肝门部胆管癌的手术治疗
Surgical management of hilar cholangiocarcinoma
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摘要:
目的 总结肝门部胆管癌的手术治疗经验。
方法 回顾性分析2007年1月至2011年12月哈尔滨医科大学附属第一医院同一医疗组手术治疗的88例肝门部胆管癌患者的临床资料。所有患者术前经影像学检查确诊，并根据黄疸程度及剩余肝脏体积进行术前辅助治疗，行PTCD 19例、门静脉栓塞4例。基本手术方式为肝门部胆管癌切除+肝十二指肠韧带骨骼化+胆管空肠Roux-en-Y吻合术，并常规放置支撑管引流6个月。计数资料采用χ2检验，以KaplanMeier法计算生存率，生存分析采用Log-rank检验。
结果 88例手术治疗的患者中，58例(含11例PTCD治疗者)行肝门部胆管癌切除术，其中43例(含4例术前门静脉栓塞者)为R0切除，15例为姑息性切除；30例行内和(或)外引流术。联合肝切除22例(包括左半肝切除9例、 扩大左半肝切除2例、左半肝联合尾状叶切除7例、右半肝切除4例)，联合胰头十二指肠切除7例，联合肝固有动脉切除3例(重建2例)，联合门静脉管壁部分切除2例。按改良Bismuth-Corlette分型，88例患者中Ⅰ型17例、Ⅱ型19例、Ⅲa型21例、Ⅲb型20例、Ⅳ型11例。58例肝门部胆管癌切除术患者中，19例出现各种术后并发症，2例术后30 d内死亡。本组共73例患者获得随访，总体1、3、5年生存率分别为68.5%、28.8%、11.0%。37例R0切除患者、14例姑息性切除患者及22例引流患者1年生存率分别为94.6%、78.6%、18.2%；3年生存率分别为43.2%、35.7%、0；5年生存率分别为18.9%、7.1%、0。R0切除患者生存率高于姑息性切除患者(χ2=4.77，P<0.05)；姑息性切除患者生存率高于内和(或)外引流患者(χ2=13.26，P<0.05)。
结论 手术治疗肝门部胆管癌，应力求R0切除，尽量避免单纯性胆汁引流；术前充分而高效的肝功能恢复与储备能确保手术的疗效。
Abstract:Objective To summarize the experience in surgical management of hilar cholangiocarcinoma.Methods The clinical data of 88 patients with hilar cholangiocarcinoma who received surgical treatment at the First Affiliated Hospital of Harbin Medical University from January 2007 to December 2011 were retrospectively analyzed. All the patients were diagnosed by imaging examination. According to the severity of jaundice and predictive remnant liver volume, 19 patients received percutaneous transhepatic cholangial drainage (PTCD) and 4 received portal vein embolization. The fundamental operation consisted of hilar cholangiocarcinoma resection, skeletonization of hepatoduodenum ligament and RouxenY cholangiojejunostomy, and the transanastomotic stent was placed for 6 months. The count data were analyzed using the chisquare test; the survival rate was analysed using the KaplanMeier method; the survival was analyzed using the Logrank test.Results Of the 88 patients, 58 patients (including 11 patients who received PTCD) received hilar cholangiocarcinoma resection. Of the 58 patients, 43 (including 4 patients who received portal vein embolization preoperatively) received R0 resection, and 15 received palliative resection. Thirty patients received internal and (or) external drainage. Commitant partial hepatectomy was performed on 22 patients (including 9 received left hemihepatectomy, 2 received extended left hemihepatectomy, 7 received left hemihepatectomy+caudate lobectomy, 4 received right hemihepatectomy). Commitant pancreaticoduodenectomy was performed on 7 patients, commitant hepatic artery resection on 3 patients, and commitant portal vein resection on 2 patients. According to the modified Bismuth-Corlette classification, there were 17 patients with type Ⅰ, 19 with type Ⅱ, 21 with type Ⅲa, 20 with type Ⅲb, and 11 with type Ⅳ.Of the 58 patients who received hilar cholangiocarcinoma resection, 19 had postoperative complications, and 2 patients died within 30 days after operation. Seventy-three patients were followed up, and the overall 1-, 3-, 5-year survival rates were 68.5%, 28.8%, 11.0%, respectively. The 1-, 3-, 5-year survival rates of patients who received R0 resection were 94.6%, 43.2%, 18.9%, respectively, which were significantly higher than 78.6%, 35.7% and 7.1% of patients who received palliative resection (χ2=4.77, P<0.05). The 1-, 3-, 5-year survival rates of patients who received palliative resection were significantly higher than 18.2%, 0, 0 of patients who received biliary drainage (χ2=13.26, P<0.05).Conclusions R0 resection is the best choice for patients with hilar cholangiocarcinoma, and biliary drainage with no resection is the last choice. Sufficient preoperative treatment, optimized choice of surgical procedure and exquisite surgical techniques are important for the improvement of the prognosis.
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