肝外胆道癌830例临床分析

作者总结并分析了４０年来收治的肝外胆道肿瘤８３０例,其中胆囊癌６０１例,胆管癌２２９例。结果表明：肝外胆道癌占同期肝外胆道疾病患者的６．７７％;胆囊癌占肝外胆道癌的７２．４％,平均年龄为５６．６岁,男女比例为１∶２．５,手术率为６５．１％,肿瘤切除率为２９．４％;胆管癌占肝外胆道肿瘤的２７．６％,平均年龄为５６．４岁,男女比例为１．５∶１,手术率为６６．４％,肿瘤切除率为２０．４％。作者在对不同时间段进行分析时发现：胆囊癌及胆管癌的发病率均有上升趋势;肿瘤切除率亦有升高。     

DPC4蛋白在不同部位胆道恶性肿瘤中的缺失表达

目的探讨DPC4蛋白的缺失表达与胆道恶性肿瘤发病机制的关系. 方法我们通过免疫组织化学法检测了71例原发性胆道恶性肿瘤中DPC4蛋白的表达,其中包括38例胆总管癌,18例胆囊癌,15例肝门部胆管癌.另外,胆总管癌按是否伴远处转移分为转移组(27例)和非转移组(11例). 结果 DPC4蛋白的缺失表达率在胆总管癌中为47.3%,在胆囊癌中为11%,在肝门部胆管癌中为13%.胆总管癌中的DPC4蛋白的缺失表达率与胆囊癌中的和肝门部胆管癌中的相比差异有极显著性(P<0.01).在胆总管癌转移组中DPC4蛋白的缺失表达率为48.1%,在非转移组为45.4%(P>0.05). 结论 DPC4基因的失活与胆道恶性肿瘤的发生关系密切,且其在不同部位的胆道恶性肿瘤中失活率差异较大,但与胆总管癌的远处转移关系不明显.     

胆道肿瘤的影像学评价

胆道肿瘤包括胆囊和胆管的肿瘤,胆囊良性肿瘤有腺瘤、纤维瘤和脂肪瘤、临床发生率不高;胆囊癌是胆囊常见的恶性肿瘤,约占胆道肿瘤的2/3.胆管肿瘤多为恶性,约占胆道肿瘤的1/3,根据肿瘤发生的部位不同,胆管癌可分为肝内胆管癌和肝外胆管癌,后者即通常所指的胆管癌,包括肝门区至胆总管下端的恶性肿瘤,一般又分为上、中、下段胆管癌.上段胆管癌是指发生于肝门部的肿瘤,又称Klatskin瘤,占肝外胆管癌的50%～75%.     

原发性胆囊癌601例临床分析

目的 对原发性胆囊癌的临床特点，早期诊断及外科治疗进行总结分析。方法 1965～1995年．四十年来601例原发性胆囊癌的临床回顾研究。结果 601例胆囊癌占同期胆道癌的72．4％(601／830)。平均年龄56．55岁．男女比例为1：2．54。胆囊癌的病理类型以腺癌居多(96．2％)；胆囊癌的手术率及切除率分别为65．1%(391／601)和29．4%(115／601)。结论 近年来胆囊癌发病率有增高趋势．胆囊癌的手术率及切除率虽有所提高．但早期诊断率仍低．早期手术切除率低，晚期手术疗效差。     

肝门部癌切除的门静脉处理

肝门部癌无论是原发于肝门或侵犯到该部位,手术切除率均很低,主要原因是肿瘤侵犯大血管,特别是门静脉受累。作者对肝门部癌侵犯门静脉患者采用肿物切除、右侧肝三叶切除及门静脉切除,从而提高了切除率。作者对68例胆管癌包括胆囊癌患者中的31例行切除手术,切除率为45.6%,其中8例行右侧肝三叶切除和门静脉汇合处切除术,包括肝内胆管癌3例,上段胆管癌2例、胆囊癌3例。术中证实肿瘤均广泛     

改善胆道恶性肿瘤切除后的生存期

在美国每年约诊断胆道恶性肿瘤 70 0 0余例 ,预后不佳 ,不足半数的肿瘤能予切除。作者分析近期放射学和腹腔镜检以改善肿瘤分期、手术彻底切除病灶及放化疗能否改善生存率。Wisconsin医学院于 1990～2 0 0 1年共治疗 14 0例胆道恶性肿瘤 ,其中胆管癌 111例 (肝内 2 2 %、肝门周围 6 5 %、远端胆管 13% )和胆囊癌 2 9例。 86例进行了手术探查 (肝内胆管癌 5 8%、肝门周围癌 5 7%、远端胆管癌 6 7%和胆囊癌 72 % ) ,其中 4 4%进行了手术切除 (肝内胆管癌 6 4%、肝门周围4 1%、远端胆管癌 70 %、胆囊癌 5 2 % )。 2 / 3病例均放置了肝内或内镜…     

胆道癌诊治的若干问题

由于胆道癌发病率有所上升,为此中美合作进行上海市胆道癌临床流行病学调查,1997～2001年间收集658例胆道癌新病例资料,包括胆囊癌390例、肝外胆管癌(以下简称胆管癌)195例和壶腹癌73例。根据收集的临床资料,本文讨论胆道癌诊断和治疗上应注意的若干问题。及早发现胆囊癌资料显     

肝内胆管结石合并肝胆管癌32例诊治分析

目的 探讨肝内胆管结石合并肝胆管癌的临床特点和诊治经验。方法 对1993-2007年间华中科技大学同济医学院附属同济医院肝胆胰外科研究所收治的32例肝内胆管结石并发肝胆管癌病例的临床资料进行回顾性分析。结果 32例肝胆管癌占同期肝内胆管结石病人的1.9%,术前确诊率为59 .4%（19/32）。其中周围型胆管癌占43.8%（14/32）,肝门部胆管癌占50%（16/32）。肿瘤根治性切除率为31.3%（10/32）,姑息性手术46.9%（15/32）。有随访资料的28例中,根治组平均存活时间22个月,姑息手术组平均存活9个月。结论 肝内胆管结石造成的胆管系统内慢性炎症环境可能是诱发胆管癌的重要原因。对于有长期肝内胆管结石病史以及胆道手术史的病人,必须警惕并发肝胆管癌的可能。该病的早期诊断和根治性切除率低,预后差。     

survivin和VEGF在原发性胆囊癌中表达的相关性及临床价值探讨

胆道恶性肿瘤包括胆囊癌、肝外胆管癌和壶腹部癌，其中胆囊癌约占2／3。我们运用免疫组化方法对39例胆囊癌及其癌旁组织、12例胆囊腺瘤性息肉组织中进行survivin、VEGF检测，研究其表达与胆囊癌发生、发展的关系。     

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总体而言 ,肝胆管肿瘤合并胆道外科急症的情况在临床上并不常见 ,主要是肿瘤合并结石或肿瘤本身阻塞胆道引起的化脓性感染。65 %～ 80 %的肝内胆管癌合并肝内胆管结石。台湾长庚纪念医院报道[1 ] 10 2例合并结石的肝内胆管癌 ,以急性肝胆管炎症状就诊的病例占 2 /3。Caroli病有 7%～ 10 %继发恶变[2 ] ,这类病人的主要临床表现依然是反复发作的急性肝胆管炎。肝门部和中、下段胆管癌合并胆道外科急症的情形相对少见 ,而在胆囊癌则时常发生 ,因为 80 %～90 %的胆囊癌合并胆囊结石[3] 。我院一组 76例胆囊癌 ,11%首先表现为急性胆囊炎。肝癌…     

肝外胆道肿瘤外科治疗远期疗效的评析(附139例随访资料)

目的 探讨胆道肿瘤的临床特征、治疗方法对远期生存率的影响，总结胆道肿瘤的诊治经验。方法 对1992年1月至2000年7月收治的139例胆道肿瘤（胆囊癌88例，胆管癌51例）的临床及随访资料进行回顾分析。应用SPSS10．0统计软件包进行统计学处理。结果 88例胆囊癌的总体5年生存率为5．22％，51例胆管癌的总体5年生存率为21．64％。根治切除组的1、3、5年生存率与姑息切除组、剖腹探查组、非手术组相比均有显著性差异（P＜0．01），而姑息切除组、剖腹探查组、非手术组间的生存率无显著性差异（P＞0．05）。多因素分析显示组织学分级、TNM分期及治疗方法与预后显著相关。结论 胆道肿瘤的远期疗效仍无显著改善；扩大根治术可望改善其预后，但需慎重选择病人；提高远期疗效的重点仍应放在肿瘤的早期诊治上。     

Immunohistochemical Study of DPC4 and p53 Proteins in Gallbladder and Bile Duct Cancers

Gallbladder and bile duct carcinomas belong to the family of biliary tract tumors, but they demonstrate different clinical behavior. We evaluated a series of biliary tract carcinomas to determine whether they also had genotypic differences by analysis of the tumor suppressor genes DPC4 and p53. Twenty-one gallbladder cancers, 20 intrahepatic bile duct carcinomas, and 10 extrahepatic bile duct carcinomas were retrieved from the surgical pathology files of Kaohsiung Medical University Hospital. Sections were immunostained with monoclonal antibodies to the DPC4 and P53 proteins. Statistical differences between gallbladder cancer and bile duct carcinomas were determined using chi2 analysis or the Fisher's exact test, when appropriate. Two of the 21 gallbladder cancers (9.5%), 7 of the 20 intrahepatic bile duct carcinomas (35%), and five of the 10 extrahepatic bile duct carcinomas (50%) were negatively labeled for DPC4. The differences were significant between gallbladder carcinoma and both intrahepatic bile duct carcinomas (p = 0.023) and extrahepatic bile duct carcinomas (p = 0.012). A higher frequency of P53 overexpression was found in gallbladder cancers (61.9%) than in intrahepatic bile duct carcinomas (26.3%) (p = 0.024). This study suggests that the DPC4 gene may play a limited role in gallbladder carcinoma; however, p53 gene mutation is more frequently found in gallbladder cancers. In contrast, DPC4 deletion may be more common in bile duct carcinomas, especially in those arising from the extrahepatic bile duct. These findings support the concept that gallbladder and bile duct carcinomas are different tumors with differing etiologies and tumorigenesis.     

Status of surgical treatment of biliary tract cancer

Complete surgical resection of biliary tract carcinoma remains the best treatment. The Japanese Society of Biliary Surgery has organized a registry project and established a classification of biliary tract carcinoma. We report here the status of biliary surgery in Japan. For hilar bile duct carcinoma, major hepatectomy is needed to increase the resection rate, and total caudate lobectomy is required for curative resection. The 5-year survival rate was 39.1%. Middle and distal bile duct carcinomas were treated with pancreatoduodenectomy (PD) or pylorus-preserving PD (PPPD) or bile duct resection alone. The 5-year survival rate was 44.0%. The treatment of gallbladder carcinoma with pT1 lesions is cholecystectomy. The treatment of pT2 lesions is extended cholecystectomy or various hepatectomy with or without extrahepatic bile duct resection along with lymphadenectomy. Treatment of pT3 and pT4 lesions includes hepatectomy with or without bile duct resection, combined with vascular resection, extended lymphadenectomy, and autonomic nerve dissection. Several groups in Japan have performed hepatopancreatoduodenectomy. The 5-year survival rate of pT1, pT2, pT3, and pT4 were 93.7, 65.1, 27.3, and 13.8%. PD or PPPD is the standard operation for carcinoma of the papilla of Vater. The 5-year survival rate was 57.5%.     

Extrahepatische distale Gallenwegskarzinome

Malignancies of the biliary tree are classified into three groups according to location: intrahepatic, central (perihilar), and distal. Of all cholangiocarcinomas, 25% are located distally and can be subdivided into middle and lower bile duct carcinomas. Surgical approaches for achieving tumor-free resection margins (R0) are directly associated with the origin of the tumor. Intrahepatic and central cancers usually must be treated by liver surgery, whereas the majority of distal cholangiocarcinomas require pancreaticoduodenectomy. In case of a small, middle bile duct carcinoma, exclusive extrahepatic bile duct resection without pancreatic resection can be adequate. Five-year survival after radical resection is about 25%. Cancer of the distal bile duct has to be distinguished from ductal adenocarcinoma of the pancreas and carcinoma of the ampulla of Vater. Curative surgery is possible if the tumor is diagnosed early and radical resection is feasible. In this context, the role of an extended lymph node dissection remains unclear. To improve survival, future studies are needed to evaluate the role of novel adjuvant strategies (i.e., gemcitabine, capecitabine).     

Clinical problems in the surgical treatment of pancreaticobiliary maljunction

The results of surgical treatment of pancreaticobiliary maljunction at our department are described. The 67 patients who underwent surgery for this disease were divided by age into an adult group (45 patients, aged 16 years and over) and a pediatric group (22 patients, aged less than 16 years). The incidence of concomitant carcinoma before surgery and the incidence and severity of postoperative cholangitis were compared between these two groups. In addition, the cell proliferating activity of the biliary tract epithelium in cancer-free patients was compared between the two groups, using the proliferating cell nuclear antigen labeling index (PCNA LI). Ten patients (all adults) were diagnosed with cancer (gallbladder carcinoma in 7 and bile duct carcinoma in 3) before surgery. The surgical techniques used for reconstruction in the cancer-free patients were: in the adult group, hepaticoduodenostomy in 9 patients, Roux-en-Y hepaticojejunostomy in 17, jejunal interposition in 8, and another technique in 1. In the pediatric group, hepatico-duodenostomy was performed in 17 patients. Roux-en-Y hepaticojejunostomy in 3, and jejunal interposition in 2. Postoperative cholangitis occurred in 6 adults (including 2 with severe form) and 1 child (mild case). The PCNA LI of the biliary tract epithelium was high compared to control findings in the biliary tract epithelium of 10 adult patients without pancreaticobiliary maljunction. In the adult group with dilated extrahepatic bile ducts (n=10 examined) this index was 11.4% for the bile duct epithelium (control, 1.5%) and 12.7% for the gallbladder epithelium (control, 1.4%). In the adult group with non-dilated extrahepatic bile ducts (n=5 examined) it was 5.9% for the bile duct epithelium and 13.1% for the gallbladder epithelium. In the pediatric group (n=10 with extrahepatic bile duct dilatation) it was 7.5% for the bile duct and 9.7% for the gallbladder epithelium. (Differences from control values were all significant.) These results suggest that surgery for this disease should be performed as early as possible and that extrahepatic bile duct excision and biliary reconstruction should be performed whether or not extrahepatic bile ducts are dilated.     

Clinical and pathological features of primary carcinoma of the cystic duct

Background  According to Farrar’s criteria, a tumor restricted to the cystic duct is defined as cystic duct carcinoma, but this definition excludes advanced carcinoma originating from the cystic duct. Patients and methods  For the purpose of this study, primary cystic duct carcinoma was defined as a tumor originating from the cystic duct. We investigated the clinicopathological features of 15 cystic duct carcinomas, including 13 that did not fit Farrar’s criteria, and compared them with those of 52 cases of gallbladder carcinoma and 161 cases of extrahepatic bile duct carcinoma. Results  The incidence of primary cystic duct carcinoma was 6.6% among all malignant biliary tumors. The main symptom was jaundice in 67% of cases. The operative procedures employed ranged from cholecystectomy to hepatopancreatoduodenectomy. The cases of cystic duct carcinoma and bile duct carcinoma showed a high frequency of perineural infiltration. The overall 5-year survival rate of the 15 patients was 40%. Conclusion  Patients with advanced cystic duct carcinoma show a high frequency of jaundice and perineural infiltration. Our data suggest that cystic duct carcinoma may be considered a distinct subgroup of gallbladder carcinoma. Radical surgery is necessary for potentially curative resection in patients with advanced cystic duct carcinoma.     

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。     

Appraisal of surgical treatment for pT2 gallbladder carcinomas

This retrospective study was designed to appraise the surgical procedures for pT2 gallbladder (GB) carcinomas. Twenty patients with pT2 GB carcinomas underwent surgical resection. Hepatectomy of segments 4b and 5 was performed in 19 patients, and an extended right hepatic lobectomy was performed in 1. The extrahepatic bile duct was preserved in 8 patients in whom the disease was limited to the GB fundus and/or body. Regional lymphadenectomy was performed in 18 patients. A separate radical second operation was performed in 8 patients after cholecystectomy. Final pathological staging was stage IB in 15 patients, IIB in 4, and IV in 1. Overall 5-year survival rate in those 20 patients was 77% without operative deaths. The 5-year survival rate in 5 patients with nodal metastasis and in 8 patients without extrahepatic biliary resection was 80% and 100%, respectively. A separate radical second operation in 8 patients yielded 75% survival after 5 years. Perineural invasion as a prognostic determinant was closely associated with tumor extending to the neck or the cystic duct. Partial hepatectomy, usually with extrahepatic biliary resection and regional lymphadenectomy, was appropriate as a standard radical operation for pT2 GB carcinoma, but preservation of extrahepatic bile duct is advocated for disease limited to the GB fundus and/or body. Radical second operation enhanced the chance for cure in patients with pT2 GB carcinoma.This International Society of Surgery/Société Internationale de Chirugie (ISS/SIC) article was presented at the 39th World Congress of Surgery International Surgical Week (ISW01), Brussels, Belgium, August 26–30, 2001.     

Preferable operative age of choledochal dilation types to prevent patients with pancreaticobiliary maljunction from developing biliary tract carcinogenesis

BACKGROUND: Pancreaticobiliary maljunction (PBM), which frequently accompanies choledochal dilation, is a high risk factor for biliary tract (gallbladder, bile duct) carcinoma because of the continuous reflux of pancreatic juice into the biliary tract. The aim of this study was to clarify the preferable operative age in PBM patients for the prevention of biliary tract carcinogenesis, with reference to the dilation types of bile ducts. METHODS: There were 165 PBM patients in total studied, including 92 pediatric patients (< or =15 y) (cystic, 63; spindle-like, 29; nondilation, 0) and 73 adult patients (>15 y) (cystic, 45; spindle-like, 18; nondilation, 10) who underwent operative excision of extrahepatic bile ducts or cholecystectomy. We investigated incidence by age of biliary tract malignancies and the risk according to types of dilation. RESULTS: In the pediatric group, no carcinoma case could be found preoperatively or postoperatively (mean follow-up period, 11.7 y). In the adult group, bile duct carcinomas could be detected in 6 cases of a cystic type (6 of 45; 13.3%) (3 preoperative, 3 postoperative). Among the bile duct carcinoma cases, the youngest patient was a 21-year-old woman who had undergone excision of an extrahepatic bile duct 3 years previously. Gallbladder carcinomas were detected in 16 patients: 3 of 45 cystic (6.7%), 6 of 18 spindle-like (33.3%), and 8 of 10 nondilation (80.0%), in whom the youngest patient was a 41-year-old woman with a spindle-like type. CONCLUSIONS: To prevent biliary tract carcinogenesis in PBM patients, cystic-dilated choledochus should be excised in childhood before the development to a precancerous stage. In spindle-like and nondilation types, cholecystectomy is absolutely necessary in early adulthood before age 40.