肝内胆管癌行微创手术后的短期预后和长期预后观察

目的探讨肝内胆管癌行微创手术后的短期和长期预后状况。方法选取2016年1月至2019年6月间武警北京市总队医院收治的86例肝内胆管癌患者,按照手术方式不同分为两组,采用腹肝切除术的40例患者纳入对照组,采用腹腔镜肝切除术的46例患者纳入观察组。比较两组患者的术后疼痛程度、卧床时间、住院时间、肝功能水平及临床疗效。结果观察组患者疼痛程度评分、卧床时间和住院时间均低于对照组,差异均有统计学意义(均P<0.05)。观察组患者各项肝功能指标均低于对照组,差异均有统计学意义(均P<0.05)。观察组患者6个月缓解率为82.6%,高于对照组的70.0%,差异有统计学意义(P<0.05)。结论腹腔镜肝切除术用于肝内胆管癌患者治疗中,能够缓解患者疼痛,缩短卧床时间和住院时间,改善肝功能,提高临床疗效,临床值得推广。     

肝外胆管癌的外科治疗与预后关系临床探讨

作者对55例肝外胆管癌的治疗方法与预后的关系进行临床探讨。按Longmire分型，上段、中段、下段胆管癌分别占43．6％、21．8％、346％；有42例得到病理诊断。手术切除11例（26．2％），“减黄”手术30例（胆肠内引流14例，外引流16例），单纯剖腹，PTCD、非手术保守治疗分别为1、6、7例。随访1～62个月，随访率87．3％。平均生存时间10．8±9．7个月；手术切除组生存时间最长（21．4±16．7个月，P＜0．01），生存率最高（P＜005）；胆肠内引流组的生存时间（12．2±6．8个月）和生存率亦明显高于其它各组（P＜0．05）。因此，对有条件的肝外胆管癌，应争取早期作根治性切除＋胆管空肠吻合，并酌情切除受累肝脏；即使无根治条件，亦应尽可能作胆肠内引流。     

136例肝外胆管癌的诊断和外科治疗

目的探讨肝外胆管癌的临床诊断和外科治疗效果。方法回顾性分析肿瘤外科收治的136例肝外胆管癌患者的临床资料。结果根治性切除(A组,42例)、姑息性切除(B组,17例)、非切除性手术组(C组,77例)的临床症状、症状持续时间和实验室检查无显著性差异。A组术前准确诊断率62%(2642),显著低于B组的94%(1617)(P=0.014)和C组的87%(6777)(P=0.002);A组肿瘤直径为2.52±0.15cm,与B组(2.53±0.26cm)接近,均显著小于C组(3.92±0.23cm)(P均<0.001)。35例(26%)出现手术并发症,手术死亡率4%(6例),B组术后感染率(35%,617)显著低于C组(23%,1877)(P=0.006)。A组中位生存25.0±5.4个月,5年生存率27%(415);B组中位生存13.0±4.1个月,没有5年生存;C组术后中位生存只有6.0±0.6个月(A组或B组对比C组,P均<0.001)。结论肝外胆管癌的早期临床诊断能力不足。只有获得阴性切缘的患者才能获得长期生存。     

肝外胆管癌84例临床分析

目的：探讨肝外胆管癌的诊断和治疗技术。方法：回顾性分析了２４ 年间沂蒙山区４ 所市直医院共收治的８４ 例肝外胆管癌的临床资料。结果：早年误诊率高达７０ ．２４ ％ ,近年来由于 Ｂ 超、 Ｃ Ｔ 等诊断技术的提高,术前确诊率明显提高。手术切除率由１９９０ 年前的２４ ．４ ％ 上升到４０ ．４８ ％ ;姑息性手术对延长病人的生存时间,提高其生活质量有肯定的临床价值。结论：临床医师应提高对本病的认识,提高警惕,对可疑病人要实行早期检查、早诊断,尽早手术,努力提高手术切除率,对不能切除的病人,也应积极采取姑息性手术,以延长病人的生存时间,提高其生活质量。     

肝外胆道肿瘤治疗的新进展

肝外胆道肿瘤是一种恶性程度较高、预后较差的肿瘤,手术治疗是其唯一有治愈可能的治疗方法。根治性手术切除时常需联合血管或肝尾状叶切除及行区域淋巴结清扫,姑息切除加术后辅助治疗也可延长患者的生存时间并提高生活质量。对重度黄疸或预计术后肝残余量不足患者,术前行健侧胆道引流或病肝侧门静脉栓塞术,可减少术后并发症。对不能手术切除或伴有转移的进展期胆管癌,化疗、放疗、分子靶向药物、介入等治疗具有一定改善整体生存和生活质量的作用,并可能获得二次手术机会。     

67例肝门部胆管癌的外科治疗及预后分析

目的：探讨肝门部胆管癌（HCC）的外科治疗特点及预后因素,以期进一步提高HCC外科疗效。方法：回顾性分析67例病理诊断为HCC患者的临床资料。结果：不同手术方法术后累计生存率差异显著（P〈0.001）。根治切除组1、3年生存率显著高于姑息切除组和单纯引流组,手术切除组较非手术切除组生存时间显著提高（P〈0.001）。术前T分期和Bithmuth分型能指导手术切除率及术式选择。不同的T分期的手术切除率及切缘阴性率差异显著（P〈0.001）。分别对16个可能影响预后的因素进行单因素预后分析表明肿瘤大小、门静脉侵犯、局部浸润及转移、手术方法、UICC分期、改良T分期、淋巴结转移对预后有影响,统计学上有显著性差异（P〈0.05）。COX模型多因素预后分析表明手术方法、UICC分期是两个独立预后因素。结论：根治性切除是最重要预后因素,扩大手术范围能获得较好切缘无癌率,术前的T分期和Bismuth分型综合评估将有助于进一步在安全的范围内提高手术切除率及根治性切除率。     

肝外胆管癌161例的外科治疗和预后分析

目的：探讨肝外胆管癌（extrahepatic cholangiocarcinoma，EHCC）的临床特征和治疗方法对患者远期生存率的影响及EHCC切除术后的预后因素。方法：对1995年4月至2006年7月收治的161例EHCC患者的临床特点、诊断、手术方式和随访结果进行回顾分析。选择对EHCC切除术后的预后可能产生影响的临床因素，通过COX比例风险模型进行多因素预后分析。结果：161例手术治疗的EHCC，根治性切除110例，姑息性切除32例，引流或探查19例。161例患者总体1、2、3、5年生存率分别为74．9％、45．3％、36．5％和11．1％。COX分析结果表明肝脏浸润、门脉或肝动脉侵犯和淋巴结转移是EHCC根治切除影响预后的独立因素（P〈0．05）。结论：根治性切除是提高EHCC患者远期生存率及改善生活质量的关键，肝叶切除和（或）胰十二指肠切除联合骨骼化切除是提高根治切除率及远期疗效的重点。     

肝内胆管癌手术治疗的预后影响因素分析

目的 探讨肝内胆管癌患者手术治疗后炎症细胞分布与预后的相关性及影响预后的相关因素.方法 纳入行手术根除治疗的肝内胆管癌患者60例,对患者的详细就诊资料、CD15、CD68炎性相关性因素及生存资料等进行相关性分析.结果 分化程度、肿瘤复发、TNM分期、CA199、术中输血、手术方式、肿瘤和手术部位、术前转氨酶水平的情况是影响胆管癌预后总生存时间的独立危险因素.炎症相关因子CD15、CD68的表达与患者的总生存时间有关(P<0.05).结论 肝内胆管癌手术治疗的预后与肿瘤的分化程度、肿瘤复发、TNM分期、CA199、术中输血、手术方式、肿瘤和手术部位、术前转氨酶水平具有相关性,局部的炎症状态CD15高表达、CD68低表达是影响胆管癌患者总生存时间的独立危险因素.     

肝外胆管癌的影像学诊断

对手术病理证实的肝外胆管癌29例，进行回顾性分析，其中上段癌16例（55．2％）；下段癌11例（37．9％）；中上段癌2例（7．95）。除2例为乳头状腺瘤癌变，1例为横纹肌肉瘤外，余均为腺癌，影像学诊断在发现肿瘤，明确病因及梗阻水平上依次为PTC3例（100％）；ERCP26例（92．3％）；CT18例（88．8％）；B超29例（82．7％）。但B超简易、无创、经济方便，应首选；CT无痛苦，准确主缟，可作为确定诊断的依据；PTC及ERCP虽为介入性影像学检查，但对肝外胆管癌早期诊断及肿瘤的定位、定性准确率高，且可清晰显示胆系统的全貌，对治疗及手术方案选择有重要指导意义。     

肝外胆管癌55例临床分析

本文报告了１９８４年１月～１９９３年１２月收治肝外胆管癌５５例。以梗阻性黄疸，右上腹不适为主要症状，Ｂ超、ＰＴＣ、ＥＲＣＰ的检查准确率分别为５８．１８％、９３．３３％、７１．４３％。按Ｌｏｎｇｍｉｒｅ分型，上段、中段、下段胆管癌分别为４３．６４％、２１．８２％、３４．５５％；其中４２例有病理诊断，腺癌４１例，浸润型２４例，结节型６型，乳头型１１例，９７．６２％为腺癌，肿瘤切除１１例，切除率２６．１９％，以切除组生存期最长（２１．３５±１６．３７月），胆肠引流次之，ＰＴＣＤ与非手术者疗效差。本文讨论了肝外胆管癌的诊断、治疗、预后之间关系，肯定了ＰＴＣ的诊断价值，否定了ＰＴＣＤ的治疗作用。     

High expression of MMP-9 is associated with better prognosis in extrahepatic bile duct cancer patients

Purpose

To evaluate the prognostic value of matrix metalloproteinase-9 (MMP-9) in patients with extrahepatic bile duct (EHBD) cancer undergoing surgical resection and adjuvant radiotherapy.

Clinical significance of extrahepatic bile duct resection for advanced gallbladder cancer

BACKGROUND AND OBJECTIVES: The aim of this study was to determine the clinical significance of extrahepatic bile duct (EHBD) resection during surgery for advanced gallbladder cancer. METHODS: Among 110 patients with pT2 or higher grade gallbladder cancer, 58 patients without microscopic invasion to the EHBD were reviewed. Prognostic factors of the 58 patients were evaluated by multivariate analysis. The impact of EHBD resection on survival was assessed in relation to two prognostic determinants: (i) lymph node metastasis: positive (n = 23) and negative (n = 35); (ii) perineural invasion: positive (n = 25) and negative (n = 33). RESULTS: Hepatic metastasis and perineural invasion were found to be independently significant prognostic factors. (i) No survival benefit of additional EHBD resection could be confirmed in each group of patients with or without nodal metastasis. (ii) In 25 patients with perineural invasion, 14 patients who underwent EHBD resection showed better survival as compared to the 11 patients who did not undergo EHBD resection (5-year survival rate, 46% vs. 0%, P = 0.009). In the remaining 33 patients without perineural invasion, the additional EHBD resection did not yield significant improvement of survival (P = 0.28). CONCLUSIONS: Resection of EHBD may offer prognostic advantage when perineural invasion exists, even in the absence of biliary infiltration.     

肝外胆管癌影像学诊断与手术病理对照分析

目的 通过肝外胆管癌的影像学诊断,探讨MR胆胰管造影（MRCP）对肝外胆管癌的诊断价值。地65例经手术病理证实的肝外胆管癌,其中行超声波检查（US）60例,电子计算机断层扫描（CT）52例,逆行胰胆管造影（ERCP）20例,经皮肝穿刺胆管造影（PTC）9例,磁共振胆胰管造影（MRCP）20例。根据各种检查方法显示的影像学表现和诊断,与手术病理结果进行对照分析。结果 定位诊断准确率US为81．7％,CT为84．6％,ERCP为75．0％,PTC为88．9,MRCP为100％;定性诊断准确率US为73．3％,CT为82．7％,ERCP为75．0％,PTC为88．9％,MRCP为95．0％。结论 MRCP对肝外胆管癌诊断定位和定性优于US、CT、ERCP及PTC。     

Diagnosis and surgical treatment of cancer of the gallbladder and extrahepatic bile ducts]

Data on 148 cases of cancer of the gallbladder and extrahepatic bile ducts were studied. Jaundice proved the cardinal symptom. No clear-cut clinical picture of the disease was identified. Diagnostic procedure should start with ultrasonography. Cholangiectasia and the enlarged pancreatic head make the case for fiber bronchoscopy and hypotonic duodenography. Cancer-negative patients should further undergo transcutaneous transhepatic cholangiography and, if proving still negative, retrograde cholangiopancreatography. Resection of bile ducts with simultaneous lymphadenectomy is considered radical. The authors suggest a surgical procedure for cancer of the gallbladder which includes resection of the liver, hepatico-choledoctomy and cholecystectomy with formation of cholangio-jejuno-anastomosis using disposable transhepatic drains. Recanalization of bile ducts by transhepatic drain is considered optimal for palliation. Survival depends upon extent of surgery and level of bile duct obstruction.     

Role of postoperative radiotherapy in the management of extrahepatic bile duct cancer

PURPOSE: To analyze the outcome of postoperative radiotherapy (RT) or chemoradiation for patients with extrahepatic bile duct cancer who had undergone either curative or palliative surgery, and to identify the prognostic factors for these patients. METHODS AND MATERIALS: Between March 1982 and December 1994, 91 patients with extrahepatic bile duct cancer underwent RT at the Department of Therapeutic Radiology, Seoul National University Hospital. Of these patients, 84 were included in this retrospective study. The male/female ratio was 3.7:1 (66 men and 18 women). The median age of the patients was 58 years (range 33-76). Gross total surgical resection was performed in 72 patients, with pathologically negative margins in 47 and microscopically positive margins in 25. Twelve patients underwent surgical exploration and biopsy or subtotal resection with palliative bypass procedures. All the patients received >40 Gy of external beam RT after surgery. Concurrent 5-fluorouracil was administered during external beam RT in 71 patients, and maintenance chemotherapy was performed in 61 patients after RT completion. The minimal follow-up of the survivors was 14 months, and the median follow-up period for all the patients was 23 months (range 2-75). RESULTS: The overall 2- and 5-year survival rate was 52% and 31%, respectively. The 2- and 5-year disease-free survival rate was 48% and 26%, respectively. On univariate analysis using the Kaplan-Meier product limit method, the use of chemotherapy, performance status, N stage, size of residual tumor, stage, and tumor location were significant prognostic factors. However, on multivariate analysis using Cox's proportional hazard model, N stage (N0 vs. N1 and N2, p = 0.02) was the only significant prognostic factor. CONCLUSION: Long-term survival can be expected in patients with extrahepatic bile duct cancer who undergo radical surgery and postoperative chemoradiation. Regional lymph node metastasis is a poor prognostic factor for these patients.     

Pathological features and surgical outcome of pancreaticobiliary maljunction without dilatation of the extrahepatic bile duct

In cases of pancreaticobiliary maljunction without dilatation of the extrahepatic bile duct (undilated PBM), preventive cholecystectomy is performed because there is a high incidence of gallbladder cancer as compared to cases of PBM with dilatation of the extrahepatic bile duct (dilated PBM). However, it is still controversial whether resection of the extrahepatic bile duct should also be performed in patients with undilated PBM. Accordingly, we analyzed pathological findings, postoperative complications and a long-term prognosis in 19 patients with undilated PBM to clarify the possibility of the bile duct cancer. In undilated PBM, hyperplasia was significantly recognized in the gallbladder as compared to the bile duct (p=0.0238), while no significant differences were found in other epithelium. Atypical epithelium and hyperplasia in gallbladder mucosa of undilated PBM were significantly recognized as compared to cases of pancreas or biliary tract cancer without PBM (p=0.0035, p=0.0019, respectively), while no significant differences were recognized in any kind of epithelium of the bile duct. In 14 cases of undilated PBM with preservation of the extrahepatic bile duct, the postoperative observation period was from 1 year and 5 months to 18 years and 10 months (mean: 8.3 years). One of the 5 patients with gallbladder cancer died 2 years and 6 months after surgery due to the cancer recurrence, while the remaining 13 patients had no complications such as liver dysfunction, cholangitis or remnant bile duct cancer, and the patients have survived in good health. These findings indicate that preventive bile duct resection is not necessary in patients with undilated PBM.     

肝外胆管癌的放射治疗：附12例分析

During the past 8 years, 12 patients with extrahepatic bile duct adenocarcinoma which was contra-indicated to operation or who underwent conservative resection wer treated by radiotherapy in our hospital. Five patients were given post-operative radiation of 60-70 Gy/7-9 weeks, 3 patients received 12 Mev beta beam of one single 30 Gy intra-operative radiotherapy and 4 were treated by intra-operative radiotherapy of 20 Gy plus external irradiation of 40 Gy/5 weeks after the operation. The results indicated that most of the patients died around 1 year and 2 are still alive for over 2 years. The present results are more favorable as compared with those treated before 1980 because biliary drainage had been done before timely high dose radiotherapy after the operation. The author considers that intra-operative radiotherapy or its combination with external irradiation might be helpful to improve the prognosis in extrahepatic bile duct cancer.