原发性肝癌伴胆管癌栓的外科治疗

目的　探讨伴胆管癌栓的原发性肝癌 (HCC)外科治疗方式的选择及对预后的影响。方法　回顾性分析 1994～ 2 0 0 1年 15例HCC伴胆管癌栓的外科治疗情况。　结果　肝癌切除加胆管癌栓清除术 7例 ,肝癌切除加肝外胆管切除术 4例 ,单纯胆总管切开取栓术 3例 ,背驮式肝移植 1例。术后 1年生存率为 73 3%,3年生存率为 40 %,其中有 2例生存已超过 5年。门静脉侵犯者的生存率显著低于未侵犯者 (P <0 0 5 )。　结论　原发性肝癌伴胆管癌栓行外科治疗是一种积极有效的治疗方法。复发后选择适当病例再次手术 ,仍可取得较好疗效。肝移植作为一种崭新的手术方式值得探讨。     

原发性甲状腺鳞癌12例临床分析

目的　总结原发性甲状腺鳞癌的诊治经验。方法　回顾分析我院 1996～ 2 0 0 1年收治的 12例原发性甲状腺鳞癌患者的临床资料。结果　单纯性鳞癌 4例 ,合并甲状腺其它疾病 8例。主要临床表现为颈部包块和声嘶。单纯性鳞癌免疫组化甲状腺球蛋白染色阳性 3例 ,阴性 1例。 12例患者中 10例行姑息性切除者于术后 1年内死亡 ,2例行根治性切除者存活时间超过 3年。结论　原发性甲状腺鳞癌呈高度恶性 ,可与甲状腺其它良、恶性疾病并存 ;要重视对该病的诊断和鉴别诊断 ,免疫组化甲状腺球蛋白染色可提高确诊率 ;根治性手术切除加综合治疗是提高其生存率的关键。     

基层医院肝切除治疗原发性肝癌35例分析

目的探讨肝切除治疗原发性肝癌的临床疗效。方法回顾性分析我院2003年4月至2005年4月35例原发性肝癌的手术治疗及随诊情况。其中右半肝切除6例,左半肝切除16例,肝中叶切除3例,单纯肝肿瘤切除10例。结果术后病理证实为肝细胞癌30例,胆管细胞癌5例。术后出血4例,再次手术出血1例,胆瘘1例,手术死亡1例,术后住院死亡1例,半年内死亡2例,1年内死亡6例,25例存活至今。结论严格掌握原发性肝癌切除手术指征及肝切除量,减少术中出血,正确处理肝创面及降低术后并发症发生率,才能保证提高手术治疗的效果。     

肝内胆管囊性肿瘤2例诊治分析

目的提高对肝内胆管囊性肿瘤的认识。方法对经根治性手术切除并由病理学确诊的2例肝内胆管囊性肿瘤患者(囊腺瘤和囊腺癌各1例)的临床和病理资料进行回顾性分析。结果术前CT、B超发现肝内囊性包块,但未获得肝内胆管囊性肿瘤的诊断。根治性切除术后,采用B超、CA19-9和CEA随访9月和15月,均无复发。结论肝内胆管囊性肿瘤术前诊断非常困难,CT、B超或ERCP检查对诊断有一定帮助。确诊必须依靠病理学检查。根治性切除是首选的治疗方法。根治性切除后,患者预后良好。     

原发性肝癌伴阻塞性黄疸的诊断及根治性手术治疗

目的探讨原发性肝癌致阻塞性黄疸的诊断和外科根治性手术治疗的方法及疗效。方法自1991年1月至2001年12月间对17例原发性肝癌致阻塞性黄疸的患者进行了诊断和外科根治性手术治疗。其中行肝叶切除及胆总管切开取癌栓者14例,行同种异体原位肝移植术3例。结果患者平均生存时间为8个月．最长存活时间为24个月。结论明确的诊断和根治性手术治疗是治疗伴阻塞性黄疸的原发性肝癌关键。     

65例中、晚期肝癌的外科治疗

中、晚期肝癌的综合治疗方法很多 ,但仍以手术切除疗效最佳。是目前唯一可获得根治效果的治疗手段。今将外科手术治疗的中、晚期肝癌 6 5例 ,报告如下。1　资料与方法1 1　一般资料　 6 5例原发性中、晚期肝癌 ,男 5 9例 ,女 6例 ,年龄 2 2～ 6 9岁 ,中位年龄 49 7岁。原发性肝细胞性肝癌 6 1例 ,胆管细胞癌 4例 ;巨块型 5 2例 ,其中癌肿直径 <10ｃｍ 2 2例 ,10～ 15ｃｍ 2 5例 ,15ｃｍ 5例 ,结节性 18例。术前合并肝硬变者占 95 7% ,ＡＦＰ阳性率 83 1% ,Ｂ超检查阳性率为 92 9%。1 2　手术方法　行右半肝切除 10例 ,左半肝切除 9例 ,肝…     

肝门部胆管癌手术治疗:附64例 报告

目的:探讨肝门部胆管癌手术方式。方法 : 回顾性分析15年间我院收治的64例肝门部胆管癌的临床资料，包括临床表现、临床分型、手术方式及治疗效果。其中35例行手术切除，包括根治性切除16例，姑息性切除19例;29例行胆管引流术，包括胆肠内引流术16例，胆管外引流术13例。结果 : 根治性切除组1，2，3年生存率分别是80.0% , 53.3%及26.7% ;姑息切除组1, 2, 3年生存率分别为50.0%, 16.7%, 0%;胆肠内引流组1,2年生存率分别是45.5%和18.2% ;外引流组则为25.0%和0 。结论:手术切除特别是根治性切除治疗是提高肝门部胆管癌疗效和提高远期生存率可选择的方法。     

肝癌破裂出血的治疗：附35例临床分析

目的探讨肝癌破裂出血的治疗方法及疗效。方法回顾分析近9年余收治的35例肝癌破裂出血患者临床资料。其中，行根治性手术12例（包括介入术后行根治性手术5例），姑息性手术9例，介入治疗19例（其中5例术后改行根治性手术）。结果根治性手术组术后彻底止血，1例术后死于肝功能衰竭；姑息性手术组术后再出血3例，其中2例死于肝功能衰竭；介入治疗组再出血1例，发生肝功能衰竭2例，死亡1例。根治性手术12例中生存1年者9例，2年者7例，5年者4例；姑息性手术9例中，生存1年者2例，2年者1例；介入治疗组14例中生存1年者8例，2年者4例，5年者1例。结论根治性手术切除是治疗肝癌破裂出血的有效方法。介入治疗止血满意，并发症少，能有效地延长患者生存期，可作为不能行切除手术患者的首选治疗方法；行介入治疗止血时可通过血管造影判断有无行根治性手术的可能，以减少不必要的急诊手术探查。     

原位肝移植70例报告

目的　探讨肝移植治疗终末期肝病的临床效果。方法　在过去2年内,70例终末期肝病患者接受了72例次原位肝移植手术,其中包括1例小儿减体肝移植。结果　手术近期死亡18例（25.7%）,随访期间死亡14例(26.9%),术后胆道并发症发生率23%,肝动脉并发症20%。术后生存时间超过6个月者30例,超过1年者17例,其中肝癌组（31例）,有9例术后生存已超过6个月,3例超过1年。结论　减少外科手术并发症是提高肝移植手术成功率以及长期存活的关键。对于肝硬化合并原发性肝癌的患者,肝移植应作为首选的治疗方法。     

损伤控制非规则性肝叶切除在外科临床中的应用

目的为提高肝内胆管结石、原发性肝癌肝叶切除水平及探讨肝脏损伤控制技术的临床应用。方法回顾分析近16年来我院101例肝内胆管结石、原发性肝癌等，除4例肝癌行规则性左半肝切除外，其余均采用非规则性肝叶切除。结果切口感染5例；肺部感染3例；膈下感染2例；胆瘘1例；高位空肠瘘1例，经非手术治疗后痊愈，1例死于肝功能衰竭。结论非规则性肝叶切除降低了手术损伤程度及手术难度，减少了手术风险、手术并发症及死亡率，取得良好的效果。     

超声引导经皮热消融治疗肝内胆管细胞癌

目的 探讨超声引导经皮热消融治疗肝内胆管细胞癌(intrahepatic cholangiocarcinooma,ICC)的临床价值.方法 1998年10月至2009年8月,14例经病理确诊的ICC患者(19个结节)于我院接受了超声引导下经皮热消融(微波或射频消融)治疗.本文对14例消融治疗的并发症及长期生存进行了回顾性分析.结果 18个结节完全消融(18/19,94.7%),1个(1/19,5.3%)消融不全.14例无一发生与消融相关的死亡,仅出现1例(1/14,7.1%)门静脉血栓.随访时间1.3～72.9个月(平均19.0个月±15.1个月,中位7.3个月).生存1年以下、1～5年、5年以上的患者分别为10例(10/14,71.4%)、2例(2/14,14.3 0A)、2例(2/14,14.3%).随访期间死亡9例(9/14,64.3%),存活5例(5/14,35.7%),肿瘤复发9例(9/14,64.3%).治疗后无瘤生存期1.1～72.9个月(平均16.6个月土26.3个月,中位4.1个月).结论 超声引导经皮热消融治疗ICC安全、有效,具有临床应用价值.

Abstract：

Objective To evaluate the clinical value of percutaneous ultrasound (US)-guided thermal ablation of intrahepatic cholangiocarcinoma. Methods 14 patients (19 nodules) with histolog-ically proven intrahepatic cholangiocarcinoma (ICC) were treated with percutaneous US-guided thermal ablation from Oct. 1998 to Aug. 2009 in our hospital. The local treatment response, complication and survival were retrospectively analyzed. Results 18 (18/19, 94.7%) nodules had complete necrosis, and 1 (1/19, 5.3%) nodule had residual tumor after ablation. There was no mortality associated with thermal ablation. Only 1 (1/14, 7.1%) patient developed portal vein thrombosis. The follow-up ranged from 1.3 to 72.9 months (mean, 19.0±15.1 months; median, 7.25 months), 10 (10/14,71.4%) patients survived less than 1 year, 2 (2/14,14.3%) survived 1-5 years, and 2 (2/14,14.3%) survived more than 5 years. Of the 14 patients, 9 (9/14, 64.3%) had died and 5 (5/14,35.7%) were alive. The causes of death included tumor progression (8/9, 88.9%) and liver failure (1/9, 11.1%). 9 (9/14,64.3%) patients developed recurrence on follow-up. The disease-free survival ranged from 1.1 to 72. 9 months (mean 16.6±26. 3 months; median 4.1 months). Conclusion Percutaneous US-guided thermal ablation therapy using microwave ablation (MWA) or radiofrequency ablation (RFA) is a safe and effective therapy for intrahepatic cholangiocarcinoma.     

肝胆管结石合并胆管癌的临床特点及防治

目的 探讨肝内胆管结石合并肝内胆管癌的临床特点及其防治.方法 对1990-2009年肝内胆管结石伴肝内胆管癌84例的临床资料进行回顾性研究.结果 肝内胆管结石合并肝内胆管癌的发生率占同期肝内胆管结石病例的4.6%(84/1840),术前明确诊断47例;肿瘤均发生于含结石的胆管处,以左肝多见;病程1～40年,平均18年.20例迟发性肝内胆管癌发生于取石后6-16年,平均9年.临床表现为久治不愈的肝脓肿、难以控制的肝内感染、肝内阻塞性进行性黄疸和影像学提示结石部位的肿瘤性改变.84例中晚期病例65例(65/84,77.4%).行根治性切除者仅35例,姑息性切除26例,射频消融4例,单纯活检19例.结论 (1)肝内胆管结石并发肝内胆管癌的概率较高.(2)对所有肝内占位性病变行术前、术中活检是避免误漏诊的重要方法.(3)早期诊断者行根治性切除可获得良好疗效.(4)对肝内结石伴胆管狭窄、肝段萎缩纤维化者行病灶肝段切除对继发胆管癌有预防作用.     

Indications for surgical treatment of intrahepatic cholangiocarcinoma with lymph node metastases

BACKGROUND/PURPOSE: The postoperative outcome of patients who have intrahepatic cholangiocarcinoma with lymph node metastases is extremely poor, and the indications for surgery for such patients have yet to be clearly established. METHODS: The demographic and clinical characteristics of 133 patients who underwent lymph node dissection during hepatic resection of intrahepatic cholangiocarcinoma were retrospectively analyzed. RESULTS: Multivariate analysis identified three independent prognostic factors: intrahepatic metastasis, nodal involvement, and tumor at the margin of resection. Of the patients with tumor-free surgical margins, none of the 24 patients who had both lymph node metastases and intrahepatic metastases survived for 3 years. In contrast, the survival rates for the 23 patients who had lymph node metastases associated with a solitary tumor were 35% at 3 years and 26% at 5 years. CONCLUSIONS: Surgery alone cannot prolong survival when both lymph node metastases and intrahepatic metastases are present, while surgery may provide a chance for long-term survival in some patients who have lymph node metastases associated with a solitary intrahepatic cholangiocarcinoma tumor.     

高位切除治疗肝门胆管癌疗效分析

目的探讨离位切除治疗晚期肝门胆管癌的疗效。方法1995～2004年收治的13例晚期肝门胆管癌均施行高位肝管切除。根据肝门胆管癌向肝内外侵犯方向和范围。分为2组。A组8例，肝门胆管癌向肝内外侵犯，其中7例侵犯肝内2、3级肝管；B组5例，2例左肝内大胆管癌侵犯右肝管，3例侵犯右侧2级肝管。A组采用肝门胆管癌骨骼化切除，中央肝切除7例、左肝叶切除1例，3—9支肝管断端重建新的肝门胆管后与空肠行Y形吻合。B组采用切除肝左叶和肝门胆管，右肝管整形后与空肠Y形吻合。结果1例术后死于肝功能衰竭，高位切除肝管的10例中存活10年1例，4年2例，2年2例。结论骨骼化切除、中央肝切除、高位肝管切除和胆肠引流重建能改善晚期肝门胆管癌的疗效。     

Surgical treatment of intrahepatic cholangiocarcinoma: four patients surviving more than five years.

BACKGROUND. To find the rational surgical strategy for the treatment of intrahepatic cholangiocarcinoma (ICC), clinical features of ICC were studied in 20 patients who underwent hepatic resection in the National Cancer Center Hospital from 1980 to 1990. METHODS. According to the morphologic pattern, we classified the ICCs into two subcategories, mass-forming and infiltrating, which correlated with their biologic behavior. RESULTS. Of 10 patients who underwent hepatectomy for mass-forming ICC, three survived more than 5 years without recurrence. The 1-, 3-, and 5-year survival rates were 59.3%, 44.4%, and 44.4%, respectively. Of 10 patients who underwent hepatectomy for infiltrating ICC, one survived more than 5 years without recurrence. The 1-, 3-, and 5-year survival rates were 72.0%, 27.0%, and 27.0%, respectively. The pathologic findings and recurrences indicated that the salient feature of the mass-forming type was its tendency for intrahepatic metastasis especially near a main lesion, and of the infiltrating type was the infiltrative spread via Glisson's capsule and hilar lymph nodal metastasis. CONCLUSIONS. An anatomic and extensive liver resection should be performed for mass-forming ICC, whereas a hepatectomy with excision of the extrahepatic bile duct and hilar lymph nodal dissection is recommended for infiltrating ICC.     

III|IV 型肝门部胆管癌的手术治疗

目的:探讨Ⅲ,Ⅳ型肝门部胆管癌的手术治疗方式和效果.方法:回顾性分析2010年4月-2013年2月期间采取手术治疗的16例Ⅲ,Ⅳ型肝门部胆管癌患者的临床资料.结果:16例中行手术切除13例,切除率为81.3％ (13/16).其中行根治性切除术(R0切除)7例,非根治性切除术6例;行左半肝+尾叶切除+右肝管成形、肝管-空肠Roux-en-Y吻合术3例,行右半肝切除+尾叶切除+左肝管成形、肝管-空肠Roux-en-Y吻合术3例,行肝方叶切除及围肝门切除+胆管开口肝门区-空肠盆式吻合术7例;其中2例因总胆红素＞400 μmm.l/L而先行经皮肝穿刺胆管引流(PTCD)后再手术.3例患者无法完成手术切除,其中2例肿瘤侵犯门静脉左右支,1例术中发现肝脏多发转移瘤,3例均行肝内扩张胆管的术中置管引流术.所有患者的术后血清总胆红素水平均明显降低或恢复至正常,术后引流有效率为100％.1例围手术期死亡.结论:对于Ⅲ,Ⅳ型肝门部胆管癌,应力争切除肿瘤,解除胆管梗阻.对肝门区胆管解剖的熟知、娴熟的手术技巧和胆大心细的操作,有望提高手术切除率.     

Aggressive surgical resection for hilar-invasive and peripheral intrahepatic cholangiocarcinoma

Abstract The clinicopathology and surgical outcome of intrahepatic cholangiocarcinomas are not fully understood. The objective of this study was to clarify the clinicopathologic features of intrahepatic cholangiocarcinoma and evaluate prognostic factors influencing survival. Forty consecutive patients with intrahepatic cholangiocarcinomas undergoing surgical resection at Chiba University Hospital between October 1981 and October 1997 were analyzed retrospectively. Intrahepatic cholangiocarcinomas were classified as hilar-invasive type (n = 26) or peripheral type (n = 14). Patients with peripheral-type tumors had a significantly (p = 0.005) better 5-year survival rate (43%) than those with the hilar-invasive type (4%). Hilar-invasive-type tumors had perineural invasion (100%) and nodal involvement (85%) more frequently than did peripheral-type tumors. Despite aggressive surgical resection, the surgical margin was positive in 88% of patients with hilar-invasive type tumors (23/26) and 29% of patients with peripheral-type tumors (4/14). There was no evidence of a survival benefit of vascular resection for patients with a hilar-invasive intrahepatic cholangiocarcinoma. Patients with lymph node metastasis had a significantly worse prognosis (p = 0.0004). No patients with nodal involvement survived more than 38 months. Negative perineural invasion (p = 0.008) and a negative microscopic margin (p = 0.008) were significantly associated with improved survival. Better survival results could be achieved by curative resection with a free margin for hilar-invasive and peripheral intrahepatic cholangiocarcinoma. Electronic Publication     

Resection of intrahepatic cholangiocarcinoma: a Western experience

We analyzed the results of an aggressive surgical approach to intrahepatic cholangiocarcinoma. Between 1990 and 1997, 30 of 42 patients with intrahepatic cholangiocarcinoma underwent resection with curative intent. Mean tumor size was 10 ± 5 cm, and the tumors were classified as TNM type III, IVa, and IVb in 63%, 34%, and 3% of the patients, respectively. All patients underwent hepaticoduodenal lymphadenectomy. Fifteen patients received adjuvant radio- and chemotherapy. The overall survival rates at 1, 2, and 3 years were 86%, 63%, and 22%, respectively, and the median survival time was 28 months. Tumor recurrence was the main cause of death. Three patients survived for more than 5 years, including 2 patients with no evidence of recurrence. Factors influencing survival were: presence of satellite nodules (P = 0.007) and lymph node invasion (P = 0.05). The width of the resection margin and the use of an adjuvant therapy had no impact on survival. Complete surgical resection may offer a chance for long-term survival in selected patients and may improve the quality of life of patients with more advanced disease. Received for publication on Dec. 14, 1998; accepted on Dec. 15, 1998     

Choledochal cysts: age of presentation,symptoms, and late complications related to Todani's classification

Purpose: The aim of this study was to compare presentation, complications, diagnosis, and treatment of choledochal cysts in pediatric and adult patients. Methods: Forty-two patients were analyzed after subdivision into 3 groups: group A, less than 2 years (n = 10); group B, 2 to 16 years (n = 11); group C, greater than 16 years (n = 21). Results: The cysts were classified as extrahepatic (n = 33), intrahepatic (n = 5), and combined (n = 4). Seventy-six percent of patients presented with abdominal pain, (20 of 21 group C), and 57% with jaundice, (10 of 10 group A). Cholangiocarcinoma occurred in 6 patients, 4 of whom had previously undergone internal drainage procedures. Excision of the extrahepatic cyst was performed in 27 of 37 patients. Five patients, of whom, 4 had cholangiocarcinoma, were beyond curative treatment at the time of diagnosis. Six patients had died at the closure of this study, 5 of them had carcinoma. Conclusions: Presenting symptoms are age dependent with jaundice prevailing in children and abdominal pain in adults. In view of the high risk of cholangiocarcinoma, early resection and not internal drainage is the appropriate treatment of extrahepatic cysts. Patients who had undergone internal drainage in the past still should undergo resection of the cyst.     

Surgical Outcome and Prognostic Factors in Intrahepatic Cholangiocarcinoma

BACKGROUND: The clinicopathologic features and surgical outcome of intrahepatic cholangiocarcinoma are not fully understood. METHODS: Fifty-six consecutive patients with intrahepatic cholangiocarcinoma who underwent surgical resection at the National Cancer Center Hospital East between October 1992 and July 2007 were retrospectively analyzed. Intrahepatic cholangiocarcinomas were subdivided into solitary tumors and tumors with intrahepatic metastasis. RESULTS: Complete tumor removal (R0 resection) was performed in 42 patients (75%). The 5-year survival rate for patients with intrahepatic cholangiocarcinoma (n = 56), patients with a solitary tumor (n = 46), and patients with intrahepatic metastasis (n = 10) were 32, 38, and 0%, respectively. There was a significant difference in survival between patients with a solitary tumor and those with intrahepatic metastasis (p < 0.0001). The 5-year survival rate for patients with stage I (n = 3), II (n = 9), III (n = 15), and IV disease (n = 26) was 100, 67, 37, and 0%, respectively. There was a significant difference in survival between stage I and stage IV (p = 0.011), between stage II and stage IV (p = 0.0002), and between stage III and stage IV (p = 0.0015). The most frequent site of recurrence was the liver. Univariate analysis showed that intrahepatic metastasis, portal vein invasion, hepatic duct invasion, lymph node metastasis, perineural invasion, and positive surgical margin (R1) were significantly associated with poor survival. Multivariate analysis confirmed that intrahepatic metastasis was a significant and independent prognostic indicator after surgical resection for intrahepatic cholangiocarcinoma (p = 0.001). No patient with intrahepatic metastasis survived more than 10 months in this study. CONCLUSIONS: Intrahepatic metastasis was the strongest predictor of poor survival in intrahepatic cholangiocarcinoma.