肝门部胆管癌外科治疗进展

肝门部胆管癌（HCCA）是指发生在左右肝管、汇合部以及肝总管上段,起源于胆管上皮细胞的一种恶性肿瘤。其发病机制的复杂性、起病症状的隐匿性、解剖结构的特殊性,使得多数患者确诊时已经处于中晚期,是当前临床诊治的难点。仅约20%的患者能得到根治性切除,R₀切除率为50%~92%。术后复发率高,预后差,5年生存率仅10%~42%。目前手术切除仍是改善预后的主要有效治疗方式。随着外科各项技术进步,HCCA的外科治疗取得一定进展,但仍面临诸多挑战。笔者就HCCA的外科治疗最新的研究进展及相关争议进行以下综述。     

肝门部胆管癌的外科治疗进展

肝门部胆管癌（HCCA）是最常见的胆道恶性肿瘤，手术切除是HCCA目前唯一的可能根治性治疗的方式，但HCCA一般发现晚，转移早，且病变复杂，故手术切除率很低，且术后复发转移率较高。随着对HCCA研究的深入以及手术技术的发展，在术前评估、肝切除术、血管切除重建、淋巴结清扫、肝移 植、新辅助治疗等方面的不断进步，HCCA的预后得到了不同程度的改善，目前关于HCCA外科治疗的研究仍在不断发展中。     

Bismuth-Corlette Ⅲ、Ⅳ型肝门部胆管癌外科治疗现状与展望

正肝门部胆管癌(Hilar cholangiocarcinoma,HCCA)是指肿瘤位于胆囊管口以上、左、右二级肝管水平以下的肝门区胆管原发胆道恶性肿瘤。其易侵犯周围组织、血管、神经,易发生淋巴转移,早期临床症状不典型,确诊时往往已处于进展期阶段,如果不进行任何治疗,预后极差。以往认为,可行根治性手术切除的HCCA宜行手术切除术,而无法达到根治性手术切除的局部晚期HCCA,可以考虑行肝移植术,但既往     

肝门部胆管癌外科治疗的问题与对策

手术切除是目前肝门部胆管癌获得治愈和患者长期生存的惟一希望.肝叶切除、肝外胆管切除、区域性淋巴结清扫以及胆道重建是目前肝门部胆管癌的主要手术方式.由于肿瘤本身具有侵袭性以及缺乏有效的术后辅助治疗方法,即使是在精准外科治疗时代,肝胆外科医师依然面临挑战.在术前可切除性评估和分期、术前胆道引流和门静脉栓塞、肝切除的范围、联合门静脉切除重建、联合肝动脉切除以及淋巴结清扫范围等方面存有诸多争议.本文聚焦肝门部胆管癌外科治疗的相关问题并提出对策.     

可手术切除的肝门部胆管癌术前胆道引流治疗争议

目的探讨可手术切除的肝门部胆管癌术前胆道引流的利弊、术前胆道引流的时机及各种引流方式的特点。方法通过查阅近20年来国内外相关文献,对可手术切除的肝门部胆管癌术前胆道引流治疗相关争议、术前胆道引流时机及各种引流方式进行综述。结果对于可手术切除的肝门部胆管癌是否需常规行术前胆道引流尚存在很大争议,但对于术前胆道引流时机有较一致的共识,且各种引流方式各有特点。结论肝门部胆管癌主要治疗方式为根治性外科手术切除,但常因胆道恶性梗阻引起胆汁淤积,为围手术期管理带来难度。对于可手术切除的肝门部胆管癌患者是否需常规行术前胆道引流治疗仍需大量前瞻性研究提供更多证据。     

肝门胆管癌外科治疗进展

肝门胆管癌的发病率逐年上升,由于起病隐匿导致疾病发现晚,即使有手术机会,但因手术 难度大、根治率低、术后易出现并发症等因素,5年生存率不足30%。肝门胆管癌作为胆道外科的重难点 病症,近年来在临床诊疗上取得了一定进展,但在术前减黄的标准、手术范围的选择、联合血管切除重建 的收益等方面仍存在争议。本文就近年来肝门胆管癌外科治疗进展做一综述。     

肝门部胆管癌外科治疗争议与进展

肝门部胆管癌是指原发于胆囊管开口以上,左、右二级肝管水平以下的肝门区胆管恶性肿瘤,占所有胆道恶性肿瘤的50%~70%。肝门部胆管癌根治性手术切除率低,病人预后差,生存期短。近年来,尽管在诊断和治疗方面取得了一定进展,但在术前胆道引流、门静脉栓塞、手术切除范围选择、联合血管切除重建、微创手术治疗和肝移植治疗等方面仍存在争议。     

肝门部胆管癌根治术关键技术标准及评价

肿瘤根治性切除是肝门部胆管癌最为有效的治疗方式,也是肝胆外科最具挑战性的技术领域。合理有效的术前准备方案以及规范的手术方案,是实现高质量肝门部胆管癌根治性切除的必要条件。肝门部胆管癌外科治疗涉及多个核心环节,包括肿瘤可切除性和肝储备功能评估、术前准备、手术操作及术后并发症处理等。有效的术前准备包括无创性影像学检查、胆道引流、肝体积测量、选择性门静脉栓塞术等,目的是减少高胆红素血症的影响、改善肝功能、确保大范围肝切除安全性。围肝门解剖、肝切除范围、门静脉切除重建、肝动脉切除重建、区域淋巴结清扫范围等是肿瘤根治性切除关键技术,目的是实现所有切缘阴性,彻底清除肿瘤及其侵袭的组织。肝门部胆管癌外科治疗仍存在诸多争议点,如术前胆道引流途径及周期、肝切除范围、肝动脉重建的必要性、淋巴结清扫数目等,仍有待进行更多临床研究以形成共识。     

肝门部胆管癌的手术选择

胆管癌发病率较低,位于消化道肿瘤第五位.根据国际抗癌协会（Union for International Cancer Control,UICC） TNM分期系统（第七版）对胆管癌的定义,胆管癌可分为肝内胆管癌、肝门部胆管癌及远端胆管癌.盱门部胆管癌（Hilar cholangiocarcinoma,HCCA）是最常见类型,占胆管癌的50％～70％.HCCA的恶性程度高,治疗效果较差,其手术切除技术要求很高,是肝胆外科医师最困难的挑战.然而,手术切除是治疗HCCA的唯一方法,许多外科医师都采用积极的态度.在过去的20年里,诊断和手术技术的进步使手术治疗效果及生存率逐渐改善[1-2].     

肝门部胆管癌外科治疗的现状与展望

目的 了解肝门部胆管癌外科治疗的现状并对其进行展望。方法 收集近年来国内外关于肝门部胆管癌外科治疗方法的相关文献并进行综述。结果 肝门部胆管癌的各种外科治疗方案都存在优缺点,目前对于行根治性手术切除术前的准备、术中手术切除范围的选择、腹腔镜及机器人的应用等方面依旧存在争议,仍应根据患者的具体病情及主刀医师的职业经验综合考虑,制定个体化的外科治疗方案。结论 对每例肝门部胆管癌患者均应进行精准的术前病情评估,从而制定出最合适的外科治疗方案,做到个体化精准治疗,使患者获益最大。     

肝门部胆管癌

肝门部胆管癌是指位于胆囊管开口以上的肝总管,左、右肝管汇合部和左、右肝管的胆管黏膜上皮癌。由于肝门部特殊的解剖学位置及肝门部胆管癌生物学特性,其极易早期侵犯肝门区血管、神经、淋巴结组织及邻近肝组织,因此,手术难度大,患者预后差。在现代影像学指导下的扩大肝切除术可能给这个凶险的疾病予以希望。但国内外学者就扩大肝切除术存在诸多争议,目前尚无统一的标准。因此,肝门部胆管癌外科治疗亟待规范化,以提高其根治性切除率,减少手术相关并发症发生率和病死率。     

Multimodal treatment strategies for advanced hilar cholangiocarcinoma

Cholangiocarcinoma (CCA) is the second most common primary malignancy of the liver arising from malignant transformation and growth of biliary ductal epithelium. Approximately 50–70 % of CCAs arise at the hilar plate of the biliary tree, which are termed hilar cholangiocarcinoma (HC). Various staging systems are currently employed to classify HCs and determine resectability. Depending on the pre-operative staging, the mainstays of treatment include surgery, chemotherapy, radiation therapy, and photodynamic therapy. Surgical resection offers the only chance for cure of HC and achieving an R0 resection has demonstrated improved overall survival. However, obtaining longitudinal and radial surgical margins that are free of tumor can be difficult and frequently requires extensive resections, particularly for advanced HCs. Pre-operative interventions may be necessary to prepare patients for major hepatic resections, including endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography, and portal vein embolization. Multimodal therapy that combines chemotherapy with external beam radiation, stereotactic body radiation therapy, bile duct brachytherapy, and/or photodynamic therapy are all possible strategies for advanced HC prior to resection. Orthotopic liver transplantation is another therapeutic option that can achieve complete extirpation of locally advanced HC in judiciously selected patients following standardized neoadjuvant protocols.     

Unusual causes of benign biliary strictures with cholangiographic features of cholangiocarcinoma

Focal strictures occurring at the hepatic duct confluence, or within the common hepatic duct or common bile duct in patients without a history of prior surgery in that region or stone disease, are usually thought to represent cholangiocarcinoma until proved otherwise. However, not uncommonly, patients undergo surgical exploration for a preoperative diagnosis of cholangiocarcinoma, based on the cholangiographic appearance of the lesion, only to find histologically that the stricture was benign in nature. Despite sophisticated radiographic, endoscopic, and histologic studies, it is often impossible before laparotomy to distinguish malignant from benign strictures when they have the characteristic radiographic appearance of cholangiocarcinoma. Even at the risk of overtreating some benign cases, most agree that aggressive surgical resection is the treatment of choice, given the serious consequences resulting from a failure to diagnose and adequately treat cholangiocarcinoma. Four patients who presented to our institution between February 1991 and June 2000 underwent laparotomy for a preoperative diagnosis of biliary tract malignancy based on clinical presentation and cholangiographic findings. The final pathology report in all patients showed marked fibrosis and inflammation of the biliary duct without evidence of malignancy. A review of the patient data and the relevant literature identified benign causes of focal extrahepatic biliary strictures associated with concomitant disease processes in two of the four patients. We present these cases and discuss the benign etiologies with emphasis on the role of surgery in both diagnosis and treatment.     

Hilar cholangiocarcinoma—surgical anatomy and curative resection

We have studied the surgical anatomy of the intrahepatic bile duct, hepatic hilus, and caudate lobe based on intraoperative findings and selective cholangiography of surgical patients and resected specimens, and have established the cholangiographic anatomy of the intrahepatic subsegmental bile duct. Thorough knowledge of the three-dimensional anatomy of the subsegmental bile duct, hepatic hilus, and caudate lobe is indispensable for curative surgery of hilar cholangiocarcinoma. We designed and actually performed 15 kinds of hepatic segmentectomies with caudate lobectomy and extrahepatic bile buct resection in 100 consecutive patients, with curative resection being possible in 82 patients. Postoperative survival after curative resection of hilar cholangiocarcinoma was better than expected, and the 5-year survival rates for all 82 patients with curative resection and for 55 patients with curative surgery without portal vein resection were 31% and 43%, respectively. Hepatic segmentectomy with caudate lobectomy and extrahepatic bile duct resection should be designed not only in accordance with the preoperative diagnosis of tumor extension into the intrahepatic bile ducts but also so that curative surgery for advanced hilar cholangiocarcinoma can be performed.     

中肝叶联合尾状叶切除术在肝门部胆管癌中的应用

肝门部胆管癌是常见胆道恶性肿瘤,其外科治疗的核心是达到R 0切除,包括切除病变胆管、受肿瘤浸润肝组织及区域淋巴结。在精准外科及多学科治疗时代,肝门部胆管癌的手术治疗应遵循可视化、可量化、可控化和多学科治疗原则。基于精准肝门部胆管癌董氏分型,包括Ⅰ+Ⅳ+Ⅴ+Ⅷ段、Ⅰ+Ⅴ+Ⅷ段及Ⅰ+Ⅳ段的中肝叶联合尾状叶切除术...     

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。     

Hepatolithiasis in the hepatic hilum mimicking hilar cholangiocarcinoma: Report of a case

We report a rare case of hepatolithiasis, which was diagnosed as hilar cholangiocarcinoma and treated with hepatectomy and extrahepatic bile duct resection. A 59-year-old woman presented to a local hospital with liver dysfunction. Diagnostic imaging revealed a biliary stricture at the hepatic hilum and middle bile duct. Hilar cholangiocarcinoma was diagnosed, and she was referred to our hospital for definitive surgical treatment. She underwent left hepatic trisectionectomy, total caudate lobectomy, and extrahepatic bile duct resection. Gross examination of the resected specimen revealed intrahepatic stones firmly adherent to the bile duct wall. Pathological examination revealed no malignant lesions. The epithelium of the bile duct was absent underneath the stone, and the boundary between the stone and bile duct wall was ill defined. To our knowledge, this is the first case report of hepatolithiasis with a biliary stricture caused by peculiar stone formation, mimicking hilar cholangiocarcinoma.     

肝门部胆管癌根治性切除中围肝门区手术处理

目的探讨围肝门区手术处理手段在肝门部胆管癌外科治疗中的临床应用。方法回顾性分析我院2002年1月-2007年12月诊治的86例肝门部胆管癌病人的临床资料。其中,实施单纯内引流术38例,姑息性切除术11例,采取联合尾状叶切除、受侵门静脉肝动脉切除重建、肝内胆管断端整形、肝门区淋巴结清扫等技术完成根治性切除37例。结果肝门部胆管癌的根治性切除率由2002年的33．3％,提高到2007年的75．0％。无围手术期死亡发生。结论联合采用尾状叶切除、肝门部胆管断端整形、受侵门静脉切除重建及肝门区淋巴清扫等围肝门区处理手段可提高肝门部胆管癌根治性切除率,降低手术并发症的发生率。