肝门胆管癌联合切肝的适应证

目的 提高对肝门胆管癌采用合理切肝手术的认识。方法 回顾性总结我院1988年以来的94例肝门胆管癌切除手术病例资料,将其分为切肝组（A组,35例）和非切肝组（B组,59例）对比两组的临床资料。结果 A组根治切除率为68．6％（24／35）,B组为35．6％（21／59）;1、2、3和5年生存率：A组分别为：84．19％,54．32％,39．84％,25．35％;B组为49．50％,20．42％,9．72％,3．24％。结论 肝门胆管癌采用合理的切肝手术,对提高生存率有显著影响。     

联合肝叶及血管切除重建根治术治疗肝动脉受侵肝门部胆管癌的近期随访

目的探讨联合肝叶及血管切除重建根治术治疗肝动脉受侵肝门部胆管癌(HCCA)的临床效果和预后情况。方法回顾性分析2016年10月至2019年10月肝动脉受侵HCCA患者98例资料,根据手术方式不同将患者分为联合组(HCCA根治术+肝叶切除+肝动脉切除重建术)51例和姑息组(姑息性胆管肿瘤切除术/内引流减黄手术)47例。所有数据均采用SPSS22.0软件处理分析,两组患者术中术后各项指标以(±s)表示,采用独立样本t检验。并发症比较采用χ^2检验;采用Kaplan-meier绘制患者的生存曲线;以P<0.05为差异有统计学意义。结果联合组手术时间、住院费用明显高于姑息组,但术中出血量、住院时间明显低于姑息组(P<0.05)。联合组并发症发生率为52.9%,与姑息组的42.6%比较,差异无统计学意义(P>0.05);两组均未发生围术期死亡。随访时间截至2019年11月,联合组的1年、2年、3年生存率分别为84.3%、66.7%、43.1%,,明显高于姑息组的17.0%、10.6%、4.3%(P<0.05)。结论联合肝叶及血管切除重建根治术用于治疗肝动脉受侵HCCA,可有效减少术中出血量,提高患者的生存率。     

Hilar cholangiocarcinoma involving the portal vein bifurcation: long-term results after resection

Abstract. Background/Purpose: Resection offers the only potential cure of hilar cholangiocarcinoma. Portal bifurcation involvement is often thought to contraindicate resection. We reviewed our experience with aggressive surgical management in 28 patients with hilar cholangiocarcinoma. Methods: All patients underwent hepatectomy and bile duct resection with hepaticojejunostomy. In 10 cases (group 1) the portal bifurcation was involved, necessitating portal resection and reconstruction; 18 (group 2) had no portal involvement. Frozen section of duct margins was routine. Survival was estimated using the Kaplan-Meier method and compared with the log-rank test. Results: Portal reconstruction in group 1 was by graft interposition (1), venoplasty using the posterior wall of the right portal vein (2), or end-end anastomosis (7). Hepatectomies included right trisegmentectomy (8), right lobectomy (4), and left lobectomy (16); 20 (71%) had concomitant caudate resection. Median survival was 18 months in group 1 and 32 months in group 2 (P, not significant [NS]). One-, 3-, and 5-year survivals were 60%, 22%, and 22%, respectively, in group 1 and 70%, 47%, and 38%, respectively, in group 2 (P = 0.319). Conclusions: Portal involvement by hilar cholangiocarcinoma does not contraindicate resection. Received: June 11, 2001 / Accepted: February 8, 2002     

联合肝切除术结合肝动脉重建治疗10例肝门部胆管癌临床分析

目的分析联合肝切除术结合肝动脉重建治疗肝门部胆管癌10例患者的应用效果。方法回顾性分析2016年1月至2017年2月10例均接受联合肝切除术结合肝动脉重建治疗的肝门部胆管癌患者资料,分析手术情况、围术期并发症及随访结果。结果10例患者中实施左半肝联合尾状叶切除4例(Ⅲb型),右半肝联合尾状叶切除3例(Ⅲa型),尾状叶切除2例(Ⅱ型),切除肝门部胆管及部分左内叶、右前叶及尾状叶1例(Ⅳ型);接受肝右动脉切除重建6例,肝固有动脉切除重建4例;R0切除率为80.0%,围术期均无死亡病例,术后胆瘘、消化道出血、肝动脉血栓继发胆道感染各1例(10.0%),均经保守治疗后症状好转;术后随访9~24个月,3例患者分别因肿瘤复发、肝动脉血栓、肝脓肿而死亡,术后24个月的生存率为70.0%(7/10)。结论给予肝门部胆管癌患者联合肝切除术结合肝动脉重建治疗可提高R0切除率,改善肝功能,且患者围术期并发症少、术后生存率高。     

联合血管切除及重建在进展期肝门部胆管癌切除中的危险因素及生存分析

目的:研究联合血管切除(VR)及重建(RM)在进展期肝门部胆管癌(HC)切除中的应用情况。方法:收集2007年1月—2013年1月确诊为HC的50例患者,经HC根治术联合VR及RM方案治疗,将其作为观察组,另选55例同期肝部体检的健康人作为对照组。对HC实施单因素及多因素分析,并研究不同病理分期HC患者生存情况。结果:观察组在胆总管结石、肝胆管结石、胆囊结石、胆囊切除、胆道蛔虫病、肝吸虫病、肝血吸虫病等方面所占比例均显著高于对照组,差异均有统计学意义(均P0.05) 。根据Logistic回归性分析,共有6个因素为危险因素,主要为胆总管结石、肝胆管结石、胆囊结石、胆囊切除、胆道蛔虫病和肝血吸虫疾病等。随访5年,失访1例,剩余49例均获随访。Ⅳ型HC患者1年存活率为88.9%(8/9);3年存活率为55.6%(5/9);5年存活率为33.3%(3/9)。Ⅲ型HC患者1年存活率为97.6%(40/41);3年存活率为82.9%(34/41);5年存活率为70.7%(29/41)。结论:HC根治术联合VR及RM方案治疗进展期HC,可明显提升患者的生存率,延长生存时间,疗效显著,值得临床推荐。     

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目的　探讨肝门部胆管癌不同外科治疗方法间的疗效差异。方法　回顾总结 1997～ 2 0 0 2年手术治疗的 63例肝门部胆管癌的临床资料。结果　 63例中手术切除 2 8例 ,切除率 44 4% ,其中根治性切除率为5 7 1%。切除组中 14例合并肝切除 ,其中 11例为根治切除。根治切除组与姑息切除组的平均生存期分别为 2 9个月和 12个月 ( P<0 0 5 )。切除组与引流组疗效差异有显著意义 ( P <0 0 5 )。结论　肝门部胆管癌应争取手术切除 ,合理的联合肝叶切除能提高根治性切除率 ,改善预后     

肝门部胆管癌的外科治疗(附181例报告)

目的　探讨肝门部胆管癌预后与临床病理因素的关系。方法　总结１９７８ 年至１９９７ 年手术治疗１８１ 例肝门部胆管癌的临床病理资料,以１９９１ 年为界分为两个阶段,对比手术切除率及生存期等。结果　１８１ 例中手术切除９７ 例,非切除性胆道内外引流者８４ 例,切除组中根治切除５１ 例,姑息切除４６ 例。根治切除者１、３ 、５ 年生存率分别为９５％ 、２７－５％ 和１７－５％ 。姑息切除者为４８－１％ 、７－４％ 和３－７％ ,非切除性胆道内外引流者１ 年生存率分别为４８％ 、３８－９ ％ ,无２ 年生存者。两阶段对比显示：手术切除率由４０－４％ 提高到６６－３ ％ ,其中根治切除率由１８％ 提高到３８％ 。结论　根治切除是提高肝门部胆管癌远期生存率及改善生活质量的关键,早期肿瘤,分化程度好,无淋巴转移者预后好。     

Bismuth Ⅳ型肝门部胆管癌的外科治疗

目的 探讨Bismuth Ⅳ型肝门部胆管癌的外科手术治疗效果.方法 10例病人(男2例、女8例;年龄35～74岁)术前诊断为BismuthⅣ型肝门部胆管癌.全组病人均接受手术治疗.结果 全组病人无围手术期死亡.术后主要并发症包括:胆肠吻合口瘘3例,胆瘘1例,右侧膈下脓肿形成1例,腹腔出血1例.6例病人术后分别随访12、16、22、26、28和30个月,病情稳定.其余4例病人分别于手术后9、10、11和15个月死于肿瘤转移播散.术后1年和2年的生存率分别为70%和60%.结论 BismuthⅣ型肝门部胆管癌应采取积极的外科手术治疗,选择恰当的手术治疗方式可以明显延长病人生存时间.     

联合肝叶切除及区域淋巴清扫治疗肝门部胆管癌的初步观察

目的:对联合肝叶切除及肝门区域淋巴清扫治疗肝门部胆管癌的实际效果作初步观察。方法:回顾性分析1998年至2005年间86例肝门部胆管癌病人根治性切除的临床与随访资料。结果:全组男58例,女28例,平均年龄(51.0±9.4)岁。均行骨骼化淋巴清扫,根据是否附加患侧半肝和(或)尾状叶切除分为肝切除组(53例)和未切肝组(33例)。全组获R0根治34例,术后疗效明显优于非R0根治者。肝切除组各种并发症发生率明显高于未切肝组,但术后生存期无明显差异。肝门部胆管癌淋巴结转移率较高(54.7%),淋巴结转移与否与术后疗效明显相关。结论:肝叶切除及区域淋巴清扫是提高肝门部胆管癌根治性切除率的重要手段,但是否能够达到根治性切除还有其他影响因素,应审慎决定是否施行肝叶切除。肝门部胆管癌有较高的淋巴结转移率,骨骼化淋巴清扫应成为操作规范,但何谓彻底的淋巴清扫仍待界定。     

联合血管切除重建技术在肝门部胆管癌根治术中的应用

目的 探讨肝门部胆管癌根治术中联合血管切除重建的安全性和有效性.方法 回顾性分析2014年6月至2019年12月武汉大学中南医院收治的113例确诊为肝门部胆管癌的病人,包括行姑息治疗50例(姑息治疗组),行开腹肝门部胆管癌根治术63例,其中行联合血管切除重建的肝门部胆管癌根治术26例(联合血管切除重建组),行常规肝门部...     

进展期肝门部胆管癌的扩大切除——肝切除合并肝动脉及门静脉切除重建手术的临床应用

目的：探讨肝门部胆管癌病例的外科治疗手段,分析肝脏切除同时进行门静脉或肝动脉重建在进展期病例中的应用。方法：回顾性分析解放军总医院肝胆外科2007年1月-2010年12月手术治疗的104例肝门部胆管癌患者的病例资料。结果：104例患者均行手术探查,手术根治性切除51例（49．O％）,其中合并肝门部血管切除重建13例,姑息性切除25例（24O％）,引流手术28例（26．9％）。根治手术组中位生存期27个月,姑息性切除组中位生存期16个月,引流组中位生存期11个月。根治性手术组1年生存率76％,3年生存率51％,5年生存率38％;姑息性手术组1年生存率61％,3年生存率35％,5年生存率21％;引流手术组1年生存率33％,3年生存率2．1％,5年生存率为0。     

手术切除治疗肝门部胆管癌

目的 总结肝门部胆管癌手术治疗的经验.方法 回顾性分析本院9年因肝门部胆管癌行手术切除的83例病人的临床资料和随访结果.结果 83例手术切除病人中行根治性切除（R0）31例,非根治切除52例（R1,R2）,术后出现并发症29例,死亡5例.根治性切除组中位生存期21.5个月,1、3、5年生存率分别为79.6%,43.3%和25.9%,明显优于非根治性切除组（P＜0.05），近5年本院根治性切除率达44.8%,中位生存期18.7个月,疗效明显提高（P＜0.05），结论 加强围手术期处理、术中行切缘冰冻病理检查、联合肝切除等可提高肝门部胆管癌根治性切除率、减少并发症和死亡率;根治性切除可更好延长病人生存期,使手术治疗肝门部胆管癌获得良好的疗效.     

Orthotopic liver transplantation after extended bile duct resection as treatment of hilar cholangiocarcinoma First long-terms results

Abstract Although the surgical treatment of hilar cholangiocarcinoma represents the only potentially curative option, survival figures remain low over the long term. After hilar and partial hepatic resections for hilar cholangiocarcinoma, loco-regional tumor recurrence appears as the primary site of failure. From April 1992 to April 1996, 14 patients underwent extended bile duct resections. Extended bile duct resections combine total hepatectomy, partial pancreatoduodenectomy, and liver transplantation in an attempt to eradicate the entire biliary tract without dissecting the hepatoduodenal ligament. The postoperative 60-day mortality rate was 14% ( n = 2). The rate of curative resections was 93% (13 of 14 extended bile duct resections). One- and 4-year survival rates after curative resections were 56% and 30%, respectively. The rate of curative resections increased by combining total hepatectomy, partial pancreatoduodenectomy, and liver transplantation, i.e., extended bile duct resection. However, survival figures have not improved accordingly. Therefore, this extended surgical procedure has to be implemented with caution and possibly not without modifications (e.g., multimodal treatment).     

联合肝叶及肝门部血管切除治疗肝门部胆管癌

目的 探讨联合肝叶及肝门部血管切除在肝门部胆管癌根治术中的应用.方法 回顾性分析解放军总医院肝胆外科2008年1月-2011年12月手术治疗的74例肝门部胆管癌患者的临床资料.74例患者均行手术探查,手术根治性切除33例(44.6％),其中26例联合部分肝切除及血管切除重建;行姑息性切除19例(25.7％);行内引流或外引流术22例(29.7％).结果 联合肝叶及肝门部血管切除的根治性切除组的中位生存时间为27个月,姑息性手术组的中位生存时间为14个月,引流手术组中位生存时间为9个月;根治性切除术的1、2、3年生存率分别为79％、64％、49％;姑息性手术组1、2、3年生存率分别为56％、25％、19％;引流手术组1、2、3年生存率分别为23％、15％、0.结论 根治性切除组的生存率较姑息性手术及引流手术组明显提高,合并肝叶、肝门血管切除可提高肝门胆管癌的手术根治率和生存率;联合肝叶切除有利于肝门胆管癌的根治性切除,提高生存率.     

Predictors of long term survival after hepatic resection for hilar cholangiocarcinoma: A retrospective study of 5-year survivors

AIM:To determine predictors of long term survival after resection of hilar cholangiocarcinoma(HC) by comparing patients surviving 5 years with those who survived 5 years.METHODS:This is a retrospective study of patients with pathologically proven HC who underwent surgical resection at the Gastroenterology Surgical Center,Mansoura University,Egypt between January 2002 and April 2013.All data of the patients were collected from the medical records.patients were divided into two groups according to their survival:patients surviving less than 5 years and those who survived 5 years.RESULTS:There were 34(14%) long term survivors(5 year survivors) among the 243 patients.Fiveyear survivors were younger at diagnosis than those surviving less than 5 years(mean age,50.47 ± 4.45 vs 54.59 ± 4.98,p = 0.001).Gender,clinical presentation,preoperative drainage,preoperative serum bilirubin,albumin and serum glutamic-pyruvic transaminase were similar between the two groups.The level of CA 19-9 was significantly higher in patients surviving 5 years(395.71 ± 31.43 vs 254.06 ± 42.19,p = 0.0001).Univariate analysis demonstrated nine variables to be significantly associated with survival 5 year,includingyoung age(p = 0.001),serum CA19-9(p = 0.0001),non-cirrhotic liver(p = 0.02),major hepatic resection(p = 0.001),caudate lobe resection(p = 0.006),well differentiated tumour(p = 0.03),lymph node status(0.008),R0 resection margin(p = 0.0001) and early postoperative liver cell failure(p = 0.02).CONCLUSION:Liver status,resection of caudate lobe,lymph node status,R0 resection and CA19-9 were demonstrated to be independent risk factors for long term survival.     

Extended right hepatic lobectomy with resection of inferior vena cava and portal vein for intrahepatic cholangiocarcinoma

We report a case of intrahepatic cholangiocarcinoma treated by extended right lobectomy and resection of the inferior vena cava (IVC) and portal vein. A 53-year-old man was referred with elevated serum alkaline phosphatase (ALP) and γ-glutamyl transpeptidase (γ-GTP) levels on April 23, 1999. He was not jaundiced and did not have any symptoms. Endoscopic retrograde cholangiopancreatography (ERCP) revealed irregular strictures in both the anterior and posterior segmental ducts. Contrast-enhanced computed tomography (CT) scan demonstrated a low-density tumor with an unclear margin in the right lobe of the liver. The patient underwent extended right hepatic lobectomy and total caudate lobectomy. Partial resection of the IVC (6 cm) was performed under total hepatic vascular exclusion. The main portal trunk and left portal vein were resected and reconstructed with an end-to-end anastomosis. Macroscopically, a 5.0 × 5.0 × 4.5-cm periductal infiltrating-type tumor occupied the right hepatic parenchyma along the posterior and anterior segmental ducts. Histological examination revealed moderately differentiated tubular adenocarcinoma with marked perineural invasion. Lymph node metastasis was observed in the hepatoduodenal ligament and posterior surface of the pancreatic head. The resected margins of the common bile duct and left hepatic duct were free of tumor. The patient's postoperative course was uneventful, and he was discharged from hospital on the 28th postoperative day. Nine months after the operation, he suddenly developed obstructive jaundice, and died with recurrent disease. This is the first reported case of intrahepatic cholangiocarcinoma treated with major hepatectomy and resection of the IVC and portal vein except ex situ procedure. This aggressive surgical approach may offer hope for patients with intrahepatic cholangiocarcinoma involving the IVC. Received: March 27, 2000 / Accepted: August 8, 2000     

Treatment strategy for hilar cholangiocarcinoma, with special reference to the limits of ductal resection in right-sided hepatectomies

The surgical anatomy of the hepatic hilar region is characterized by the three-dimensional formation of the branches of the bile duct, portal vein, and hepatic artery. The limit of ductal resection in hepatectomy for hilar cholangiocarcinoma is the most peripheral point where the hepatic ducts can be separated from the vasculature. The limit is different for each type of hepatectomy because the portal vein branches that should be preserved or divided vary with the extent of the hepatectomy, and therefore the limit of separation of the hepatic ducts differs. Surgeons are required to understand the surgical anatomy and to identify the precise area of cancer spread on a preoperative cholangiogram so as to choose the appropriate type of hepatectomy, and to ensure that the remnant ductal margin is cancer-negative. This article is a translated excerpt from a work entitled “Surgical anatomy of the hepatic hilum” (S. Kondo, S. Hirano, et al.), originally published in Japanese, without an English abstract, in the Journal of Gastroenterological Imaging in 2004 (6:337–43). The publishers have granted permission for the use of the material as a secondary publication in English.     

肝门部胆管癌切除术中的血管切除重建

目的 探讨血管切除重建在肝门部胆管癌切除术中的价值.方法 2000年1月至2009年9月收治的肝门部胆管癌手术切除患者中,17例合并血管切除或重建,其中男性10例,女性7例,年龄30～72岁,平均53岁.病程4～30 d,平均(21±8)d.门静脉部分切除端端吻合6例,门静脉壁楔形切除、缝合修补3例,肝动脉结扎切除1例,肝动脉切除端端吻合2例,门静脉动脉化1例,1例同时行门静脉壁楔形切除+肝动脉结扎切除,2例同时行门静脉部分切除端端吻合+肝动脉部分切除端端吻合,1例同时行门静脉部分切除端端吻合+肝右动脉、胃十二指肠动脉端端吻合.对患者的临床资料进行分析.结果 住院死亡4例,病死率4/17,3例为术后出现肾功能不全后继发多器官功能衰竭,1例死于感染性休克.未死亡的13例患者中,6例恢复过程顺利,无并发症;7例发生并发症:3例胆瘘,1例呼吸衰竭,1例因U管阻塞发生胆管炎,1例腹腔内感染、门静脉血栓形成,1例远期门静脉狭窄、肝脓肿.中位生存期18个月,4例至今尚存活.结论 肝门部胆管癌切除联合血管切除重建有利于提高切除率但术后风险仍高,术后应警惕并发症的发生;肝动脉切除重建可能有利于降低术后风险.

Abstract：

Objective To investigate the value of vascular resection and reconstruction in resection of hilar cholangiocarcinoma.Methods The clinical data of 17 patients with hilar cholangiocarcinoma received resection in combination with vascular resection and reconstruction from January 2000 to September 2009 was retrospectively analyzed.Among the 17 patients,6 underwent portal vein segmental resection and end-to-end anastomosis,3 underwent portal vein wedge resection,1 underwent hepatic artery ligature,2 underwent hepatic artery segmental resection and end-to-end anastomosis,1 underwent portal vein arterialization,1 underwent portal vein wedge resection and hepatic artery ligature simultaneously,2 underwent portal vein segmental resection and heapatic artery segmental resection and end-to-end anastomosis simultaneously,1 underwent portal vein segmental resection and right heapatic artery and gastroduodenal artery end-to-end anastomosis simultaneously.Results Four patients died and the mortality was 4/17.Three patients died of renal dysfunction followed with multiple organ dysfunction and 1 patient died of sepsis shock.Among the 13 survive patients,6 had a smooth postoperative recover and 7 developed complications:3 had bile leakage,1 had respiratory failure,1 had cholangitis due to obstruction of U tube,1 had abdominal infection and thrombosis in portal vein system and 1 had portal vein stenosis and liver abscess.Follow-up investigation showed that the median survival time was 18 months and four patients still alive.Conclusions Combination of vascular resection and reconstruction in the resection of hilar cholangiocarcinoma may help to improve the resection rate but still have a high postoperative risk.The complications of renal dysfunction should be alert during the postoperative observation.The procedure of hepatic arterial reconstruction may help to reduce postoperative morbidity.     

腹腔镜在肝门部胆管癌切除术中的应用

目的探讨腹腔镜肝门部胆管癌切除术的可行性。方法2007年3月至2008年8月完成4例腹腔镜肝门部胆管癌手术,术中解剖肝十二指肠韧带,分离显露出胆总管、肝总动脉、门静脉,低位横断胆总管,将肝十二指肠韧带骨骼化,胆囊自肝床分离,切断显露的左右肝管,远端及近端切缘送冰冻病理,结果回报阴性。从肝固有韧带分离并切除肿瘤、胆囊及淋巴结。在消化道的重建步骤中,先进行左右肝管成型,然后将其与空肠施行Roux-en—Y吻合。总结病例资料及手术录像,进行分析。结果4例手术均在腹腔镜下顺利完成,无中转开腹,胆管切缘阴性,手术时间5．5～8．5h,平均6．4h,术中出血260～850ml,平均440ml,无围手术期并发症及死亡发生。结论由有丰富腹腔镜及肝胆外科经验的外科医师操作,腹腔镜肝门部胆管癌切除术在技术上是可行的。