肝门部胆管癌的外科治疗

肝门部胆管癌(Klatskin瘤)主要指左右肝管至肝总管的恶性肿瘤,占肝管癌的50％～58％,不包括肝内的胆管癌。肝管癌的外科治疗与其解剖关系非常密切,常因技术原因而显得困难,目前最有效的治疗仍然是切除肿瘤。 一、手术前治疗 1.护肝治疗:血清蛋白<30g/L直接影响围手术期病死率,通过适当治疗纠正低蛋白,贫血,增强手术耐受力。 2.减黄治疗:术前PTCD减黄可能带来引流管脱落,胆管炎,水电解质平衡紊乱,只引流了需要切除的一侧肝脏等问题,术前引流和不引流在围手术期病死率,并发症发生率和1、3、5年生存率均无差异。因此,只有行肝移植的病人在等待供肝     

根治性切除术治疗肝门部胆管癌临床意义的探讨

目的探讨肝门部胆管癌根治性切除的经验及临床意义。方法回顾性分析2002年至2005年收治的129例肝门部胆管癌患者临床资料,其中75例行根治性切除术。结果肿瘤切除联合行规则性左半肝切除25例,规则性右半肝切除15例,右三肝切除3例,左三叶切除5例,中肝叶切除19例;所有患者同时附加尾状叶切除手术和肝十二指肠韧带骨骼化清扫。根治性切除率为58．1％（75／129）。1、3年生存率分别为86．7％和37．3％。结论积极提高根治切除率是改善肝门部胆管癌预后的惟一有效方法,肝门部胆管癌根治性切除可以改善术后患者的预后。     

肝门部胆管癌治疗的进展

肝门部胆管癌由于所处位置的解剖复杂及特殊的毗邻关系，切除率非常低，近年来由于诊断技术的提高，以及联合肝部分切除或周围血管整块切除手术的实施，使切除率明显提高，本文重点就其病理特点，诊断和治疗进展进行介绍。     

43例肝门部胆管癌的临床分析

目的探讨如何提高临床医师对肝门部胆管癌的早期诊断及根治性切除率。方法总结我院2004年5月-2009年5月收治的43例肝门部胆管癌的临床资料,包括诊断情况、临床分型、手术方式及效果。结果术前确诊90．7％;行手术切除37例,根治性切除14例,姑息性切除8例,引流术9例,单纯剖腹探查术6例;根治性切除者1、3年生存率85．7％、42．9％。结论肝门部胆管癌早期诊断应提高对本病的认识,对临床表现可疑患进行影像学诊断。联合B超、CT、MRCP等可以提高早期诊断率;术前已诊断为肝门部胆管癌就应采取积极的手术态度。做好术前评估、选择合适手术方式。可以提高手术切除率。     

肝门部胆管癌的诊治进展

肝门部胆管癌（hilar cholangiocarcinoma，HCC）是指原发于胆囊管开口以上的肝总管至左、右肝管部位的粘膜上皮癌。目前国内外对肝门部胆管癌病人仍然广泛采用Bismuth—Corlette分型，但还是缺乏统一的分类标准。肿瘤的分期作为判断肝门部胆管癌术后存活率的主要参考标准为人们广泛接受，但肝门部胆管癌临床分期的可操作性比较困难。肝门部胆管癌的临床表现较易识别，为临床诊断提供了有效依据。其诊断主要依靠影像学检查，检查的目的除了确诊是否为肝门部胆管癌以外，还需要提供有关手术方法选择和判断预后的证据。对肝门部胆管癌实施病灶整块切除，仍是现阶段最主要的确定性治疗手段。     

中晚期肝门部胆管癌26例手术体会

目的探讨中晚期肝门部胆管癌的手术方式。方法自2000年9月-2004年1月收治中晚期肝门部胆管癌病人,对26中晚期肝门部胆管癌病人采用了不同的手术方式,对其进行回顾性分析。结果根治性切除组10例,非根治性切除组16例。根治性切除组中位生存期为21.3月,非根治组中位生存期为10.2月,两者有显著差异（P〈0.05）。非根治组中内引流者中位生存期为13.1月,而外引流者中位生存期仅为5.8月,两者有显著差异（P〈0.05）。结论对于中晚期肝门部胆管癌病人尽量手术切除,能够延长患者生存期。无法切除者,桥式胆管空肠吻合内引流术是一种不错的选择。     

骨形成蛋白3在肝门部胆管癌组织中的表达及其临床意义

目的:探讨肝门部胆管癌组织中骨形成蛋白3(BMP3)的表达情况及其临床意义。方法:收集30例肝门部胆管癌的临床标本,应用real-time PCR和Western blot检测BMP3 mRNA和蛋白在癌组织和癌旁组织的相对表达情况。收集103例肝门部胆管癌石蜡标本,免疫组织化学法检测肿瘤组织中BMP3蛋白的表达,并分析其与临床病理的关系。结果:全组30例肝门部胆管癌组织中,22例癌组织BMP3蛋白和mRNA的表达水平较癌旁组织明显下降。免疫组织化学方法显示103例肝门部胆管癌组织中,87例阴性,16例弱阳性,BMP3蛋白的表达与肿瘤TNM分期、淋巴结转移、肿瘤的分化程度密切相关(P0.05)。结论:肝门部胆管癌组织中BMP3基因处于抑制状态,其表达的下调可能与肝门部胆管癌的发生、发展密切相关。     

肝胃胰及十二指肠转位伴先天性无脾1例

作者解剖一足月顺产因呼吸衰竭死亡 ,2 0ｄ女婴 ,发现右位心及大血管畸形 (另文报道 )外。还发现部分腹腔器官转位 ,先天性脾脏缺如。现报道如下 :1　肝　肝大部分位于腹上区 ,小部分位于左、右季肋区。呈楔形 ,其右端扁薄 ,左端钝厚 ,长 4 .5ｃｍ、宽9.5ｃｍ、厚 7.3ｃｍ。由肝镰状韧带分为肝右叶 (约占 4 /5 )和肝左叶 (约占 1/ 5 ) ,肝脏面“Ｈ”形沟各结构位置正常。2　胃、十二指肠和胰　胃、十二指肠和胰均转位 ,即 :胃小弯朝左上、胃大弯朝右下。十二指肠在Ｌ1～ 3椎体右前方呈反“Ｃ”形包绕胰头 (附图 )。胰头宽大位于第 2腰椎右侧…     

区域性肝门阻断在Ⅲ型肝门部胆管癌根治性切除中的应用-附49例报告

目的　探讨区域性肝门阻断在Ⅲ型肝门部胆管癌根治性切除中的应用。 方法　回顾性分析2002年-2010年11月收治的49例III型肝门部胆管癌的临床资料,其中治疗组24例解剖第1、2、3肝门后进行区域性阻断后,行根治性切除;对照组25例不解剖第2、3肝门,行常规根治性切除。 结果　治疗组无围手术期死亡发生,术后发生胆漏2例,肺部感染2例,均经积极非手术治疗恢复。对照组围手术期死亡2例,肝断面出血1例,胆漏2例,肺部感染2例。术后获得随访40例,随访率为82%,平均生存时间26月(2~65月)。总胆红素≥300μmol/L的患者其并发症发生率明显高于胆红素＜300μmol/L者（P<0.05)。 结论 当总胆红素≥300 μ mol/L时,手术前应作减黄处理;根治性切除是治疗肝门部胆管癌最有效的方法,区域性肝门阻断可明显降低手术出血量、死亡率及术后并发症的发生率。     

部分肝胆胰十二指肠联合切除治疗肝门部胆管癌

<正>肝门部胆管癌又称高位胆管癌,是指位于肝总管、汇合部胆管、左右肝管的一级分支以及尾状叶肝管开口的胆管癌。由于肿瘤的位置高,肝门部胆管癌的手术难度较大,若再并发了腹膜后淋巴结的广泛转移,临床上常常会放弃手术治疗。我科近期通过肝胆胰十二指肠联合切除为1例肝门部胆管癌并胰后肝总淋巴结转移患者成功实施了手术治疗,效果满意,现报告如下。1资料与方法患者,女,65岁,以上腹部不适半月并皮肤巩膜黄染3 d入     

肝移植后慢性排异反应1例

背景：慢性排异反应进展缓慢,往往呈隐匿性,移植肝功能逐渐减退或丧失。这种损伤是不可逆的,目前尚无有效的治疗办法。 目的：分析1例肝移植后慢性排异反应病例,以早期作出正确诊断。 方法：分析1例肝移植后3次入院诊断治疗的经过。B超显示：①肝实质回声增高,粗,不均匀。②胆囊切除术后。③脾大。④腹水。腹部CT显示：①肝移植术后。②脾大。住院期间积极给予护肝、支持、对症治疗,丙氨酸转氨酶、天门冬氨酸转氨酶无下降,总胆红素持续不降并有上升,反复腹腔感染。排除其他肝损害原因,经肝组织病理证实为肝移植术后慢性排异反应。 结果与结论：病例提示肝移植后不明原因肝脏损害,慢性排异反应应引起重视并应作为鉴别诊断之一,且肝组织病理检测将有助于诊断。对于肝移植后慢性排异反应除外其他肝损害病因并及时进行肝组织病理检测将有助于诊断。     

肝移植治疗肝原发性鳞状细胞癌1例

背景：肝原发性鳞状细胞癌较罕见,各种治疗方法疗效不佳,预后差。 目的：随访观察1例肝移植治疗肝原发性鳞状细胞癌患者的近期疗效。 方法：观察中山大学附属第一医院1例肝原发性鳞状细胞癌患者经肝移植治疗后的情况,并回顾性分析迄今为止见于文献报道的国内外65例肝原发性鳞状细胞癌的临床表现、组织来源、治疗方法及预后。 结果与结论：该患者经肝移植后肝功能恢复正常,肿瘤标志物癌胚抗原、糖类抗原199、鳞状细胞癌抗原等均降至正常水平,恢复良好。国内外研究表明,肝原发性鳞状细胞癌的临床表现不典型,组织来源多样,手术切除、化疗等治疗方法疗效不佳,预后差。本例结果显示,肝移植治疗肝原发性鳞状细胞癌近期疗效良好。     

A case of emphysematous hepatitis with spontaneous pneumoperitoneum in a patient with hilar cholangiocarcinoma

An 80-year-old woman with hilar cholangiocarcinoma was hospitalized due to sudden-onset abdominal pain. Computed tomography revealed hepatic necrosis accompanied with emphysematous change in the superior segment of the right liver (S7/S8), implying spontaneous rupture, based on the presence of perihepatic free air. Although urgent percutaneous drainage was performed, neither pus nor fluids were drained. These findings suggest emphysematous hepatitis with a hepatic mass. Despite the application of intensive care, the patient''s condition deteriorated rapidly, and she died 3 days after admission to hospital. Liver gas has been reported in some clinical diseases (e.g., liver abscess) to be caused by gas-forming organisms; however, emphysematous hepatitis simulating emphysematous pyelonephritis is very rare. The case reported here was of fatal emphysematous hepatitis in a patient with hilar cholangiocarcinoma.     

Metallothionein overexpression and its prognostic relevance in intrahepatic cholangiocarcinoma and extrahepatic hilar cholangiocarcinoma (Klatskin tumors)

Metallothionein is a group of small molecular weight cysteine-rich proteins with a broad variety of functions. Metallothionein has been shown to regulate apoptosis and proliferation. Overexpression of metallothionein frequently occurs in human tumors and is related to prognosis as well as therapy response. However, metallothionein expression and its clinical relevance in cholangiocarcinoma have not been investigated. The present study aimed to analyze metallothionein over-expression and its possible prognostic impact in intrahepatic cholangiocarcinoma and hilar extrahepatic cholangiocarcinoma (Klatskin tumors). We investigated the relationship of immunohistochemically demonstrated metallothionein expression with various clinicopathological parameters in a series of 56 intrahepatic and 56 extrahepatic cholangiocarcinoma. In noncancerous bile duct epithelia metallothionein was only occasionally weakly expressed; strong metallothionein overexpression (>50% metallothionein -positive tumor cells) was noted in 7 (12.5%) of 56 intrahepatic cholangiocarcinoma and 14 (25%) of 56 Klatskin tumors, which was associated with poor clinical outcome in univariate Kaplan-Meier testing in both intrahepatic cholangiocarcinoma (P = .002) and Klatskin tumors (P = .034). Moreover, strong metallothionein expression was identified as an independent prognostic parameter in multivariate Cox regression analysis in both intrahepatic cholangiocarcinoma (P = .005) and Klatskin tumors (P = .035). In contrast, cholangiocarcinoma with a papillary phenotype (8/112; 7.1%) exhibited a significant lack of strong metallothionein expression in all 8 of 8 cases. Strong metallothionein expression is identified as an independent poor prognostic parameter, and determination of the metallothionein expression may serve as an additional tool for the therapeutic management of patients with cholangiocarcinoma. In comparison, lack of metallothionein expression seems to be associated with cholangiocarcinoma with a papillary phenotype, which is generally recognized to have a better prognosis.     

Overexpression of Prdx1 in hilar cholangiocarcinoma: a predictor for recurrence and prognosis

Prdx1 is an important member of peroxiredoxins (Prdxs) regulating various cellular signaling and differentiation. Prdx1 confers an aggressive survival phenotype of cancer cells and drug-resistance, yet its role in hilar cholangiocarcinoma is not fully investigated. In present study, we detected the expression profile of Prdx1 in 88 hilar cholangiocarcinoma by tissue arrays and immunohistochemistry. Prdx1 level was down-regulated by specific Prdx1-shRNA in vitro and the possible mechanism was investigated. Overexpression of Prdx1 was observed in 53 of 88 cases (60.2%). Prdx1 expression was significantly associated with tumor invasion, nodal metastasis, advanced disease stage. Down-regulation of Prdx1 inhibited cell proliferation and colony formation of QBC939 cells and reduced the level of SNAT1 expression. Patients with Prdx1 overexpression had a shorter disease-free survival and overall survival than those without Prdx1 expression. Multivariate analysis showed that Prdx1 was an independent prognostic factor for patients with hilar cholangiocarcinoma. The data indicate that Prdx1 may contribute to the development and progression of hilar cholangiocarcinoma, partially through regulating SNAT1 expression, and may be used as a biomarker in predicting the outcome of patients with hilar cholangiocarcinoma.     

合并心血管病高龄肝门部胆管癌病人围手术期处理

目的:探讨合并心血管病高龄肝门部胆管癌病人围手术期的处理.方法:根据2001年美国心脏病学院/美国心脏病学会制定的非心脏手术围手术期心血管评估指南标准,将1998年1月至2007年5月在中国医科大学附属第一医院肝胆外科手术的72例70岁以上合并心血管病肝门部胆管癌病人,分为高度危险、中度危险、低度危险3级后进行围手术期...     

Interleukin-8 is a prognostic indicator in human hilar cholangiocarcinoma

Interleukin-8 (IL-8), matrix metalloproteinase-9 (MMP-9) and neovascularization have been implicated to be associated with biological processes, especially cancer progression. However, few studies have investigated the role of IL-8 in human hilar cholangiocarcinoma. In this study we detected the expression of IL-8 combined with MMP-9 and microvessel density (MVD) in hilar cholangiocarcinoma to evaluate their clinicopathological significance and prognostic value. A total of 62 patients with hilar cholangiocarcinoma who underwent curative surgery were enrolled in this study. The expression of IL-8, MMP-9 and MVD were examined immunohistochemically. The correlation of IL-8 with MMP-9 expression, MVD, clinicopathological features and survival time of patients were then analyzed. Expression of IL-8 was observed in 56.5% tumors, which was related to advanced TNM stage (P = 0.026) and tumor recurrence (P = 0.018). IL-8 had a positive correlation with MMP-9 expression and MVD. Furthermore, patients with high IL-8 expression had a significantly shorter overall survival than those with low IL-8 expression (P = 0.01). Multivariate analysis confirmed IL-8 as an independent prognostic factor (P = 0.005). In conclusion, IL-8 expression significantly correlated with MMP-9 expression and MVD, and IL-8 was a valuable prognostic factor for human hilar cholangiocarcinoma.