肝门部胆管癌手术治疗：附44例报告

背景与目的：对于肝门部胆管癌（HCCA）而言，R0切除率仍然很低。目前对术前评估、术前胆道引流、门静脉栓塞、手术切除范围、手术方式、血管切除、淋巴结清扫、化疗等问题仍有很多争议。R0切除被认为是HCCA患者获取长期生存的最重要的治疗手段。笔者总结HCCA的治疗体会，并分析不同术式的有效性及近远期疗效。方法：回顾性分析2015年1月—2020年1月行手术治疗的44例HCCA患者的临床资料。结果：44例患者中，Bismuth-Corlette分型I型5例，II型7例，IIIa型8例，IIIb型13例，IV型11例；29例行半肝/扩大半肝+全尾叶切除（联合半肝切除），13例行肝门部/围肝门区+全尾叶切除（围肝门切除），术中包括门静脉部分切除修补2例，门静脉切除重建2例，肝动脉切除重建2例，另2例因肿瘤转移无法切除行T管引流。全组均完成手术，无手术死亡。术后病理结果显示，镜下切缘阴性（R0）切除37例（联合半肝切除组26例，围肝门切除组11例），镜下切缘阳性（R1）切除5例（半肝切除2例、围肝门切除3例）。临床指标分析结果显示，联合半肝切除组的手术时间（240.4 min vs. 358.1 min）、术中出血量（705.5 mL vs. 809.9 mL）明显少于围肝门切除组，肿瘤标本切缘阳性率（6.9% vs. 23.1%）明显低于围肝门切除组（均P<0.05）；生存分析结果显示，联合半肝切除组术后与无复发生存期及1年累积生存率明显优于围肝门切除组（均P<0.05）。结论：根治性R0切除是HCCA患者可能获得治愈的唯一方法，与围肝门切除术比较，联合半肝、尾状叶切除的大范围肝切除术，能提高R0切除率，改善无复发生存期及1年生存率。术前精确评估、合理的围手术期治疗、选择个体化的手术方案可提高HCCA的疗效。

Surgical treatment of hilar cholangiocarcinoma: a report of 44 cases

Background and Aims: For hilar cholangiocarcinoma (HCCA), the R0 resection rate remains unsatisfactory. At present, there are still many controversies with regard to the preoperative evaluation, preoperative biliary drainage, portal vein embolization, surgical resection scope, surgical methods, vascular resection, lymph node dissection, chemotherapy and other issues. R0 resection is considered to be the most important treatment method for HCCA patients. Here, the authors summarize the experience in treatment of HCCA, and analyze the effectiveness as well as the short- and long-term efficacy of different surgical methods. Methods: The clinical data of 44 patients with HCCA undergoing surgical treatment from January 2015 to January 2020 were retrospectively analyzed.Results: Among the 44 patients, 5 cases were classified as Bismuth-Corlette type I, 7 cases were type II, 8 cases were type IIIa, 13 cases were type IIIb and 11 cases of type IV; 29 cases underwent hemihepatectomy/extended hemihepatectomy plus caudate lobectomy (combined hemihepatectomy), and 13 cases underwent hilar hepatectomy/perihilar hepatectomy plus caudate lobectomy (perihilar hepatectomy), including partial portal vein resection plus repair in 2 cases, portal vein resection plus reconstruction in 2 cases and hepatic artery resection plus reconstruction in 2 cases, and anther 2 cases underwent T-tube drainage only due to unresectable metastases. Operation was completed in all patients, with no surgical death. The postoperative pathological findings showed that there was negative microscopic margin (R0) in 37 cases (26 cases in combined hemihepatectomy group and 11 cases in perihilar hepatectomy group), and positive microscopic margin (R1) in 5 cases (2 cases in combined hemihepatectomy group and 3 cases in perihilar hepatectomy group). Results of clinical variable analysis showed that the operative time (240.4 min vs. 358.1 min), intraoperative blood loss (705.5 mL vs. 809.9 mL) and rate of positive margin of the resected specimens (6.9% vs. 23.1%) were all significantly reduced in combined hemihepatectomy group compared with perihilar hepatectomy group (all P<0.05). The results of survival analysis showed that the recurrence-free survival time and 1-year accumulate survival rate in combined hemihepatectomy group were all superior to those in perihilar hepatectomy group (both P<0.05).Conclusion: Radical R0 resection is the only chance of cure for HCCA patients. Compared with perihilar hepatectomy, the large scope hepatectomy hemihepatectomy plus caudate lobectomy can improve the R0 resection rate, recurrence-free survival and 1-year survival rate. Accurate preoperative evaluation, appropriate perioperative treatment and selection of individualized operation plan can improve the curative effect of HCCA.