肝部分切除联合肝十二指肠韧带骨骼化治疗肝门部胆管癌

目的 总结应用肝部分切除联合肝十二指肠骨骼化治疗肝门部胆管癌的临床经验。方法回顾1999年1月～2001年12月手术治疗67例肝门胆管癌的临床资料。结果67例患者中65例手术切除,49例根治性切除(22例肝十二指肠韧带骨骼化切除,27例联合部分肝切除)。根据Bismuth分型,Ⅰ、Ⅱ型行骨骼化切除,Ⅲa型行右半肝加右尾叶切除,Ⅲb型行左半肝加左尾叶切除,Ⅳ型中行右半肝加全尾叶3例切除,左半肝加全尾叶9例切除,方叶切除者2例。2例外院曾行部分肿瘤切除加肝门胆管空肠吻合术者,我们再次行左半肝加全尾叶切除加右肝管空肠吻合术根治肿瘤。8例患者行肿瘤部分切除加肝内胆管支撑加肝门胆管空肠吻合。13例患者行门静脉部分切除,27例患者切除肝动脉。24例患者术后无并发症发生,加例发生了严重并发症。后者中14例经治疗后康复,余6例患者术后7、12、14、42、57、89d死于肝功能衰竭、心源性休克、腹内大出血、消化道大出血。术后30d病死率4、5％,根治性手术后患者中位生存期16个月(1个月～41个月),姑息治疗者为7个月(1个月～16个月)。结论 肝部分切除联合肝十二指肠韧带骨骼化可用以根治肝门部胆管癌,尾叶切除可提高根治性切除率。

Partial hepatectomy with skeletonization of the hepatoduodenal ligament for hilar cholangiocarcinoma

OBJECTIVE: To sum up author's experience and to define the role of partial hepatectomy with skeletonization resection in the treatment of hilar cholangiocarcinoma. METHODS: Between January 1999 and December 2001, 67 patients underwent exploration in our hospital. The clinical records of these patients were reviewed. RESULTS: Sixty-five (97%) patients underwent surgical resection. Forty-nine patients (73%) had curative resection 22 skeletonization resection (SR), and the other 27 undergone SR combined with partial hepatectomy]. According to the Bismuth-Corlett classification, tumors were classified into four types. SR was performed in type I (5 cases) and type II (17 cases). Right lobectomy with right caudate lobectomy was performed in type IIIa (6 cases), left lobectomy with left caudate lobectomy in type IIIb (15 cases). Right lobectomy with whole caudate lobectomy (3 cases), left lobectomy with whole caudate lobectomy (9 cases), and quadrate lobectomy (2 cases) were undertaken in type IV. We successfully did SR and left lobectomy with whole caudate lobectomy in 2 patients (3%) who had suffered palliative biliary cancer resection and cholangiojejunostomy before. Eight patients (12%) had local resection of the tumor with Roux-en-Y hepaticojejunostomy reconstruction and intrahepatic bile ducts support. Two patients (3%) had palliative biliary drainage. Combined portal vein resection was performed in 13 (20%) patients and hepatic artery resection in 27 (40.3%). Twenty-four (35.8%) patients had no postoperative complications, and 20 (30.2%) patients developed major complications. Of the 20 patients with major complications 14 recovered; the remaining 6 patients died of liver-renal failure with other organ failure or of heart attack, intraabdominal bleeding, and gastrointestinal bleeding in 7, 12, 14, 42, 57, or 89 days after surgery. Thirty days operative mortality was 4.5%. The median survival of patients with curative resection was 16 months (ranging from 1 to 41 months), while the median survival with palliative operation was 7 months (ranging from 1 to 16 months). CONCLUSIONS: Partial hepatectomy with skeletonization resection for hilar cholangiocarcinoma can be performed with acceptable morbidity and mortality. For curative treatment of hilar cholangiocarcinoma, Caudate lobectomy is always recommended in Bismuth type III/IV.