肝中裂分离高位胆管狭窄修复术

作者采用自行研制的彭氏多功能手术解剖器(PMOD),通过解剖肝门部及肝内大胆管,治疗医源性左右肝管汇合部过失切除和肝门部肝管癌40余例,疗效满意。认为充分的肝中裂分离是显露肝门部和肝内主要胆管的重要途径,是成功修复高位胆管狭窄的可靠保证。     

肝内胆管和门静脉的解剖变异是左侧肝切除的危险因素

在作者过去施行的左侧肝切除病例中，术后有2例发生右后叶肝管扩张并导致死亡。认为肝内胆管和门静脉的解剖变异是这些致死性并发症的原因。本文研究了肝内胆管和门静脉的解剖变异，并对其在左侧肝切除术中的潜在危险性进行评价。对210例患者的胆管造影和动脉性门静脉造影片进行分类研究。肝管分型：互型138例，右前、右后叶肝管形成右肝管，然后在肝门区与左肝管汇合；刀型35例，左肝管和右前、右后叶肝管在肝门区以三叉状汇成肝总管；血型7例，右前或右后叶肝管在靠近肝门区汇入左肝管；IV型24例，右前或右后叶肝管在脐部或靠近脐部汇入…     

肝门部胆管癌的分期分型及术式选择

梁力建教授有不少作者提出胆管癌的分型，大多数的分型包括了肝外胆管的各部，如Nakeeb（1996）把肝外胆管瘤分为肝内型、肝门周围型、末段型，其中肝门周围型包括了肝门部、肝总管和胰腺上缘以上的胆管瘤。而Pitt（199）把胆管癌分为9型，其中属于肝门部胆管癌的有Ill型（右肝管）、IV型（左肝管）、V型（左右肝管汇合部）、对型（肝总管）。1975年Bismuth－COrlette将肝门部胆管瘤分为4型：l型，肿瘤位于肝总管，未侵犯汇合部；0型，肿瘤波及汇合部，未侵犯左右肝管；m型，已侵犯右肝管（Illa）或侵犯左肝管（Illb）；IV型，已侵犯…     

多发性肝胆管结石的手术治疗

２１例多发性复杂胆管结石在采用肝门部胆管切开取石胆肠Ｒｏｕｘ－Ｙ吻合术的基础上，对局限于肝段的肝内胆管结石行肝总结切除术。其中行ⅡⅢ肝段切除１８例，行Ⅵ肝段切除３例，行胆管总管空肠Ｒｏｕｘ－Ｙ吻合术１１例，行左右肝管汇合部切开＋原位整形盆状胆肠吻合术８例，左／右肝管残端及肝总管与空肠行双口Ｒｏｕｘ＝Ｙ吻合术２例。结果：２１例均痊愈，无死亡，随访１年以上１６例，疗效优良率１５／１６例。     

提问与解答

关于Ⅳ型胆管癌：本组中75例，大多数（48例）可行半肝加尾状叶切除治疗。一般认为已无手术切除可能，除非行肝移植。因为均累及肝内左右肝管或汇合部（左内外及右前后胆管），如1例累及肝内肝管汇合部．另1例仅累及左或右肝管开口处是否划入Ⅳ型？     

肝门胆管显露与肝胆管结石症手术疗效分析

肝内胆管结石症目前尚未获得满意解决，术后残余结石问题一直令人困扰。为了掌握肝门胆管显露的一般规律，提高手术疗效，我们对30例成人肝脏标本进行了肝门胆管及其毗邻结构的解剖观察，并对手术治疗的41例肝胆管结石症病例进行了随访及疗效分析。     

磁共振胰胆管成像在成人活体右半供肝术前胆道评估中的应用

目的 探讨磁共振胰胆管成像( MRCP)在成人活体右半供肝术前胆道评估中的应用.方法 76例活体肝移植供者,均切取右半肝用于移植.脂肪餐后进行术前MRCP检查,比较MRCP胆管分型与术中胆道造影胆管分型的一致性;在MRCP图像上测量右后肝管汇入部距左右肝管汇合部的距离及相应右后肝管的直径,对相应胆管测量长度及直径与术中胆道重建方式进行二分类Logistic回归分析,并得出术中胆道是否成形的ROC曲线及其长度临界值.结果 MRCP胆管分型与术中胆道造影胆管分型的符合率为97.4％.MRCP所测右后肝管汇入部距左右肝管汇合部的距离和胆管分型是术中胆道重建方式的重要影响因素,而右后肝管直径对术中胆道重建方式的选择无影响.胆道解剖结构变异或Ⅰ型胆管(MRCP分型)中右肝管长度≤4.2mm时,95％的供肝胆道断端数多于1支,且95％行胆道成形术;Ⅲ、Ⅳ型胆管(MRCP分型)所测胆管长度为3.8mm,是选择胆道成形术的分界点.结论 MRCP胆管分型能准确反映胆道解剖结构,MRCP右后肝管汇入部距左右肝管汇合部距离测量值可以指导术中胆道重建方式的选择.     

切开肝内胆管治疗复杂肝内胆管结石的手术入路和方法

目的 探讨显露和剖开肝内各叶、段胆管的手术方法,提高复杂性肝内胆管结石病的治疗效果。方法 从肝内胆管手术显露的角度,研究了30个成人肝脏标本肝内各叶、段胆管与血管走行位置的解剖关系,设计了新的手术方法、用于治疗复杂性肝内胆管结石46例。结果 肝内胆管与血管走行的位置关系。从肝脏的脏面观：左右肝管均位于门静脉左右干的前上缘。左内叶胆管、右前叶胆管位于相应门静脉支的前内侧（近肝门侧）。右后叶胆管有73.3%(22/30)位于门静脉右前支（18／30）或门静脉右前下段支（4／30）脏面深侧;80％（24／30）走行于门静脉右后叶支脏面深侧（20／30）或后上缘（4／30）。左外叶胆管基本上都走行于门静脉矢状部脏面深侧,只有2个标本的左外叶下段支胆管在其浅侧。肝动脉在肝内各叶段的分支基本上走行与Glisson鞘内胆管与门静脉之间或侧旁。从肝脏膈面观：肝内各叶、段胆管与血管的解剖位置关系大致与脏面观相反或接近相反。据此,从肝脏脏面显露肝门、可以连续切开左右肝管和多数左内叶及右前叶胆管,但难以显露右后叶及右叶各段胆管和左外叶胆管;而从肝脏膈面进路切开肝方叶或肝中裂、再沿右后叶胆管投影方向切开肝实质,则可避开右肝内的门静脉主要分支,比较容易显露和切开右肝内各叶、段胆管汇合部及狭窄段。从肝左叶膈面切开左外叶胆管,可避免损伤左门静脉矢状况。设计经肝的脏面显露和剖开肝门及左右肝管与经肝的膈面显露和剖开肝内叶、段胆管相结合的手术方法,治疗复杂性肝内多叶、多段胆管多发结石并胆管狭窄的病人46例。无手术死亡。31例平均随访39个月,效果优良28例（90％）,好转2例（6.5%),无效1例（3.5%)。结论 经肝的脏面和膈面相结合的手术入路,显露和剖开肝内外胆管及其狭窄段,便于取出结石。将剖开的肝内外胆管与空肠Roux－en-y大口吻合,则可解除胆道狭窄,建立通畅的胆流通道,是治疗复杂性肝内胆管结石有效的手术方法。     

右肝各肝段胆管的显露和切开

为适应右肝内各段胆管的显露，切开和肝段切除手术的需要．作者研究了30个人肝标本的肝内各叶、段胆管、血管的解剖关系。选择肝脏膈面切开肝实质进路，比较容易显露右肝各段胆管的汇合部，便于进行右肝内胆管的切开．肝段切除等肝内手术。用于临床手术治疗右肝内胆管多发结石并多处狭窄的患者10例，取得成功，效果满意。     

胆石致胆管狭窄伴肝纤维化胶原蛋白的免疫组化观察

对２１例择期手术定位取材所获得的５例左右肝管汇合部狭窄、７例Ⅰ级肝管狭窄、７例Ⅱ级肝管汇合部狭窄、１０例Ⅱ级肝管狭窄及１０例Ⅲ级肝管狭窄标本进行Ⅲ、Ⅳ型胶原蛋白的免疫组化观察及定量分析。结果：正常胆管壁、门脉区及肝窦的Ⅲ型胶原呈浅淡而不连续的阳性染色，而狭窄胆管壁、门脉区及肝窦的Ⅲ型胶原则呈连续粗线状阳性染色，与正常对照组比较，其差异非常显著（Ｐ＜０．０１）；在有胆管狭窄处的肝窦部，Ⅳ型胶原呈连续粗线状阳性染色。     

复杂性肝内胆管结石的外科治疗

目的　总结复杂性肝内胆管结石的外科治疗方法及效果。 方法　 总结分析１９９２ ～１９９８ 年外科治疗复杂性肝内多段胆管结石并多处胆管狭窄３５ 例的手术方法,总结显露与切开肝内狭窄段胆管、取出结石、解除狭窄的经验和体会。 结果　３５ 例无手术死亡,术后近期并发感染、胆漏、肝功能不全或消化道出血共７ 例,均治愈;残留结石９ 例,术后经胆道镜取净结石７ 例。随访６ 个月至５ 年６ 个月２４ 例,优良２１ 例（８８ ％ ） ,好转２ 例（８ ％ ） ,无效１ 例（４ ％ ） 。 结论　复杂肝内胆管结石外科治疗的关键是显露和切开肝内各叶段胆管的狭窄段,取出结石、建立通畅的胆流通道。经肝门区或肝方叶可以显露和切开肝门胆管、左右肝管和左内叶、右前叶胆管,经肝膈面切开肝实质进路,可以显露和切开右肝内各叶段胆管。     

Diagnosis and therapy of stenosis or obstruction of the intrahepatic bile ducts]

15 patients are reviewed who had stenosis or obstruction at the hilus of the bile duct. Percutaneous transhepatic or endoscopic transduodenal cholangiography is indispensable for establishing the diagnosis before operation. Primary carcinomas involving the junction of the hepatic ducts may be regarded as resectable if proximal extension of the tumor is limited to below the second bifurcation of the intrahepatic bile ducts in both the right and left lobes and if the proper hepatic artery and portal vein are still free from tumor invasion. Our favourable operation procedures for resection or palliative decompression of the biliary tree are discussed.     

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.     

Surgical anatomy of the bile ducts at the hepatic hilum as applied to living donor liver transplantation

OBJECTIVE: To evaluate anatomic variations of the biliary tree as applied to living donor liver transplantation. SUMMARY BACKGROUND DATA: Anatomic variability is the rule rather than the exception in liver surgery. However, few studies have focused on the anatomic variations of the biliary tree in living donor liver transplantation in relation to biliary reconstruction. METHODS: From November 1992 to June 2002, 165 patients underwent major hepatectomy with extrahepatic bile duct resection; right-sided hepatectomy in 110 patients and left-sided hepatectomy in 55. Confluence patterns of the intrahepatic bile ducts at the hepatic hilum in the surgical specimens were studied. RESULTS: Confluence patterns of the right intrahepatic bile ducts were classified into 7 types. The right hepatic duct was absent in 4 of the 7 types and in 29 (26%) of the 110 livers. Confluence patterns of the left intrahepatic bile ducts were classified into 4 types. The left hepatic duct was absent in 1 of the 4 types and in 1 (2%) of the 55 livers. CONCLUSIONS: In harvesting the right liver from a donor without a right hepatic duct, 2 or more bile duct stumps will be present in the plane of transection in the graft in 3 patterns based on their relation to the portal vein. Accurate knowledge of the variations in the hepatic confluence is essential for successful living donor liver transplantation.     

一种治疗肝胆管结石和狭窄的术式——皮下通道型肝胆管成形术35例临床分析

对于肝胆管结石的治疗目前已取得了很多成功的经验，但最常使用的胆肠吻合术虽经不断改进，仍未能从根本上解决返流性胆管炎、胃肠分泌功能紊乱等并发症。为此，设计了一种新术式：即皮下通道型胆囊肝胆管成形术。在清除结石，解除肝内外胆管狭窄、肝门整形的基础上，利用胆囊壶腹部切开相应大小的切口与之吻合，并适当游离胆囊，使其底部可以被固定到切口皮下。患者必须具备基本正常的胆囊、肝外胆管和Ｏｄｄｉ括约肌。同时要求术中基本取尽肝内结石或切除病灶。已完成此手术共３５例，所有患者手术顺利，术后未发现并发症。其中１例３年后结石复发，１例２年后发生胆道蛔虫，均经皮下胆囊通道用胆道镜轻易取出。该术式既能处理好结石和狭窄问题，又能保存胆囊、胆管、Ｏｄｄｉ括约肌的功能，保持胃肠道的正常生理通路，并能以最简捷的方法处理术后结石复发和胆道内其它问题     

Abnormal hepatic expression of fibrillin-1 in children with cholestasis

Fibrillin-1, one of the main constituents of microfibrils, is present in normal adult liver and overexpressed in fibrotic area around cirrhotic nodules and hepatocellular carcinoma. In this work fibrillin-1 expression was studied by immunohistochemistry in liver samples from children with various cholestatic diseases corresponding to paucity of intrahepatic bile ducts, biliary atresia, congenital hepatic fibrosis, Byler's disease, mitochondrial cytopathy, sclerosing cholangitis, or choledochal cyst. As controls, histologically normal liver samples were used. In control liver, as in adult, fibrillin-1 was expressed in vessel walls, sinusoids, and portal connective tissue, particularly at the interface with the limiting hepatocytic plate and close to the basement membrane of bile ducts. In paucity of intrahepatic bile ducts without fibrosis, the fibrillin-1 distribution was similar to controls. In cholestatic diseases associated with severe fibrosis, such as biliary atresia, congenital hepatic fibrosis, Byler's disease, mitochondrial cytopathy, or sclerosing cholangitis, an enhanced deposition of fibrillin-1 was observed in portal connective tissue and fibrous septa. The strong fibrillin-1 expression close to the basement membrane of biliary structures was lost in cholestatic diseases, except biliary atresia. Finally, in normal and pathologic tissues, fibrillin-1 was co-localized with its putative receptor alphaVbeta3 in sinusoids but not around biliary structures.     

Computer-generated three-dimensional morphology of the hepatic hilar bile ducts in biliary atresia

BACKGROUND/PURPOSE: In biliary atresia (BA), although the intrahepatic bile ducts are reported to appear in the fetal configuration in about 20% to 60% of cases, information about the 3-dimensional (3-D) morphology of the hilar biliary structures is limited. The authors, therefore, have applied the technique of computer-generated 3-D reconstruction, to study the morphology of the hilar biliary structures in patients who have undergone biliary decompression. METHODS: Computer-generated 3-D reconstructions were performed from serial sections of the hepatic hilum of 4 BA patients and compared with those obtained from a 3-day old infant who had no apparent biliary disease but died of congenital diaphragmatic hernia (CDH) and with normal human fetal ductal plate at 11 weeks of gestation. RESULTS: In all 4 BA patients, the hilar bile ducts strongly resembled the ductal plate structures of the fetus rather than the bile ducts of the CDH infant. This leads the authors to suggest that these abnormal biliary structures are the result of improper ductal plate remodeling at the hepatic hilum. In 3 of the BA patients there were some tubular bile ducts that probably are the result of delayed and abnormal attempt at ductal plate remodeling.     

Intrahepatic periductal glands and their significance in primary intrahepatic lithiasis

Resected hepatic tissues of 24 patients with primary intrahepatic lithiasis were examined histo-pathologically. Calcium bilirubinate stones, cellular debris and mucinous substances occupied the lumen of large dilated intrahepatic bile ducts. Numerous mucin secreting glands were seen within or around the wall of these bile ducts. Similar structures were demonstrated in two patients with non calculous congenital dilatation of the intrahepatic bile ducts. Cholestasis was often absent in the hepatic parenchyma. Production of intrahepatic gallstones may be caused by not only biliary stasis and infection, but also by intraductal mucin and slow flowing bile in combination with cellular debris, bile pigment and other bile components. Presented at the Third Annual Meeting of the International Biliary Association, New York, May 21, 1981