选择性胆管外引流在肝门部胆管癌根治性切除术中的应用

目的 观察选择性胆管外引流在肝门部胆管癌根治性切除术中的价值.方法 总结2000年1月至2008年1月收治的118例肝门部胆管癌的临床资料.结果 选择性胆管外引流后行手术治疗25例,其中右肝管引流12例,左肝管引流10例,左肝外叶胆管引流1例,右后叶胆管引流2例;腹腔广泛种植转移1例,左或右半肝及尾状叶切除22例,扩大左肝切除1例,扩大右肝切除1例;术后胆漏3例,肺部及腹腔感染各1例,围手术期肝功能衰竭死亡1例;其余24例病人术后随访3个月至5年,平均23个月,其中最长的1例已存活4年4个月.结论 选择性胆管外引流可以达到与全肝胆道外引流相似的改善肝功的目的 ,同时选择性胆管外引流也可以较安全的在肝门部胆管癌根治术予以应用.     

选择性胆管外引流在肝门部胆管癌根治性切除术中的应用

目的 观察选择性胆管外引流在肝门部胆管癌根治性切除术中的价值.方法 总结2000年1月至2008年1月收治的118例肝门部胆管癌的临床资料.结果 选择性胆管外引流后行手术治疗25例,其中右肝管引流12例,左肝管引流10例,左肝外叶胆管引流1例,右后叶胆管引流2例;腹腔广泛种植转移1例,左或右半肝及尾状叶切除22例,扩大左肝切除1例,扩大右肝切除1例;术后胆漏3例,肺部及腹腔感染各1例,围手术期肝功能衰竭死亡1例;其余24例病人术后随访3个月至5年,平均23个月,其中最长的1例已存活4年4个月.结论 选择性胆管外引流可以达到与全肝胆道外引流相似的改善肝功的目的 ,同时选择性胆管外引流也可以较安全的在肝门部胆管癌根治术予以应用.     

肝门胆管癌根治性切除的结果和预后

目的:评估肝门胆管癌根治性切除的治疗效果,分析影响预后的因素。方法 :回顾性分析2004年3月至2014年12月我院肝移植中心单个治疗组手术切除肝门胆管癌病人的临床资料和随访结果 ,分析影响病人预后的因素。结果:166例肝门胆管癌病人接受治疗,其中127例经手术切除,切除率为76.5%。手术切除病人的1、3、5年生存率分别为72.0%、34.0%、20.0%。中位生存时间为22.9个月。术后发生并发症共35例(27.6%),其中死亡3例,2例为肝功能衰竭,1例为消化道大出血,死亡率为2.4%。单因素Log-Rank检测结果显示,手术切缘(χ~2=50.30,P<0.001)为重要的预后影响因素。多因素分析显示,手术切缘阳性及肿瘤TNM分期差为肝门胆管癌的独立预后不良因素。结论:肝门胆管癌的治疗以手术切除为主,根治性切除(R0切除)是改善病人预后的最佳选择,扩大手术切除范围可提高R0切除率,但需充分的术前评估和准备,以减少术后并发症和死亡率。     

肝切除在肝门胆管癌根治术中应用

目的 总结肝切除在肝门部胆管癌根治术中应用经验.方法 回顾分析1993年1月至2007年12月手术切除的肝门部胆管癌病人临床资料及随访结果.结果 全组共有69例肝门胆管癌,切除率66.4%(69/104).其中局部切除31例;合并肝叶部分切除38例;合并胰头十二指肠切除3例;合并门静脉壁部分切除2例.根治手术为44例.手术根治切除率由28.2%(2000年以前)提高到50.8%(2000年后),肝功能衰竭、感染等严重并发症以及围术期死亡率均控制较好.总体1,2,3年生存率为73.9%,38.4%和14.9%,根治手术1,2,3年生存率分别为87.1%,58.2%和23.6%,非根治切除1,2,3年生存率分别为44.0%,21.6%和11.4%.结论 根治性切除的生存率比非根治切除显著提高,联合肝部分切除能明显提高根治性手术的切除率,可考虑为首要的治疗选择.     

肝门部胆管癌术前行门静脉栓塞以提高较大肝切除术的安全性

对于肝门部胆管癌合并黄疸施行较大的肝切除术,由于术后易发生肝功能衰竭而具有较高的死亡率和并发症发生率.为了最大限度地减少术后肝功能不全的发生,作者从1982年6月始,对14例肝门部胆管癌患者术前行门静脉支栓塞(PE),以使将要切除的肝叶萎缩,保留的肝叶代偿性增大,并避免在肝切     

哑铃式肝门部胆管癌根治术

手术切除是目前治疗肝门部胆管癌最有效的手段,切除范围不足是术后肿瘤复发的主要因素之一.近年来国内外趋于实施扩大的根治性切除,能够提高远期生存率,但大范围肝叶切除的主要风险是术后发生肝功能衰竭.本文报道一种既保证足够的肝内外胆管切除范围、又最大限度地减少肝组织切除的肝门部胆管癌根治性切除术式.该术式的切除范围包括肝Ⅳb段、右肝蒂前部分肝Ⅴ段的肝组织,左右肝管、分叉部、肝外胆管及尾状叶(肝Ⅰ段),同时行肝门区血管骨髂化及至少包括第2站淋巴结的清扫.因所切除组织整体上形似哑铃状,我们称之为“哑铃”式肝门部胆管癌根治术.手术指征:(1) BisnuthⅡ型肝门部胆管癌,以及部分肿瘤局限于一级肝管内的Ⅲa、Ⅲb型肝门部胆管癌;(2)无门静脉分叉部或左右支受侵;(3)第3站淋巴结无转移;(4)无肝内或远处组织器官转移.本研究23例患者完成该术式,术前多数患者TBil＞ 300 μmol/L,均未行PTCD或胆管内支架引流.平均手术时间为355 min.术中平均出血量为350 ml.患者1、3年无瘤生存率分别为95.7％(22/23)和7/15.其结果表明:该术式适宜于我国目前条件下BismuthⅡ型肝门部胆管癌及部分肿瘤局限于一级肝管内的Ⅲa型或Ⅲb型的患者.     

门静脉动脉化在肝门部胆管癌根治术中的应用价值

目的探讨肝动脉重建加门静脉动脉化在肝门部胆管癌根治性切除术中应用的安全性和有效性。方法对笔者所在医院2016年10月收治的1例Bismuth-Corlette分型Ⅳ型肝门部中晚期胆管癌患者施行扩大左半肝切除加尾叶切除术并采用肝固有动脉与门静脉吻合行门静脉动脉化的患者进行回顾性分析。结果患者术后恢复顺利,肝功能逐渐恢复正常,术后未发生急性肝功能衰竭、吻合口栓塞、胆道感染等并发症,随访截至2017年8月(术后10个月)未发现门静脉高压症及肿瘤复发征象。结论该例患者的结果提示,门静脉动脉化在肝门部胆管癌行扩大根治术中使用可防止急性肝功能衰竭,促进术后肝功能恢复,提高肝门部胆管癌的根治性切除率。     

肝部分切除联合肝十二指肠韧带骨骼化治疗肝门部胆管癌

目的 总结应用肝部分切除联合肝十二指肠骨骼化治疗肝门部胆管癌的临床经验。方法回顾1999年1月～2001年12月手术治疗67例肝门胆管癌的临床资料。结果67例患者中65例手术切除,49例根治性切除(22例肝十二指肠韧带骨骼化切除,27例联合部分肝切除)。根据Bismuth分型,Ⅰ、Ⅱ型行骨骼化切除,Ⅲa型行右半肝加右尾叶切除,Ⅲb型行左半肝加左尾叶切除,Ⅳ型中行右半肝加全尾叶3例切除,左半肝加全尾叶9例切除,方叶切除者2例。2例外院曾行部分肿瘤切除加肝门胆管空肠吻合术者,我们再次行左半肝加全尾叶切除加右肝管空肠吻合术根治肿瘤。8例患者行肿瘤部分切除加肝内胆管支撑加肝门胆管空肠吻合。13例患者行门静脉部分切除,27例患者切除肝动脉。24例患者术后无并发症发生,加例发生了严重并发症。后者中14例经治疗后康复,余6例患者术后7、12、14、42、57、89d死于肝功能衰竭、心源性休克、腹内大出血、消化道大出血。术后30d病死率4、5％,根治性手术后患者中位生存期16个月(1个月～41个月),姑息治疗者为7个月(1个月～16个月)。结论 肝部分切除联合肝十二指肠韧带骨骼化可用以根治肝门部胆管癌,尾叶切除可提高根治性切除率。     

合并肝动脉切除重建的肝门部胆管癌根治术

目的观察肝动脉切除重建在肝门部胆管癌治疗中的价值。方法1998年1月至2005年12月计收治125例肝门部胆管癌，其中行肝动脉切除13例，对该资料进行分析。结果在行肝动脉切除13例中，同时合并门静脉切除重建3例，其中部分肝固有动脉＋右或左肝动脉切除联合左或右半肝及尾状叶切除10例，局部切除联合肝固有动脉切除1例，部分肝固有动脉＋右或左肝动脉切除联合扩大左或右半肝及尾状叶切除各1例，肝动脉切除后未重建2例。术后胆肠吻合口漏4例，围手术期肝功能衰竭死亡1例，其余12例病人术后随访4个月至6年，平均20个月，其中最长的1例已存活5年5个月。结论肝动脉切除重建可提高肝门部胆管癌的治愈切除率，改善术后病人预后；肝脏大部切除联合肝动脉切除在中、重度黄疸病人须重建动脉血供。     

肝门部胆管癌胆道引流后扩大的肝右叶切除的结果

虽然肝门部胆管癌的可切率不断增加,但对本病的最佳洽疗方案仍有争议.本文旨在对肝门部胆管癌胆道引流后的扩大的肝右叶切除术(ERH)进行评价.讨论与围术期有关的实验室资料、肝内未予引流的胆道树的分布和范围、肝段的量以及无病生存期.方法与结果 作者对25例患肝门部或弥散性胆管癌病人施行肝外胆管切除术和区域淋巴结清扫(EBDR)并扩大的肝右叶切除.在行ERH病人中6例病人加作胰十二指肠切除术(PD),未加作19例.扩大的肝右叶切除术包括切除肝右叶并左内叶下段,加作或不加作左尾叶切除.其余12例行下列手术:EBDR1例,EBDR加左内叶下部和尾叶切除2例,EBDR并右前叶切除和PD1例,EBDR并左肝     

仅保留门静脉血供的肝门部胆管癌根治术

目的 探讨仅保留门静脉血供的肝门部胆管癌根治术的适应证和方法,以进一步提高肝门胆管癌的治疗效果.方法 对2006年7月至2007年12月收治的6例肝门部胆管癌,均采取左半肝切除、肝外胆管切除、肝动脉切除、右肝管空肠吻合术. 结果6例均顺利恢复,术后发生胆漏1例、无肝功能衰竭及围手术期死亡病例;术后随访10～23个月,均存活.结论 仅保留门静脉血供的肝门部胆管癌根治术在严格掌握适应证的前提下是可行的,可提高肝门部胆管癌的根治切除率,改善患者预后.     

Management strategies in resection for hilar cholangiocarcinoma.

Between 1960 and 1990, resection was performed in 23 of 122 patients who underwent surgical treatment for hilar cholangiocarcinoma. Local excision of the lesion alone was performed in 10 cases (43%). Hepatic resection for tumor extending to the secondary bile ducts or hepatic parenchyma was performed in 13 cases (57%): extended right hepatectomy (3), right hepatectomy (1), extended left hepatectomy (6), left hepatectomy (2), and left lobectectomy (1). In three other cases, resection by total hepatectomy and liver transplantation was performed, but these were not included in the analysis of results for resection. Significant operative complications occurred in only two cases (8.7%), and the operative mortality rate was zero. In four cases, complete excision of the tumor could not be achieved macroscopically (macroscopic curative resection rate 19/122; 15.6%). In nine cases, the margins of the resected specimens were free from tumor on histologic examination (microscopic curative resection rate, 9/122; 7.4%). In 10 cases, the resection margins were found to contain tumor on histologic examination. The overall survival rate was 87% at 1 year, 63% at 2 years, and 25% at 3 years (median survival, 24 months). The survival and freedom from recurrence rates for patients with free resection margins was superior to that for patients with involved resection margins or residual macroscopic disease. A potentially curative resection, with histologically negative margins and no recurrence to date, was achieved in seven patients using the following procedures: local excision for two type I lesions; left hepatectomy plus excision of segment 1 for two type IIIb lesions and one type IV lesion; right hepatectomy and right hepatectomy plus excision of segment 1 for two type IIIa lesions. These results indicate that improved survival in hilar cholangiocarcinoma can be achieved by resection, with minimal morbidity and zero mortality rates, if histologically free resection margins are obtained. To achieve this, we recommend the following procedures for each type of lesion, based on our experience and on anatomic considerations: local excision for type I; local excision plus resection of segment 1 for type II; local excision, resection of segment 1, and right or left hepatectomy for types IIIa and b; hepatectomy plus liver transplantation for type IV.     

保留下腔静脉的离体低温右肝扩大切除治疗不可切除IV型肝门部胆管癌

目的:探讨保留下腔静脉的离体低温肝切除治疗不可切除Ⅳ型肝门部胆管癌的效果.方法:回顾性分析2例Ⅳ型肝门部胆管癌患者临床资料,其中1例行保留下腔静脉的原位低温灌注扩大右肝切除术,另1例采用保留下腔静脉的全离体扩大右肝切除治疗.结果:原位低温灌注扩大右肝切除术历时14h,术中输血3 000 mL,然而,患者术后第1天死于多器官功能衰竭.全离体扩大右肝切除术历时15h,术中输血2 000 mL,热缺血时间20 min,冷缺血时间195 min,术后30d出院,无肝衰和其他重大并发症发生,随访11个月,患者仍然存活且无血管、胆管并发症及肿瘤复发和转移.结论:在有复杂肝切除经验和活体肝移植经验的前体下,保留下腔静脉的离体低温肝切除是安全的,且可能是治疗精选的不可切除Ⅳ型肝门部胆管癌的有效选择.     

肝切除、肝门-空肠吻合治疗Bismuth Ⅳ肝门部胆管癌

目的 探讨肝切除、肝门-空肠吻合治疗Bismuth Ⅳ型肝门部胆管癌.方法 9例Bismuth Ⅳ型肝门部胆管癌均行肝切除(Ⅳb段、Ⅴ段及尾状叶部分肝组织切除),胆道的重建采用肝门-空肠吻合,所有胆管分支均不结扎,均汇人肝门胆汁湖.结果 9例患者均行肝切除、达到Rο根治性切除、肝门-空肠吻合.围手术期无死亡,术后四周血清AST、ALT、TB明显下降.术后出现胆漏1例、胆道少量出血1例、伤口感染1例,4例均经保守治疗后顺利出院.Karnofsky评分平均为86分.平均随访24.9(9～42)个月,1例于术后9个月死于肿瘤肝内转移,1例于术后17个月死于肿瘤腹腔广泛转移,其余7例目前健康生存,术后已平均生存28.3个月.结论 肝切除、肝门-空肠吻合可提高肝门部胆管癌手术根治切除率、利于胆道通畅引流,延长患者生存时间.     

Preoperative biliary drainage for biliary tract and ampullary carcinomas

We posed six clinical questions (CQ) on preoperative biliary drainage and organized all pertinent evidence regarding these questions. CQ 1. Is preoperative biliary drainage necessary for patients with jaundice? The indications for preoperative drainage for jaundiced patients are changing greatly. Many reports state that, excluding conditions such as cholangitis and liver dysfunction, biliary drainage is not necessary before pancreatoduodenectomy or less invasive surgery. However, the morbidity and mortality of extended hepatectomy for biliary cancer is still high, and the most common cause of death is hepatic failure; therefore, preoperative biliary drainage is desirable in patients who are to undergo extended hepatectomy. CQ 2. What procedures are appropriate for preoperative biliary drainage? There are three methods of biliary drainage: percutaneous transhepatic biliary drainage (PTBD), endoscopic nasobiliary drainage (ENBD) or endoscopic retrograde biliary drainage (ERBD), and surgical drainage. ERBD is an internal drainage method, and PTBD and ENBD are external methods. However, there are no reports of comparisons of preoperative biliary drainage methods using randomized controlled trials (RCTs). Thus, at this point, a method should be used that can be safely performed with the equipment and techniques available at each facility. CQ 3. Which is better, unilateral or bilateral biliary drainage, in malignant hilar obstruction? Unilateral biliary drainage of the future remnant hepatic lobe is usually enough even when intrahepatic bile ducts are separated into multiple units due to hilar malignancy. Bilateral biliary drainage should be considered in the following cases: those in which the operative procedure is difficult to determine before biliary drainage; those in which cholangitis has developed after unilateral drainage; and those in which the decrease in serum bilirubin after unilateral drainage is very slow. CQ 4. What is the best treatment for post-drainage fever? The most likely cause of high fever in patients with biliary drainage is cholangitis due to problems with the existing drainage catheter or segmental cholangitis if an undrained segment is left. In the latter case, urgent drainage is required. CQ 5. Is bile culture necessary in patients with biliary drainage who are to undergo surgery? Monitoring of bile cultures is necessary for patients with biliary drainage to determine the appropriate use of antibiotics during the perioperative period. CQ 6. Is bile replacement useful for patients with external biliary drainage? Maintenance of the enterohepatic bile circulation is vitally important. Thus, preoperative bile replacement in patients with external biliary drainage is very likely to be effective when highly invasive surgery (e.g., extended hepatectomy for hilar cholangiocarcinoma) is planned.     

围肝门胆道手术方式方法的探讨附79例报告

目的探讨围肝门胆道手术的术式选择及手术技巧。方法2003年6月至2007年6月进行的围肝门胆道手术79例，其中肝门胆管癌22例（按Bismuth分型，Ⅳ型16例，Ⅲ型6例）；肝癌侵犯肝门7例；胆囊癌侵及肝门20例；肝移植术后肝门胆管狭窄4例；伴左右肝管起始部病变的肝内胆管结石22例。Ⅲ型Mirrizzi综合征4例。手术中将肝门部分为三个区域：门口、门外和门内，分别使用肝门显露技术、肝十二指肠韧带骨骼化技术和肝门拆开技术来处理，联合应用可显露病灶并切除之。然后通过肝管成形、胆肠吻合等技术完成胆道引流。结果79例患者均顺利完成手术，9例BismuthⅣ肝门部胆管癌获得根治性切除（56．3％）。本组患者均恢复良好，无重大并发症发生，无围手术期死亡病例。平均手术时间3．5h，平均出血量为450ml，大部分患者不需要输血即可以完成手术。切口感染4／79例；肺部感染、肺不张10／79例；胆瘘6／79例，经保守治疗，通畅引流10～28d后治愈。结论围肝门胆管是围肝门手术的核心，门口、门外和门内三技术的联合应用大大地提高了围肝门病灶的切除率，是成功手术的关键之所在。     

肝门区域血管阻断肝段切除335例报告

目的总结在肝门H沟中阻断各肝叶、肝段或肝亚段的入肝血管分支,施行各种类型肝切除的经验。方法回顾性分析四川大学华西医院和成都康桥医院1987-2006年行肝门区域血管阻断肝段切除的335例病人资料,其中根据肿瘤的部位和大小分别行大型肝切除(65例)、间隔性多个肝亚段切除(15例)、邻接多个肝亚段切除(209例)和单个肝亚段切除(46例)。结果术后死亡10例(3.0%)。死于肝衰8例,出血2例。肝细胞癌(HCC)存活10~19年8例,肝内胆管癌术后存活0.5~3年。肝门胆管癌存活11年、5年、4年各1例。胆囊癌存活0.5~1年。良性肝病切肝后皆痊愈。6例肝内胆管结石尚需处理他处残留结石。结论(1)间隔性多个肝段切除是一次手术治愈多支肝内胆管簇集性结石的有效方法。(2)该手术避免了全阻断入肝血流,缩小了术中肝缺血的范围,有效地减少了术中失血,提高了大肝癌的切除率,减轻了术后肝功能损害,是一个合理、有效、成本低廉的切肝手术方法。(3)从术后长期存活者体会乙肝的现代治疗对预防肝癌的转移和复发有重要意义。     

Recent advances in the treatment of hilar cholangiocarcinoma: portal vein embolization

The clinical application of portal vein embolization (PVE) has contributed to improving the postoperative outcome of hilar cholangiocarcinoma. The enlarged nonembolized lobe after PVE protects the patient from postoperative hepatic failure, due to the increased functional reserve, and shortens the hospital stay. Although numerous reports have shown beneficial effects of PVE on postoperative outcome after extended hepatectomy, no randomized controlled study has been performed so far. It is urgent to establish a “gold standard” of PVE, because the indications, approach to the portal vein, types of embolic materials, and methods used to evaluate the function of the future liver remnant are variable among institutions. The indications and procedures of PVE for hilar cholangiocarcinoma may be different from those for hepatocellular carcinoma or colorectal metastasis, because, in many patients with hilar cholangiocarcinoma, biliary cancer is associated with biliary obstruction and cholangitis. This review article summarizes the contribution of PVE to the outcome of postoperative management in patients with hilar cholangiocarcinoma needing extended hepatectomy. We also describe our PVE procedure, which has been established from our experience of more than 240 cases of biliary cancer. Furthermore, the drawbacks of PVE, which may reduce the pool of candidates for surgery, are also discussed.     

肝部分切除治疗肝内胆管结石50例体会

目的探讨肝部分切除术治疗肝内胆管结石的疗效。方法回顾分析1997年1月至2004年6月50例肝内胆管结石采用肝切除治疗的术式和治疗效果。结果围手术期死亡2例,1例术中出血,1例术后中毒性休克继发肝、肾功能衰竭,手术病死率4.0%。术后残余结石7例,经术后胆道镜治疗,均取净结石。33例获随访1月至7年,2例症状复发,仅于发作时在当地抗炎治疗。1例肝胆管癌者术后4月死于全身衰竭。结论肝切除是治疗肝内胆管结石的有效手段,对于多数病人来说,附加引流术是必要的,规则的右肝切除需有丰富的经验和娴熟的技巧,应尽可能避免行急诊肝切除手术,术中、术后胆道镜是提高疗效的重要措施。     

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??Objective:Present the experience on a variety of hepatectomy by occluding the branches of hepatic artery(HA) and portal vein(PV) to the liver lobe,segment or subsegments in hilar H fissure for 335 patients from 1978 to 2006. Methods:According to the size and location of liver tumor,major hepatectomy (65 cases),resection of separated hepatic subsegments (15cases,HS),resection of adjacent HS (209 cases),and resection of single HS(46 cases) were used to treat these patients. Results:??1??Operative mortality rate was 3.0%(10/335,8 for liver failure and 2 for bleeding)??2??Long??term survival:8 HCC patients survived for 10-19 years.11,5,4 years survival for 1 patient respectively in hilar cholangiocarcinoma.1/2-3years survival for intrahepatic cholangiocarcinoma.1/2-1 year survival for carcinoma of gallbladder.All patients of benign liver diseases were cured. Conclusion:??1??Separated multiple hepatic subsegmentectomy is an effective procedure in one operation to cure the compacted stones in 2-6 subsegmental hepatic ducts both in right and left lobes.??2??This procedure is reasonable,effective and low cost for hepatectomy.??3??Current treatment of B hepatitis is essential for preventing metastasis or recurrence after resection of HCC associated with B hepatitis based on the experience of long??term survivals.