精准右半肝联合肝尾状叶切除术治疗肝门部胆管癌

扩大肝切除可提高部分肝门部胆管癌患者的长期生存率.2013年5月川北医学院附属医院为1例Ⅲa型肝门部胆管癌患者运用精准肝脏外科的现代理念与临床精细的手术操作完成右半肝联合全尾状叶切除术.术中间断阻断第一肝门3次,手术历时8h,术中出血量约600 mL,患者于术后第14天出院.病理检查结果示右半肝肝门部胆管中高度分化腺癌,浸润管壁全层,切缘无癌残留.术后随访6个月未见肿瘤复发.该手术是在综合应用三维立体重建技术、肝脏储备功能评估、术中控制性低中心静脉压以及精细肝切除操作技术下进行,取得满意效果.     

围肝门切除联合左三区切除治疗Bismuth Ⅳ型肝门部胆管癌

对进展期肝门部胆管癌,多需要在围肝门切除的基础上联合肝叶切除[1].与联合左半肝切除相比,联合左三区切除可以获得更长的阴性胆管切缘和更高R0切除率[2],但考虑到预留肝叶体积较小且肝实质离断平面较难控制,此种术式被认为是12种定型肝切除术式中最难的一种,在文献中报告较少[3 ,4].近年来作者团队对该术式积累了一定的经...     

选择性肝门阻断法在右半肝切除中的可行性

正前言肝切除术中出血一直是困扰外科医生的重点和难点。出血量的多少直接关系着患者术后并发症发生率和死亡率,可通过血流阻断控制出血量。与间断血流阻断法相比,持续性血流阻断可引起更为严重的肝脏缺血再灌注损伤。选择性半肝血流阻断技术可以避免剩余肝脏不必要的的缺血再灌注的打击。正常的肝外门脉解剖走形比较固定,     

联合门静脉切除的肝门部胆管癌根治切除术

目的观察联合门静脉切除在肝门部胆管癌治疗中的作用，以进一步提高肝门胆管癌的治疗效果。方法总结1990年3月至2002年3月我院收治的78例肝门部胆管癌的临床资料。结果本组联合门静脉切除12例，其中门静脉分又部联合左半肝切除3例，门静脉主干切除6例，门静脉侧壁切除修补术3例；术后肝肠吻合13漏、肝功能衰竭死亡1例；其余11例病人术后随访6个月至6年，平均19个月，其中最长的1例已存活6年。结论联合门静脉切除可提高肝门部胆管癌的治愈切除率，改善术后病人预后。     

肝门胆管癌的外科争议及围肝门切除

肝门胆管癌（hilar cholangiocarcinoma,HC）发生率约占肝外胆道肿瘤的2/3、肝胆肿瘤的10%。因其位置隐蔽,经常直到患者出现黄疸或者明显腹痛等临床症状时,才能得到诊断。由于HC所处的肝门处解剖位置复杂,且致死率非常高,所以患者的总体生存率非常低。外科切除依旧是根治HC的唯一方式。在HC外科治疗方面,目前还存在许多争议,新的争议点也在不断出现,包括最近出现的联合肝脏分隔和门静脉结扎的二步肝切除术（associating liver partition and portal vein ligation for staged hepa-tectomy,ALPPS）是否可以取代经皮肝穿刺门静脉栓塞（portal vein embolization,PVE）。我们回顾并分析了术前是否行胆汁引流以及如何引流、如何增加剩余肝脏体积、如何确定手术切除范围等争议点。回顾这些年HC手术方式的变化,我们也在思考,如何在达到R0切除的基础上,合理减少肝脏损伤。因此,我们尝试探索围肝门切除在HC的应用价值,并试图阐述其适用范围。     

腹腔镜右半肝切除术

患者,男,49岁,因上腹部疼痛10余天入院。既往有乙型病毒性肝炎(简称乙肝)病史20余年,高血压病史5余年。查体:上腹部轻压痛,无反跳痛。腹部计算机断层扫描(computed tomography,CT):肝右后叶异常强化结节,肝细胞肝癌可能性大。甲胎蛋白:112.90μg/L。病毒系列示:乙肝表面抗原阳性、乙肝e抗原阳性和乙肝核心抗体阳性。Child-Pugh评分为6分。心肺功能良好,未见手术禁忌证。手术过程:患者取仰卧人字位,麻醉生效,导尿、消毒、铺巾、建立气腹,脐下戳卡置入腹腔镜,腹腔镜引导下置入其余各戳卡,并置入相关器械探查:腹腔内无腹水;胆囊大小形态正常;盆腔、大网膜未见异常;肝脏质地尚软,颜色正常,表面未见明显异常。     

腹腔镜右半肝切除术

腹腔镜右半肝切除术一般选择平卧位,常规采用"五孔法"操作。建立气腹后,常规腹腔镜探查。探查完毕后,依次离断肝圆韧带,镰状韧带,右三角韧带,右冠状韧带,肝肾韧带。解剖胆囊三角,切断胆囊动脉及胆囊管,切除胆囊。打开Glisson鞘,解剖出右肝胆管,并显露右肝动脉、右肝门静脉,均用丝线结扎。沿肝脏表面的缺血线,用超声刀切开肝脏实质,联合百克钳进行止血,其中较大的管道以Hem－o－lok夹闭,必要时缝扎处理。对于肝静脉分支及小静脉血管可采用连发钛夹夹闭。切除完毕后,将断面彻底止血。将标本装入一次性取物袋,取出标本。     

右半肝切除术前应用门静脉栓塞的前瞻性临床研究

由于残肝体积较小导致肝脏功能下降甚至衰竭仍是大范围肝切除术后常见的并发症。术前应用选择性门静脉栓塞(PVE)使预计残肝体积 (FL R)得到增加 ,确保足够的残肝以维持肝脏功能 ,可以提高肝切除术的安全性以及耐受性。作者根据严格的标准筛选了 5 5例原发性、转移性肝癌和肝内胆管癌的患者作为研究对象。术前通过螺旋 CT对每例患者预计残肝体积 ,即左半肝的体积进行计算 ;根据非病肝活检的结果将患者肝脏状态分为正常肝实质 (2 7例 )和慢性肝脏疾病 (2 8例 )。其中在两组中分别有 13例和 14例患者手术前在超声引导下于门静脉的右前支和…     

联合肝叶切除治疗肝门部胆管癌

目的研究联合肝叶切除术治疗肝门部胆管癌的手术方式、并发症及疗效。方法回顾性分析2000年1月至2011年3月67例肝门部胆管癌患者临床资料。联合左半肝切除23例,右半肝切除9例,尾状叶切除3例,右三叶、右前叶切除各4例,姑息性切除15例,内引流术4例,经皮肝穿刺胆道引流外引流术5例。结果死亡1例,手术并发症发生率37．31％（25／67）。联合肝叶切除组术后中位生存时间为31．1个月,高于姑息性切除组（15．8个月）。联合肝叶切除组的1、3、5年存活率为78．5％、48．3％和29％,姑息性切除组的1、3、5年存活率为43．5％、6．8％、0。术后随访率67．16％（45／67）。结论肝门部胆管癌应积极手术切除治疗,对无明显手术禁忌证的患者行包括肿瘤切除的联合肝叶切除的扩大根治术可延长患者存活期;围手术期正确处理是减少术后并发症,提高患者生活质量和延长存活期的关键。     

Complications of hepatectomy for hilar cholangiocarcinoma

We retrospectively reviewed postoperative complications in 105 patients with hilar cholangiocarcinoma who underwent hepatectomy at Nagoya University Hospital from January 1990 through March 1999. Of the 105 subjects, 97 (92.4%) underwent resection of two or more Healey's segments of the liver. Combined portal vein resection was performed in 33 (31.4%) patients and pancreatoduodenectomy in 10 (9.5%). Twenty (19.0%) patients had no postoperative complications, another 39 (37.1%) patients had minor complication(s) only, and the remaining 46 (43.8%) developed major complication(s). The morbidity rate reached as high as 81.0%. Major complications required relaparotomy in 11 (10.5%) patients. Of the 46 patients with major complication(s) 36 recovered; the remaining 10 patients died of liver failure with other organ failure(s) or of intraabdominal bleeding 12, 14, 18, 21, 57, 75, 75, 87, 93, or 134 days after surgery. Thus the 30-day mortality was 3.8% and the overall mortality 9.5%. Pleural effusion was the most frequent complication found in 66 (62.9%) patients, followed by wound sepsis in 39 (37.1%), and then liver failure in 29 (27.6%). Liver failure developed in 16.7% of 48 patients with less than 50% liver resection and in 36.8% of 57 patients with 50% or more resection (P < 0.05). Other organ failures, including renal, respiratory, gastrointestinal, and hematologic failures, developed as a sign of multiple organ failure following liver failure in most patients or preceding liver failure in a few patients. None of the six patients with four or more organ failures survived. Hepatectomy for hilar cholangiocarcinoma is risky owing to impaired hepatic functional reserve in jaundiced patients and the technical difficulty associated with hepatobiliary resection. Our goal is to reduce mortality to less than 5% while keeping a high resectability rate (above 80%).     

联合肝叶切除及区域淋巴清扫治疗肝门部胆管癌的初步观察

目的:对联合肝叶切除及肝门区域淋巴清扫治疗肝门部胆管癌的实际效果作初步观察。方法:回顾性分析1998年至2005年间86例肝门部胆管癌病人根治性切除的临床与随访资料。结果:全组男58例,女28例,平均年龄(51.0±9.4)岁。均行骨骼化淋巴清扫,根据是否附加患侧半肝和(或)尾状叶切除分为肝切除组(53例)和未切肝组(33例)。全组获R0根治34例,术后疗效明显优于非R0根治者。肝切除组各种并发症发生率明显高于未切肝组,但术后生存期无明显差异。肝门部胆管癌淋巴结转移率较高(54.7%),淋巴结转移与否与术后疗效明显相关。结论:肝叶切除及区域淋巴清扫是提高肝门部胆管癌根治性切除率的重要手段,但是否能够达到根治性切除还有其他影响因素,应审慎决定是否施行肝叶切除。肝门部胆管癌有较高的淋巴结转移率,骨骼化淋巴清扫应成为操作规范,但何谓彻底的淋巴清扫仍待界定。     

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.     

Recent advance in the treatment of hilar cholangiocarcinoma: hepatectomy with vascular resection

Radical surgical resection has been revealed to be the only hope of cure for the patient with hilar cholangiocarcinoma. Therefore, major efforts have been made to increase the resection rate by surgeons employing combined hepatic resection and vascular resection of the portal vein and the hepatic artery. Especially, the technical feasibility and surgical safety of hepatic resection with combined portal vein resection have recently been reported by several authors. On the other hand, there have been few reports of combined hepatic artery resection in hilar cholangiocarcinoma. There are fears that combined vascular resection with extended hepatectomy for hilar cholangiocarcinoma may lead to high surgical morbidity and mortality. Herein, we describe the results of aggressive surgical approaches in our series, and we also review the outcomes of hepatic resection with combined vascular resection in the previously reported literature.     

Anterior approach for right hepatectomy for hilar cholangiocarcinoma

Background/Purpose. Right hepatectomy is indicated for hilar cholangiocarcinoma, but mobilization of the right lobe could be difficult when perihepatic adhesion develops in response to repeated cholangitis and forceful mobilization may disseminate bacteria if the obstructed biliary tract contains pus. We encountered a patient who died from postoperative sepsis and multiorgan failure. Methods. To circumvent such a difficulty, we employed the anterior approach right hepatectomy in a second patient with hilar cholangiocarcinoma. In this patient, liver transection and division of the hepatic vein were performed before mobilization of the right lobe. Results. The second patient recovered uneventfully. Conclusion. The anterior approach (utilizing the no-touch technique) may be a preferred procedure for right hepatectomy for hilar cholangiocarcinoma.     

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.     

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。