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。     

肝内外管道的研究及临床应用

对肝内、外管道走行及肝段划分的正确认识,是肝叶、肝段和亚肝段手术切除的基础.近年来,普遍采用的肝段划分法是Couinaud's肝段,Couinaud's肝段是依据Glisson系统的分支、分布和肝静脉的走行进行划分的,Glisson系统包括肝门静脉、肝固有动脉及胆道.通过综述Glisson系统的解剖学及影像学研究与进展,将为肝癌的介入治疗、肝叶肝段和亚段切除方式及肝移植手术策略提供新的思路.     

125I粒子腔内治疗在中晚期胆管癌的临床应用进展

摘 要：胆管癌是指源于肝外胆管包括肝门区至胆总管下端胆管的恶性肿瘤,发病隐匿,发现肿瘤时大都已是中晚期,预后非常差,肿瘤引起的梗阻性黄疸等一系列并发症,使患者生活质量明显降低。姑息性治疗目前主要是经皮肝穿刺引流（PTCD）或内镜下胆道引流或支架植入,缓解患者的梗阻性黄疸征象,但随着肿瘤的进展,胆道再发梗阻发病率非常高。在胆道引流或支架基础上,行125I粒子腔内植入,在缓解梗阻基础上局部对肿瘤进行治疗,现就125I粒子腔内治疗在中晚期胆管癌的临床应用作一综述。     

经皮胆道内支架置入术姑息性治疗恶性梗阻性黄疸临床观察

目的研究经皮胆道内支架置入术姑息性治疗恶性梗阻性黄疸的临床价值。方法28例恶性梗阻性黄疸接受经皮经肝胆道内支架置入术,男18例,女10例。胆管癌13例,胰头癌4例,胆囊癌3例,肝门区转移癌8例。共置入胆道内28枚金属内支架。结果28例采用经皮经肝穿刺置入胆道内支架均获得成功。结论经皮胆道内支架置入术是姑息治疗手术不能切除的恶性梗阻性黄疸的有效方法,配合动脉内灌注化疗可提高恶性阻塞患者的生存率。     

金属内支架置入治疗恶性梗阻性黄疸12例

目的 研究经皮胆道内支架置入术姑息性治疗恶性梗阻性黄疸的临床效果并进行分析。方法 12例恶性梗阻性黄疸患者共植入14枚胆道内支架,其中原发性肝癌4例,胃癌肝门转移2例,胰腺癌3例,壶腹癌3例,10例支架植入后进行了局部治疗。结果 12例采用经皮肝穿放置胆道支架均获得成功,技术成功率8.3％（1／12）,早期并发症率16.7％（2/12）,6个月生存率58.3％,6个月胆道再狭窄率25％（3／12）,春中1例进行了再次介入治疗。结论 经皮胆道内支架置入术是姑息性治疗手术不能切除的恶性梗阴性黄疸患者的有效方法。     

关于肝门部胆管癌外科治疗的几点认识

肝门部胆管癌是胆道外科的难题之一，目前仍以手术治疗为主要手段。对肿瘤侵犯范围和可切除性作出正确的判断，选择合理的治疗方法，严格掌握手术切除范围及预防手术并发症，是使手术取得良好治疗效果的重要保证。现结合临床经验，对肝门部胆管癌的外科治疗谈几点体会。     

不能手术的肝门区胆管癌支架置入结合三维适形放疗疗效初步评价

目的探讨胆管支架置入结合三维适形放疗(three-dimensional conformal radiotherapy,3DCRT)治疗不能手术的肝门区胆管癌(Klatskin tumor)的疗效.方法回顾分析了23例不能手术切除的肝门区胆管癌患者的临床资料,其中综合治疗组(胆管支架置入结合三维适形放射治疗)15例,对照组(单胆管支架置入)8例.用Kaplan-Meier法分析比较两组患者生存率和支架开通率.结果两组患者支架置入术后总胆红素均逐渐下降.综合治疗组获得了60.0%(9/15)的肿瘤局部缓解率.综合治疗组和对照组1,2年生存率分别为53.3%(8/15)、13.3%(2/15)和25%(2/8)、0;1,2年支架开通率分别为40.0%(6/15)、13.3%(2/15)和12.5%(1/8)、0.中位生存期分别为13.4和7.5个月(P=0.04);支架中位开通时间分别为12.0和5.1个月(P=0.00).结论3DCRT对肝门区胆管癌有较好的局部治疗效果,结合胆管支架置入明显提高了不能手术的肝门区胆管癌患者的生存率及支架开通率.     

胆汁体外转流联合伽马刀治疗无法切除肝门部胆管癌的临床分析

0引言近年来,肝门部胆管癌的发病率呈上升趋势[1],而多数病例出现症状时已属晚期而错失手术切除时机.有研究报道指出BismuthⅢa型及Ⅳ型手术切除率仅分别是57.14％、50.00％[2],故而肝门部胆管癌的姑息性治疗方法 值得关注.我们分析了2005年1月-2009年12月我院收治的68例无法切除的肝门部胆管癌的病例资料,对比研究胆道外引流、胆道外引流联合伽马刀治疗、胆汁体外转流联合伽马刀治疗的效果,现报道如下.     

1例肝外胆管肉瘤样癌报告及肉瘤样癌治疗现状

回顾1例肝外胆管肉瘤样癌病人的诊疗过程,并对肉瘤样癌的组织病理学特点及各组织肉瘤样癌报道等进行文献回顾.由于肝外胆道肉瘤样癌术前难与普通胆管癌鉴别,一般在术中病理偶然发现,所以还需探索新的诊断以及治疗方法.     

内镜下胆道金属支架治疗肝门部胆管恶性梗阻的临床研究

为了探讨经内镜放置胆道金属支架治疗肝门部胆管恶性梗阻的可行性及安全性,回顾分析我院接受胆道金属支架治疗的67例肝门部恶性梗阻患者临床资料.所有患者术前行B超、CT、MRCP或ERCP检查.常规ERCP检查,置入导丝越过狭窄段,经胆道扩张管扩张后,在X线监视下置入胆道金属支架,支架近端超过狭窄1.5 cm.67例患者中置入支架62例,成功率91.9%,术后出现胆道感染15例,全部经抗感染治疗后控制.放置支架1周后血清胆红素由术前(349.32±62.39)μmol/L降至(67.43±12.56)μmol/L,平均通畅时间145 d.对其中支架堵塞后的26例患者,再次行内镜检查及治疗,分别置入塑料支架8例,放置鼻胆引流管11例,治疗失败7例.初步研究结果提示,胆道金属支架置入对难以手术切除的肝门部胆管恶性梗阻有较明显治疗效果,是一种操作简单、经济有效、并发症少的方法,具有安全性和可行性.     

Intrahepatic cholangiocarcinoma: Limitations for resectability,current surgical concepts and future perspectives

Intrahepatic cholangiocarcinoma (iCCA) is the second most common hepatic malignancy and its incidence has been shown to increase significantly during the past decades. Complete surgical resection is currently acknowledged as the only curative treatment option able to provide adequate long-term outcomes. We herein review technical, functional and oncologic limitations for resectability, discuss current surgical aspects as well as highlight the fields in which future research and practice should focus on in order to ameliorate long-term outcomes in patients with iCCA.     

肝门胆管癌的放疗进展

肝门胆管癌手术切除率及切净率均较低,极大地影响了疗效.放疗作为一种常用的恶性肿瘤治疗方式,对肝门胆管癌的运用有限.近年来随着放疗技术的发展,放疗与肝门胆管癌的研究成为热点.许多研究认为放疗作为手术辅助治疗或保守治疗,可提高肝门胆管癌患者生存期并改善其生存质量.     

Multidisciplinary management of intrahepatic cholangiocarcinoma: Current approaches

Intrahepatic cholangiocarcinoma (ICC) is a common primary hepatic tumor. However, its outcomes are usually worse than those of hepatocellular carcinoma owing to its non-specific presentation and detection at an advanced stage. The most widely used serum marker, carbohydrate antigen 19-9, is non-specific. Furthermore, imaging studies rarely identify any pathognomonic features. Surgery is the only treatment option that offers a chance of long-term survival. However, the resectability rate is low owing to the high frequencies of intrahepatic metastases, peritoneal carcinomatosis, or extrahepatic metastases. Surgical treatment should be tailored according to the macroscopic classification of ICC (e.g. mass-forming, periductal infiltrating, and intraductal growth types) because it reflects the tumor's dissemination pattern. Although lymph node metastasis is a negative prognostic factor, the importance and extent of lymph node dissection is still controversial. To improve patient survival, liver transplantation is considered in some patients with unresectable ICC, especially in those with an insufficient remnant liver volume. Minimally invasive procedures, including laparoscopic and robotic liver resection, have been tested and achieved comparable outcomes to conventional surgery in preliminary studies. No randomized trials have confirmed the efficacy of adjuvant chemotherapy in ICC, and several trials have evaluated molecular-targeted agents as monotherapy or in combination with cytotoxic chemotherapy. Multidisciplinary approaches are necessary to improve the outcomes of ICC.     

Ultrasonic Demonstration of Anicteric Biliary Obstruction

25 non jaundiced patients with dilatation of the biliary tree are presented. In 22 of these cases the cause of obstruction was shown either by ultrasound alone, on radionuclide (RN) study or at endoscopic retrograde cholangiography (ERCP) and was subsequently proven at surgery. In 2 cases ultrasound showed dilatation of the common duct, which was proved to be non-obstructive dilatation on ERCP. One patient had multiple benign hepatic cysts with intrahepatic biliary dilatation and was not subjected to surgery. Twenty out of 23 patients with obstructive dilatation showed a variable rise in serum alkaline phosphatase. Bile duct size did not show any correlation with serum alkaline phosphatase levels. It is stressed that ultrasound is a more sensitive indicator of obstructive biliary disease than clinical and biochemical parameters.     

Positive telomerase activity in the majority of bile duct carcinoma

Background. Studies of human tumors and human tumor cell lines indicate that telomerase activity may play a critical role in the tumor cell growth by sustaining cellular immortality. Telomerase activity has been detected in different percentages in various carcinomas, but the incidence of positive telomerase activity in bile duct carcinomas and surrounding normal bile duct tissues in its relation with malignancy grades of tumors, depth of invasion, lymphatic and vascular invasion, and lymph node metastases has not been studied. Methods. Telomerase activity was assayed in surgically resected specimens of seven human bile duct carcinomas and seven adjacent nonneoplastic tissues using the PCR-based Oncor TRAP (a telomeric repeat amplification protocol)-eze telomerase detection kit. The correlation between the results of telomerase activity and clinicopathological data was examined. Results. The telomerase activity was detected in six of seven (86%) bile duct carcinoma cases with only one negative case in our series, whereas no telomerase activity was detected in nonneoplastic adjacent bile duct tissues. Although the number of cases in our study was small, telomerase activity was regarded as independent of tumor grade, depth of invasion, lymphatic and intravascular invasion, or lymph node metastasis. Conclusions. These results indicate that increased telomerase activity is a common phenomenon in the majority of bile duct carcinomas, and that it is negative in nonneoplastic bile duct tissues. Received: June 29, 1998 / Accepted: June 16, 1999     

胆汁酸与肿瘤的相关性

近年来的研究表明,胆汁酸与肿瘤的发生发展密切相关.胆汁酸可以通过氧化应激、慢性炎症、核受体信号转导等途径影响肿瘤的形成过程,对肿瘤细胞生长、凋亡产生一定影响.     

Validation of the ISGLS classification of bile leakage after pancreatic surgery: A rare but severe complication

IntroductionHepaticoenterostomy is an important step of reconstruction during hepatopancreatobiliary (HPB) surgery with a subsequent bile leakage rate of up to 5%. The International Study Group of Liver Surgery (ISGLS) proposed a severity grading system for defining bile leakage after HPB surgery, which has not been validated after pancreatic surgery in a large patient cohort. The present study aimed to validate the ISGLS definition for bile leakage in pancreatic surgery and to investigate the postoperative outcomes of bile leakage after pancreatic resections.Materials and methodsData from the prospectively maintained database for pancreas surgery were extracted for any type of pancreatectomy with hepaticoenterostomy between 2006 and 2019. The severity of bile leakage was graded according to the ISGLS definition. The influence of our standardized hepaticoenterostomy technique and of the complexity of the surgical procedure on the rate of clinically relevant bile leakages (B and C) were assessed in three different timeframes.ResultsBile leakage was detected in 152 of 5,300 patients (2.9%). Clinically relevant bile leakages included seventy patients with grade B and eighty-two patients with grade C bile leakages (46.1% and 53.9%, respectively). During the study period, the overall rate of bile leakage showed to be stable (from 3.5% to 2.4%). Patients with grade C bile leakage had a higher rate of postoperative wound infection (P < 0.001) and longer ICU stays and hospital stays compared to patients with grade B bile leakage (P = 0.03 and P < 0.001 respectively). These parameters were significantly higher in patients with late grade C bile leakage but were similar between patients with grade B bile leakage and early grade C bile leakage (<5th day POD). In the whole patients’ cohort, the 90-day mortality rate was 3.2% (174/5,300), with a rate of 25% in patients with bile leakage (38/152).ConclusionThe ISGLS classification is a valid method for classifying postoperative bile leak after pancreas surgery. Standardization of our hepaticoenterostomy technique resulted in a stable rate of bile leakage. Although rare, bile leakage following pancreas surgery is a severe complication that has a major impact on patient outcomes and contributes significantly to morbidity and mortality, even in the absence of POPF.     

HGF/c-Met通路及其与肝癌和胆管癌的相关研究

肝细胞生长因子及其受体(HGF/c-Met)通路的过度激活在肿瘤的演进过程中起到非常重要的作用.研究证实HGF/c-Met在肝癌及胆管癌中呈高表达,直接或间接参与肿瘤的发生、侵袭和转移过程,且与预后有重要关系.近年来,针对该通路抑制剂的研发已成为抗肿瘤药物的研究热点.     

Spectrum of Non Atretic Biliary Tract Obstruction in Children

11 cases of biliary tract obstruction with bile duct dilatation have been seen at the Royal Children's Hospital over a 4 year period. Pathologies included choledochal cysts, calculi, lyphoma and a post operative stricture. Ultasound correctly diagnosed the nature of the obstruction in 9 cases. Illustrative case studies are presented, and the specific ultrasound features are discussed.