的可能因素。方法对我院自2001年1月至2006年1月收治的68例肝门部胆管癌病例的临床资料进行回顾性分析。结果根据Bismuth分型,Ⅰ型26例,Ⅱ型13例,Ⅲ型18例,Ⅳ型11例。手术切除39例,手术切除率为57.4%,其中根治切除29例,姑息切除10例,附加肝叶切除术32例,发生并发症9例。结论肿瘤的Bismuth分型、肿瘤近端胆管长度、肝动脉和门静脉受累情况等是影响肝门部胆管癌切除的主要因素。熟练的肝门部外科技术,必要的肝切除有助于提高手术切除率。     

哑铃式肝门部胆管癌根治术

手术切除是目前治疗肝门部胆管癌最有效的手段,切除范围不足是术后肿瘤复发的主要因素之一.近年来国内外趋于实施扩大的根治性切除,能够提高远期生存率,但大范围肝叶切除的主要风险是术后发生肝功能衰竭.本文报道一种既保证足够的肝内外胆管切除范围、又最大限度地减少肝组织切除的肝门部胆管癌根治性切除术式.该术式的切除范围包括肝Ⅳb段、右肝蒂前部分肝Ⅴ段的肝组织,左右肝管、分叉部、肝外胆管及尾状叶(肝Ⅰ段),同时行肝门区血管骨髂化及至少包括第2站淋巴结的清扫.因所切除组织整体上形似哑铃状,我们称之为“哑铃”式肝门部胆管癌根治术.手术指征:(1) BisnuthⅡ型肝门部胆管癌,以及部分肿瘤局限于一级肝管内的Ⅲa、Ⅲb型肝门部胆管癌;(2)无门静脉分叉部或左右支受侵;(3)第3站淋巴结无转移;(4)无肝内或远处组织器官转移.本研究23例患者完成该术式,术前多数患者TBil＞ 300 μmol/L,均未行PTCD或胆管内支架引流.平均手术时间为355 min.术中平均出血量为350 ml.患者1、3年无瘤生存率分别为95.7％(22/23)和7/15.其结果表明:该术式适宜于我国目前条件下BismuthⅡ型肝门部胆管癌及部分肿瘤局限于一级肝管内的Ⅲa型或Ⅲb型的患者.     

In-continuity hepatic resection for advanced hilar cholangiocarcinoma

BACKGROUND: The purpose of this study was to examine outcomes of patients undergoing concomitant hepatectomy and bile duct excision for advanced Klatskin tumors. METHODS: Thirty-one patients, 16 men and 15 women, with an average age of 64 years, underwent concomitant biliary and hepatic resections for Klatskin tumors. Outcomes, including complications and survival, are reported. RESULTS: Fifteen patients had postoperative courses free of complications. Sixteen patients experienced a total of 50 complications; 13 patients experienced 1 or more major complications (including hemorrhage [n = 1], pneumonia [n = 5], intra-abdominal abscess [n = 8], hepatic failure [n = 3], and myocardial infarction [n = 2]). Five patients died perioperatively, 1 from adult respiratory distress syndrome and 4 from multisystem organ failure precipitated by hepatic failure. One-, 3-, and 5-year survival after resection was 69%, 33%, and 26%, respectively. American Joint Committee on Cancer stage and margin status did not impact long-term survival after resection. CONCLUSIONS: Concomitant hepatic and biliary resections for Klatskin tumors carry relatively high risk but offer hope for long-term survival. This study supports in-continuity hepatectomy and extrahepatic biliary resection for advanced Klatskin tumors even when microscopically negative margins cannot be obtained.     

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。     

肝门部胆管癌根治性切除手术的规范化问题

效果的报告相差较大.     

Surgery for hilar cholangiocarcinoma: feasibility and results of parenchyma-conserving liver resection

BACKGROUND/AIM: Major liver resection has improved the resectability rate of hilar cholangiocarcinomas, but morbidity and mortality may be significant. The aim of this study was to assess the value of parenchyma-conserving liver resection (resection of bile duct with liver segments I and IVb; PCLR) in hilar cholangiocarcinoma. METHODS: Retrospective analysis of prospectively collected data. Factors influencing survival following three types of operations were studied by univariate and multivariate analyses. The three types of operations were: (1) local resection of the bile duct alone (LR); (2) major liver resection (resection of three or more segments, hepatic resection; HR), and (3) PCLR. RESULTS: Forty-six patients (21 males, 25 females; age range 35-77 years, mean age 57, median age 57 years) underwent surgery. There were 11 LR, 12 HR, and 23 PCLR procedures. There were 3 deaths (mortality 6.5%). The mortality was higher following HR (3 out of 12; 25%) than following LR or PCLR (0 out of 34; p = 0.01). Survival was longer following curative resection (median 27 months) than after palliative resection (median 15 months; p = 0.001). Lymph nodal and perineural involvement were adverse factors on univariate, but not on multivariate analysis. PCLR produced better survival (median 29 months) as compared with LR (median 15 months) or HR (median 22.5 months; p < 0.01). CONCLUSIONS: PCLR is applicable to selected patients with Bismuth-Corlette type III disease without major vascular involvement and produces survival rates comparable to those of LR and HR. PCLR may help avoid major liver resections in some patients with hilar cholangiocarcinoma.     

Surgical resection techniques for locally advanced hilar cholangiocarcinoma

Background

Resection of perihilar cholangiocarcinoma involves major hepatectomy including caudate lobectomy. It is technically challenging because of the complex, intimate and variable relationship between biliary and vascular structures in the liver hilum. Resectability rates vary from 30 to 80 % and about one third of patients have microscopically involved margins. However, adequately performed resections provide 5-year survival of 30–40 % and are worth pursuing.

Purpose

Better understanding of anatomy, better imaging, improved surgical techniques and progress in perioperative care of these patients have pushed the limits of resection of these tumours. Many of the traditional indicators of inoperability such as bilateral involvement of second-order hepatic ducts, contralateral biliary and vascular involvement, and need for arterial resection have been overcome or are being challenged. This review discusses techniques that may increase margin-free resectability of Bismuth–Corlette type III and IV perihilar cholangiocarcinoma.

Conclusion

Advanced perihilar cholangiocarcinoma requires extended liver resection and often vascular resection, despite which the margin may be compromised in about one third of patients. Right sided tumours are likely to need right trisectionectomy and portal vein resection, best served by an en bloc hilar resection or Rex-recess approach. Left-sided tumours often involve contralateral blood vessels and require left trisegmentectomy with possible right portal vein or right hepatic artery reconstruction. These tumours are best tackled by hepatobiliary surgeons with experience in microvascular techniques. Salvage procedures when arterial reconstruction is not feasible are still under evaluation.     

肝门部胆管癌根治术中的门静脉切除与重建的体会

目的探索门静脉切除与重建在肝门部胆管癌扩大根治术中的价值。方法回顾性分析2003年1月至2009年12月收治的在行根治性手术同时,行联合门静脉切除重建和/或肝切除的扩大根治术的肝门部胆管癌10例的临床资料。结果全组获R0切除6例,R1切除4例。行门静脉壁部分切除修补4例中,术后病理检查未提示门静脉壁肿瘤侵犯2例。行门静脉主干切除重建6例中,联合肝叶切除术者4例,联合肝动脉切除重建病例2例。术后发生胆漏3例,出现肝动脉血栓形成1例,无门静脉血栓形成或吻合口狭窄,无术后肝功能衰竭和消化道出血。本组无围手术期死亡病例,平均住院时间(32.5±15.7)d。本组2003年至2008年完成手术的6例中,存活超过1年者4例,超过3年者2例,尚无存活5年者。2009年完成的4例中,3例尚存活。结论肝门部胆管癌联合肝叶切除和门静脉切除与重建的扩大根治术并不增加围手术期死亡率和并发症发生率。     

Prognostic factors after surgical resection for hilar cholangiocarcinoma

AIMS: To evaluate short and long-term results in 23 patients resected for hilar cholangiocarcinoma. METHODS: Between January 2001 and December 2003, 23 patients with hilar cholangiocarcinoma were resected and considered for retrospective analysis. Univariate and multivariate analysis were performed on several clinicopathological variables in order to evaluate the short-term results. Median follow-up was 11 months (interquartile range 2-20 months). RESULTS: A major liver resection was performed in 19 out of 23 patients (82%): a right hepatectomy extended to segment 4 in 5 patients and a left hepatectomy in 14 patients. Resection of the caudate lobe was performed in 7 patients (30%). No hospital mortality occurred. Overall morbidity rate was 43%. The 1-year survival rate was 63.2% with a median survival of 19 months. Tumor recurrence appeared in 12 patients (52%). Low preoperative albumin level (P=0.006), presence of positive resection margin (P=0.03) and T-stage (P=0.02) were found to be related to a worse median survival. On multivariate analysis, only the preoperative albumin level and the presence of positive margin were confirmed as independent prognostic factors. CONCLUSION: Aggressive surgical approach remains the only potentially curative therapy for the hilar cholangiocarcinoma. Low preoperative albumin level, presence of positive resection margin and T-stage resulted as factors influencing the prognosis after resection.