肝门部胆管癌的影像分型与治疗方式的选择

肝门部是胆管癌的好发部位，由于其部位隐蔽，诊断困难，同时由于其空间狭窄，治疗棘手，并且由于肿瘤的生物学特性，很难做到根治性切除。近年来随着现代影像技术的发展，术前诊断尤其是定位诊断水平不断提高，治疗方式也得以不断改进，同时可以正确地根据术前定位诊断和分型来选择相应的治疗方式。     

肝门胆管癌的分型诊断和治疗

目的　介绍我们对肝门胆管癌分型诊断和治疗经验。方法　我科治疗肝门胆管癌 2 2例 ,根据PTC结果作出Bismuth分型诊断。Ⅰ、Ⅱ型早期手术局部切除后胆肠吻合术 ,ⅢB 型左肝切除、加局部切除后胆肠吻合术 ,ⅢA、Ⅳ型支撑管留置后装放疗。结果　后装放疗 10例 ,均因慢性胆汁性肝硬变、肝功能衰竭死亡 ,死亡时间从术后 3个月～ 18个月 ,平均 8个月。无后装期 2例 ,死于术后 2月。左肝叶切除 1例 ,术后胆系造影、B超、TBIL正常 ,术后 4个月失访。肿瘤切除 2例 ,1例术后 8个月肝门胆管癌复发 ,术后 10个月死亡 ;1例术后 10个月肝转移 ,术后 14个月死亡。结论　PTC对肝门胆管癌的术前诊断和Bismuth分型的重要作用是其它检查不能完全取代的。术前根据肝门胆管癌的Bismuth分型和有无肝转移即可决定治疗方案。能使生存期延长的根本方法是早期诊断 ,使阻塞性黄疸发生的时间短 ,免于发生胆汁性肝硬变 ,后装放疗明显延长生存期     

肝门部胆管癌可切除性的影像学判断价值

正肝门部胆管癌(Hilar cholangio carcinoma,HCCA)也称Klatskin瘤,由Klatskin于1965年首先发现并报道,是起源于胆管上皮的恶性肿瘤,位于左右肝管或(和)肝总管上段,占肝外胆管癌的50%~60%。其解剖部位特殊、呈浸润性生长及与肝门部血管关系密切,且对放疗及化疗不敏感,目前认为手术切除是唯一可能治愈的方法。术前准确的影像学     

肝门部胆管癌的分型及外科治疗

肝门部胆管癌（hilar cholangiocarcinoma,HCCA）早期诊断困难,根治性切除是唯一可能治愈该病的治疗方式,但其手术切除难度大,预后差。近年来,随着外科手术技术和现代影像医学的不断进步,尤其是近10年来“计划性肝切除”和“第四肝门”理念逐渐由临床实践中提炼出来,并在临床实践中得到持续应用,     

肝门部胆管癌的影像学诊断及评价

肝门部胆管癌（又称Klatskin瘤）血供较差，对放、化疗不敏感。手术切除仍是最好的治疗方法。早期诊断和对术前可切除性的判断是手术治疗成功与否的的关键。本文就肝门部胆管癌的影像学诊断方面的情况，结合个人的经验加以综合和评价。     

肝门部胆管癌：肝门部胆管癌的临床分期与分型及其评价

肝门部胆管癌发病隐匿、呈多极化浸润性生长,与肝门区肝动脉、门静脉等重要结构密切相关,当肿瘤沿着近端胆管系统进展时常会累及神经束膜、淋巴结、血管及肝脏。并且,近年来肝门部胆管癌的根治手术有扩大化趋势。为达到R0（边缘阴性）切除,除须行肝十二指肠韧带骨骼化清扫外,经常需要联合肝叶、半肝、肝门部血管甚至胰十二指肠切除。因此,术前明确肿瘤的整体范围及病灶周围浸润程度,建立准确的临床分期和分型,将有助于合理选择手术方式、规范肝门部胆管癌的治疗。     

肝门部胆管癌的治疗

目的探讨肝门部胆管癌的治疗方法。方法回顾性分析我院1996，2004年间52例肝门部胆管癌患者的临床病例资料。I型癌肿切除率最高，Ⅳ型癌肿切除率最低。结果本组52例肝门部胆管癌中，围手术期死亡2例，均死于肝肾功能衰竭，余50例中31例术后获得随访，失访19例，随访率为62％。结论疑似或诊断肝门部胆管癌应早期积极手术探查，争取行根治性切除术；肝门部胆管癌肿瘤切除疗效明显优于其他治疗方式。     

肝门部胆管癌的外科治疗

目的 探讨肝门部胆管癌各种术式的疗效。方法 回顾性分析经手术和病理证实的肝门部胆管癌35例手术方式和随访结果。结果 手术切除13例（根治性切除9例,姑息性切除4例）,总手术切除率为37．1％,其中1996年以后的23例中切除12例,手术切除率为52．2％;胆管内引流5例;外引流1例;剖腹探查6例。随访23例,随访率65．7％。切除术组13例,存活7－30个月,平均17．5个月,现仍存活4例,生存期分别为12,13,15和21个月;引流组存活2．5－24个月,平均9．2个月,1例已生存13个月;单纯剖腹探查术者多于术后3个月内死亡。结论 根治性切除和扩大手术切除范围是肝门部胆管癌首选的治疗方法。对不能切除者,不应放弃手术探查,应争取行胆管内、外引流术。     

影像学检查在肝门部胆管癌诊断中的应用

肝门部胆管癌又称Klatskin肿瘤,是指起源于左、右主肝管和肝总管近端1cm以内的胆管细胞癌,包括肝总管、汇合部胆管、左右肝管的一级分支以及双侧尾叶肝管的开口的胆管癌。根据其生长方式肝门部胆管癌分为3种类型:浸润型、外生型、管内型[1]。该病近年来发病率呈上升趋势,原发性     

影像学技术对肝门胆管癌的诊断价值

肝门部胆管梗阻可由许多病变引起,如结石、炎症、损伤、畸形、肿瘤、结核、硬化性胆管炎、肝癌累及肝门部胆管、肝癌胆管癌栓、胆囊癌累及肝门部胆管、肝门部转移性淋巴结肿大等。采用各种影像学诊断技术的目的在于:(1)确定是否为肝门胆管癌;(2)确定癌肿累及胆管的范围,毗邻器官受浸润,肝脏和淋巴结转移以及腹腔种植等情况。这样可为肿瘤切除可能性的术前评估和治疗方法的选择提供依据。     

Resectable Hilar Cholangiocarcinoma: Surgical Treatment and Long-Term Outcome

Unresected hilar cholangiocarcinoma has a dismal prognosis, but advances in staging and surgical techniques have given well-selected patients a chance of long-term survival if curative resection is possible. This review summarizes the state of the art in diagnosis, treatment, and outcome for patients with biliary obstruction at the hilus of the liver.     

Effectiveness of Radiation Therapy After Surgery for Hilar Cholangiocarcinoma

Purpose Some studies suggest that giving radiation therapy after surgery for hilar cholangiocarcinoma improves the survival rate; however, many of these studies did not specify numbers of subjects or provide an impartial analysis. Thus, we evaluated the effectiveness of radiation therapy as adjuvant treatment after surgery and attempted to establish appropriate adaptation standards.Methods We reviewed the records of 69 patients who underwent surgery for hilar cholangiocarcinoma between June 1980 and April 1998. Thirty-nine patients were treated with surgery followed by radiation therapy and 30 were treated with surgery alone.Results The clinicopathologic features that might have influenced prognosis were similar in the patients who received radiation therapy and those who did not. Radiation as adjuvant therapy did not have a beneficial effect on overall survival (P = 0.554, log-rank test); however, it tended to improve survival in the group of patients who underwent curative resection for with p-stage III or IVa disease (P = 0.042, log-rank test).Conclusions Radiation therapy after surgery did not show any clinical benefits for patients with hilar cholangiocarcinoma. However, it may be effective as adjuvant therapy after curative resection in a small subgroup of patients with p-stage III or IVa disease.     

肝外胆管癌的诊断与治疗

探讨肝外胆管癌的诊断与治疗。方法:男58例,女14例,共72例,平均年龄58.3岁。上段占75％,中段11.1％,下段13.86％。本组病人均依靠临床表现及B超检查做出初步诊断,术中B超扫查明确肿瘤部位、范围、门脉通畅情况以指导手术。结果与结论:本组总切除率45.83％,其中上段为33.33％,中段62.5％,下段为100％。对不能切除者行胆肠内、外引流术,以改善病人生存质量,延长生存时间。     

肝门部胆管癌的手术治疗

目的探讨肝门部胆管癌2种手术方法的疗效。方法回顾性分析我院1998～2006年期间收治的37例肝门部胆管癌患者的临床资料。结果37例患者中13例行根治性手术切除,其1年与3年的生存率分别为100%（13/13）和76.92%（10/13）,中位生存期为22.43个月;另24例行姑息性手术（均为肝内胆管内引流术）,其1年与3年生存率分别为54.55%（12/22）和9.09%（2/22）,中位生存期为15.42个月。结论根治性手术是治疗肝门部胆管癌的主要手段;姑息性手术,如合理的肝内胆管内引流能改善患者的生存质量。     

Safety and Effectiveness of Left Hepatic Trisegmentectomy for Hilar Cholangiocarcinoma

Left hepatic trisegmentectomy has been performed for huge malignant tumors, but it is rarely applied in patients with hilar cholangiocarcinoma. Twelve consecutive patients (7 men and 5 women; mean age, 64 years) underwent left hepatic trisegmentectomy in our institution between January 2000 and December 2003. The preoperative management and postoperative outcomes of this surgical procedure were presented and retrospectively analyzed. Preoperative biliary drainage and portal vein embolization were performed in 6 patients (50%) and 9 patients (75%), respectively. The preoperative estimated volume ratio of the posterior segment /the whole liver was 44.8 ± 7.0% (34.3–54.3), the plasma retention rate of indocyanine green at 15 minutes was 8.6 ± 2.2% (4.7–13.7), and the serum total bilirubin level before surgery was 1.0 ± 0.4 mg/dl (0.4–1.7). The serum total bilirubin level on the first postoperative day was 3.3 ± 0.4 mg/dl (1.4–6.2). There was no hospital death or postoperative hepatic failure. The incidence of positive resectional margin was 25%. With biliary decompression and preoperative portal embolization techniques, left hepatic trisegmentectomy was a safe and curative resectional option for hilar cholangiocarcinoma.     

Outcome of Surgical Treatment of Hilar Cholangiocarcinoma

To evaluate surgical results and the effect of adjuvant chemotherapy in cases of hilar cholangiocarcinoma, we retrospectively analyzed 27 consecutive patients who underwent surgical resection (eight bile duct resections, 18 bile duct resections plus hepatectomy, one hepatopancreaticoduodenectomy). There was no operative mortality, and the morbidity was 37%. Curative resection (R0 resection) was achieved in 20 (74%) patients. Overall survival at 3 and 5 years was 44% and 27%, significantly higher than that of 47 patients who did not undergo resection (3.5% and 0% at 3 and 5 years, p < 0.0001). Survival of patients with positive margins (R1/2 resection) was poor; there were no 5-year survivors. However, survival was better than that of patients who did not undergo resection (median survival: 22 vs 9 months, p = 0.0007). Univariate analysis identified lymph node metastasis as a negative prognostic factor (p = 0.043). Median survival of patients who underwent adjuvant chemotherapy was significantly longer than that of patients who did not (42 vs. 22 months, p = 0.0428). Resection should be considered as the first option for hilar cholangiocarcinoma. There appears to be a survival advantage even in patients with cancer-positive margins. Adjuvant chemotherapy may increase long-term survival.     

肝门部胆管癌诊治进展

肝门部胆管癌（hilar cholangiocarcinoma,HCCA）,解剖部位隐蔽,早期临床表现不典型,手术切除率低,预后较差。HCCA的诊断和治疗一直是肝胆外科医师公认的难题。近年来随着以肝胆外科为中心的多学科综合治疗日渐成为趋势,影像诊断技术及外科手术技术的不断进步,HCCA的诊断和治疗取得了一定进步。本文结合近年来相关文献报道就HCCA的诊治进展作如下综述。     

Oncological Superiority of Hilar En Bloc Resection for the Treatment of Hilar Cholangiocarcinoma

Purpose

Long-term results after liver resection for hilar cholangiocarcinoma are still not satisfactory. Previously, we described a survival advantage of patients who undergo combined right trisectionectomy and portal vein resection, a procedure termed “hilar en bloc resection.” The present study was conducted to analyze its oncological effectiveness compared to conventional hepatectomy.

Patients

During hilar en bloc resection, the extrahepatic bile ducts were resected en bloc with the portal vein bifurcation, the right hepatic artery, and liver segments 1 and 4 to 8. With this “no-touch” technique, preparation of the hilar vessels in the vicinity of the tumor was avoided. The long-term outcome of 50 consecutive patients who underwent curative (R0) hilar en bloc resection between 1990 and 2004 was compared to that of 50 consecutive patients who received curative conventional major hepatectomy for hilar cholangiocarcinoma (perioperative deaths excluded).

Results

The 1-, 3-, and 5-year survival rates after hilar en bloc resection were 87%, 70%, and 58%, respectively, which was significantly higher than after conventional major hepatectomy. In the latter group, 1-, 3-, and 5-year survival rates were 79%, 40%, and 29%, respectively (P = 0.021). Tumor characteristics were comparable in both groups. A high number of pT3 and pT4 tumors and patients with positive regional lymph nodes were present in both groups. Multivariate analysis identified hilar en bloc resection as an independent prognostic factor for long-term survival (P = 0.036).

Conclusions

In patients with central bile duct carcinomas, hilar en bloc resection is oncologically superior to conventional major hepatectomy, providing a chance of long-term survival even in advanced tumors.

     

Prognosis of Perihilar Cholangiocarcinoma: Hilar Bile Duct Cancer versus Intrahepatic Cholangiocarcinoma Involving the Hepatic Hilus

Background Clinically hepatobiliary resection is indicated for both hilar bile duct cancer (BDC) and intrahepatic cholangiocarcinoma involving the hepatic hilus (CCC). The aim of this study was to compare the long-term outcome of BDC and CCC. Methods Between 1990 and 2004, we surgically treated 158 consecutive patients with perihilar cholangiocarcinoma. The clinicopathological data on all of the patients were analyzed retrospectively. Results The overall 3-year survival rate, 5-year survival rate, and median survival time for BDC patients were 48.4%, 38.4 %, and 33.7 months, respectively, and 35.8%, 24.5 %, and 22.7 months, respectively, in CCC patients (P = .033). On multivariate analysis, three independent factors were related to longer survival in BDC patients: achieved in curative resection with cancer free margin (R0) (P = .024, odds ratio 1.862), well differentiated or papillary adenocarcinoma (P = .011, odds ratio 2.135), and absence of lymph node metastasis (P < .001, odds ratio 3.314). Five factors were related to longer survival in CCC patients: absence of intrahepatic daughter nodules (P < .001, odds ratio 2.318), CEA level ≤2.9 ng/mL (P = .005, odds ratio 2.606), no red blood cell transfusion requirement (P = .016, odds ratio 2.614), absence or slight degree of lymphatic system invasion (P < .001, odds ratio 4.577), and negative margin of the proximal bile duct (P = .003, odds ratio 7.398). Conclusions BDC and CCC appear to have different prognoses after hepatobiliary resection. Therefore, differentiating between these two categories must impact the prediction of postoperative survival in patients with perihilar cholangiocarcinoma. T. Sano is currently with: Hepato-Biliary and Pancreatic Surgery Division, Aichi Cancer Center Hospital, Nagoya, Japan.