肝圆韧带在肝门部胆管癌手术中的应用

2002～2006年，我们在肝门部胆管癌手术中应用肝圆韧带包绕胆肠吻合，效果良好。现报告如下。 临床资料：全组12例，男8例，女4例；年龄52～72岁。Bismuth分型Ⅰ型2例，Ⅱ型3例，Ⅲ型7例。其中3例合并肝内胆管结石，2例合并慢性乙肝中度肝硬化。术后病理皆证实为胆管腺癌。     

87例肝门部胆管癌手术切除的诊疗分析

目的分析手术切除治疗肝门部胆管癌的疗效及技术要点。方法回顾性分析87例肝门部胆管癌患者行肝管高位切除及联合肝切除、肝肠吻合术及姑息性手术的临床资料。总结患者的手术方式,并发症发生情况,观察患者术后5年生存率。结果手术切除率为72.4%(63/87),姑息性引流率为27.6%(24/87)。术后病理结果均回报为胆管细胞癌,63例患者行手术切除,其中根治性切除(R0)占69.8%(44/63),姑息性切除(R1、R2)占30.2%(19/63),姑息性引流24例。围手术期死亡患者3例(2.3%),术后发生胆漏的患者13例(14.9%),术后发生应激性上消化道出血4例(4.6%),其他并发症如发生腹腔出血3例(3.4%),腹腔感染5例(5.7%),肝性脑病8例(9.2%),胸腔积液7例(8.0%),切口感染或裂开者6例(6.9%)。随访患者5年,根治性切除术组的患者5年生存率(28.4%)明显高于姑息性切除组(14.1%)及姑息性引流组(0)。结论肝门部胆管癌手术复杂,连同尾状叶的左、右半肝切除治疗肝门部胆管癌有助于提高根治性手术切除率,并能明显提高患者5年生存率。     

联合血管切除与重建在肝门部胆管癌外科治疗中的应用

肝门部胆管癌的外科治疗是肝胆外科领域中最具挑战性的常规手术之一。而血管侵犯是导致肝门部胆管癌根治性切除率低的重要原因。目前,学者们普遍公认受侵犯的门静脉切除重建是提高肝门部胆管癌R0切除率以及远期生存率的关键因素。然而,对于肝动脉受侵犯以后是否行切除重建目前仍存争议。结合既往文献和本中心临床治疗实践,阐述了联合血管切除与重建在肝门部胆管癌外科治疗中的应用及前景。指出随着计算机辅助外科技术的进步,以及更多病例资料的总结,联合血管切除重建在肝门部胆管癌中的适应证及远期疗效等问题仍需要进一步探索和研究。     

刮吸解剖法在直视微创治疗高龄急性胆道感染中的应用

近年来,高龄患者发生急性胆道感染的几率明显提高,而且大多伴随一个或多个基础病变,少数患者已有胆道手术史[1],腹腔内黏连严重.常规经腹直肌或肋缘下切口进腹手术虽然可以解决该类疾病,却违背了"外科微创治疗"的理念,而同样具有微创手术优点的直视微创手术则有它独特的优势和易推广性[2].     

肝门胆管癌手术进展与争论

肝门胆管癌由于位置的特殊和不良的预后一直是外科医生关注的重点.目前手术是唯一可以治愈肝门胆管癌的手段,但是其面临的风险很大,难点较多,探索性的进步也很快.本文就目前在围手术期的处理和手术技能的发展与争论作一述评,以期帮助临床外科医生积极投身到提高技能的实践中去.     

肝门部胆管癌的手术治疗

对33例肝门部胆管癌患者的治疗进行回顾性分析。认为手术是治疗该病的重要方法,术中肝门板电凝锐性解剖及由上而下切除可提高肿瘤切除率,根治性切除术可提高患者生存率。     

肝门部胆管癌手术切除范围的争议及诊疗进展

肝门部胆管癌(HCCA)是肝外胆管常见的恶性肿瘤,具有解剖位置特殊、肿瘤沿胆管生长、肿瘤恶性程度高、易侵犯肝实质等特点。目前HCCA主要的治疗方式包括手术切除、非手术胆道引流、新辅助放化疗、光动力学疗法等,但手术切除仍是其首选方法。关于HCCA术前是否需要减黄和门静脉栓塞及手术切除范围一直存在争议。对HCCA的临床分型、术前检查及诊断、治疗方法的进展进行阐述。     

复杂性肝门胆管癌手术根治的新技术

复杂性肝门胆管癌是肝脏外科面临的巨大挑战。不仅手术难度高,手术风险更大且R0切除率低。而R0切除、侵犯淋巴结及血管切除被认为是三个独立的预后因素。近年来的手术技术进步主要包括了利用现代的影像3D技术实施术中的精准切除,对适合的患者实施保留肝实质的根治性肿瘤切除、联合肝叶及血管的切除以及合理的淋巴结清扫,以期望提高BismuthⅢ、Ⅳ型的复杂性肝门胆管癌有效切除率,提升患者的生存质量,延长生存期。     

Technical considerations for the management of primary cholangiocarcinoma of the porta hepatis

Surgical management of primary hilar cholangio-carcinoma remains challenging and controversial. Our policy in dealing with the disease includes local resection of the tumor with the bifurcation of the common hepatic duct, or combined tumor and liver resection with or without resection of the regional vascular structures. The various technical options regarding these alternatives have been described in detail in this article.     

Neurofibroma of the porta hepatis

Neurofibromas are generally well-circumscribed tumors of the nervous system, often found in association with neurofibromatosis 1 (NF1). They uncommonly present as a single sporadic form in the retroperitoneum and in the pancreas. We present a case of a 40-year-old man who presented with a 4- to 5-year history of right upper quadrant pain with associated nausea and vomiting. Medical imaging showed a 3.8 by 3.4-cm mass encasing the hepatic artery and the porta hepatis. Surgical resection was performed, with removal of the gallbladder. The mass was histologically diagnosed as a neurofibroma. At 1 year following his surgery, the patient is doing well.     

Surgical approaches to the management of primary biliary cholangiocarcinoma of the porta hepatis: the decision-making dilemma

Fifty patients with proximal malignant biliary obstruction confined to or above the junction of the main hepatic ducts underwent surgical treatment. Group A patients (n = 30) underwent complete or partial removal of the tumor with no supplementary procedure, group B patients (n = 20) complete removal of the tumor and a supplementary procedure. Additional procedures were liver resection alone (11/20), and liver resection plus resection and reconstruction of regional vascular structures (9/20). Reconstruction of the intrahepatic biliary tree was carried out in all patients using intrahepatic cholangiojejunostomies between common segmental hepatic stomata and a Roux-en-Y jejunal loop. In each common segmental hepatic stoma, two or three segmental hepatic ducts were drained. Transanastomotic tubes were used only temporarily. Eight patients died, three from group A (3/30) and five from group B (5/20). Survivors were relieved of jaundice and had no subsidiary cholangitis or problems associated with the anastomotic tubes. Seventeen patients of group A and 12 of group B are alive, with a mean survival of 29 and 31 months, respectively. Both alternatives offer good results. The choice of the surgical approach should be based on a precise evaluation of each patient's anatomical and individual clinical peculiarities.     

Ectopic thyroid gland in the porta hepatis and lingua.

A rare case of an ectopic thyroid gland in the porta hepatis and in the tongue in an asymptomatic euthyroid 24-year-old woman is reported. A solitary inhomogeneous, hypoechogenic and hyperechogenic mass in the porta hepatis was accidentally discovered by ultrasonography. Subsequent computed tomography demonstrated a heterogeneous, well-defined tumor with small calcifications without signs of environmental invasion. A hemangioma and focal nodular hyperplasia were excluded by blood pool and hepatobiliary scintigraphy. Surprisingly, fine-needle aspiration cytology revealed normal thyroid tissue. (123)I-scintigraphy confirmed the presence of ectopic dual thyroid tissue in the hepatic porta and lingua. At clinical inspection the lingual thyroid gland was palpable and visible, and appeared solid and spheroidal. The subhepatic, ectopic thyroid mass was resected. Postoperatively, thyroid hormone replacement was started to prevent an enlargement of the lingual thyroid. Today, 4 years after surgery, the patient remains euthyroid.     

A case of benign schwannoma in the porta hepatis]

Schwannomas or neurilemmomas are uncommon tumors arising from schwann cells of neural sheath, which most frequently affect the extremities, trunk, head and neck area. Moreover, benign schwannoma in the porta hepatis is extremely rare. Approximately, 2 cases of benign schwannoma in the porta hepatis have been reported in the literatures. We report a case of benign schwannoma in the porta hepatis occurring in a 53-year-old woman who was asymptomatic and incidentally found to have a mass. Abdominal CT scan showed a 4.5 cm-sized low attenuating mass with septum-like enhancing solid portion at porta hepatis. Abdominal exploration revealed a yellowish, cystic and encapsulated mass attached to portal vein, common bile duct, liver and duodenal wall above the hepatoduodenal ligament. There has been no evidence of recurrence during 11 months of follow-up.     

ERCP联合PTCD治疗肝门部胆管恶性梗阻1例

1例48岁男性患者,因胃癌浸润肝门胆管导致梗阻性黄疸。ERCP治疗失败后行PTCD术,随后行ERCP联合PTCD在左右肝管放置双塑料支架成功。     

Evaluation of intrahepatic,extra-Glissonian stapling of the right porta hepatis vs. classical extrahepatic dissection during right hepatectomy

Background:

Control of hepatic inflow is a key manoeuvre during right hepatectomy and has traditionally been achieved by extrahepatic dissection of the component right portal inflow structures at the hepatic hilum. An alternative technique is the anterior intrahepatic approach (AIA), in which the Glissonian sheath is isolated within the substance of the liver during parenchymal transection and secured using an endovascular stapling device. This study evaluates the intrahepatic, extra-Glissonian technique in comparison with classical extrahepatic dissection (EHD) in right hepatectomy.

Methods:

A retrospective case-controlled study referring to a 20-year period identified 342 consecutive patients who underwent right hepatectomy for colorectal liver metastases from a prospectively compiled database. The AIA to right hepatectomy was used in 182 of these patients and the extrahepatic approach in 160. The two groups were matched for age, gender, stage of primary tumour and number and size of metastases. Outcome measures included safety factors (bleeding, bile duct injury and gun failure), operative duration, oncological margin, morbidity and mortality.

Results:

There were no significant differences between the two groups in terms of operative duration (240 min vs. 260 min) or postoperative change in haemoglobin (1.3 g/dl vs. 1.4 g/dl). The AIA was associated with lower operative blood loss (355 ml vs. 425 ml; P≤ 0.001), a reduced rate of significant morbidity (14.6% vs. 23.1%; P= 0.005), better R0 resection rates (93% vs. 89%; P= 0.014) and a lower 90-day mortality rate (3% vs. 7%; P= 0.046). There was one minor bile leak in each group, two clinically significant bile leaks requiring endoscopic retrograde cholangiopancreatography and stenting in the extrahepatic group, and a further persistent bile leak requiring biliary reconstruction in each group. In two instances the endovascular stapler misfired. Both cases were dealt with at the time of surgery with no further sequelae. The length of hospital stay was equivalent in the two groups (8 days vs. 9 days).

Conclusions:

In selected patients, intrahepatic, extra-Glissonian stapled right hepatectomy is feasible, safe and avoids the need for EHD. The anterior approach to right hepatectomy may achieve outcomes at least as good as those associated with the classical extrahepatic approach.     

肝门部汇管区胆管癌的超声表现

目的探讨肝门部汇管区（左肝管、右肝管与肝总管汇合部）胆管癌的超声诊断价值。方法常规肝胆超声探查,配合患者呼吸动作,在肝门区详细观察肝门部脉管,胆管的走行及分布状,肿块大小及边界,肝内胆管扩张程度和分布范围,远段肝外胆管显示状态,所伴行的门静脉及肝门部其它组织结构回声情况等。将异常所见照片记录,并与CT、MRI及手术结果对照分析。结果超声诊断54例汇管区胆管癌病例中,CT、MRI证实29例,手术证实25例,所有病例均有不同程度的肝内胆管扩张。结论汇管区胆管癌的直接、间接超声表现具有一定的特征性,超声对汇管区胆管癌的判定具有较高的诊断价值。