联合精准半肝切除治疗肝门部胆管癌

Concomitant precise hemihepatectomy for the treatment of hilar cholangiocarcinoma

    摘要
  • 摘要:
    目的 探讨联合精准半肝切除治疗肝门部胆管癌的疗效及术前精准评估的应用价值。
    方法 回顾性分析2009年1月至2012年10月西安交通大学医学院第一附属医院采用联合精准半肝切除术治疗38例肝门部胆管癌患者的临床资料。患者术前分别行B超、CT、MRCP、CT血管造影等影像学检查以及肝功能等实验室检查。7例梗阻性黄疸患者，5例行PTCD、2例行ENBD。根据影像学检查结果确定手术方式。分析肝门部胆管癌手术切除情况，比较手术前后肝功能指标变化，术后并发症情况，术后病理检查结果以及预后的影响因素。计数和计量资料分别采用χ2和t检验，Kaplan-Meier法绘制生存曲线，生存分析采用Log-rank检验，多因素分析采用COX比例风险模型。
    结果 38例患者术前均行B超、CT、MRCP检查，其阳性检出率分别为65.8%(25/38)、71.1%(27/38)、89.5%(34/38)，5例行CT血管造影检查者均为阳性表现。全组患者行联合左半肝切除28例，联合右半肝切除10例，其中联合尾状叶切除22例、联合门静脉部分切除并重建4例(肝左静脉补片修补1例)、联合肝动脉切除12例(肝动脉重建3例)。R0切除32例、R1切除4例、R2切除2例。全组患者术后肝功能指标TBil、DBil、ALP、GGT、ALT及AST较术前均显著改善，两者比较，差异均有统计学意义(t=7.799，8.445，5.697，6.633，4.469，4.140，P<0.05)。全组患者围手术期死亡2例，病死率为5.3%(2/38)；术后并发症主要为胆汁漏和肝功能不全，其发生率分别为28.9%(11/38)和21.1%(8/38)。术后病理检查结果：浸润型腺癌31例、结节性腺癌5例、黏液腺癌1例、腺鳞癌1例。联合半肝切除术后患者第1、2、3年总体生存率分别为66%、37%、21%，半数生存时间为22.0个月，R0切除与R1/R2切除，N0期与N1/N2期患者生存率比较，差异有统计学意义(χ2=4.516，10.397，P<0.05)。多因素分析结果显示：切缘癌细胞残留和淋巴结转移与预后相关。
    结论 联合精准半肝切除可提高肝门部胆管癌的根治性切除率和疗效。术前全面的影像学和肝功能检查精确评估肝门部胆管癌的可切除性，术前选择性减轻黄疸治疗是降低术后并发症和病死率的关键。
     

     

    Abstract:
    Objective  To investigate the efficacy of concomitant precise hemihepatectomy for the treatment of hilar cholangiocarcinoma.
    Methods  The clinical data of 38 patients with hilar cholangiocarcinoma who received concomitant precise hemihepatectomy at the First Affiliated Hospital of Xi′an Jiaotong University from January 2009 to October 2012 were retrospectively analyzed. All patients were examined by B ultrasonography, computed tomography (CT), magnetic resonance cholangiopancreatography (MRCP) and CT angiography (CTA) preoperatively. The hepatic function was tested before operation. Of the 7 patients with obstructive jaundice, 5 received percutaneous transhepatic cholangial drainage, and 2 received endoscopic nosalbiliary drainage. Surgical procedures were determined according to the results of imaging examination. The resection of hilar cholangiocarcinoma, postoperative histopathological examination, pre- and postoperative hepatic function and prognostic indicators were analyzed. The count data and measurement data were analyzed using the chi-square test and t test,
    respectively; the survival curve was drawn by KaplanMeier method, and the survival rate was analyzed using the Logrank test. COX proportion hazards model was used for multivariate analysis.
    Results  The positive rates of B ultrasonography, CT and MRCP were 65.8%(25/38), 71.1%(27/38) and 89.5%(34/38), respectively. The results of 5 patients who received CTA were positive. Concomitant left hemihepatectomy was performed on 28 patients, concomitant right hemihepatectomy on 10 patients; concomitant caudate lobectomy on 22 patients, concomitant resection and reconstruction of portal vein on 4 patients (including 1 patient who received left hepatic vein repair), concomitant hepatic artery resection on 12 patients (including 3 patients who received hepatic artery reconstruction). Of the 38 patients, R0 resection was performed on 32 patients, R1 resection on 4 patients, R2 resection on 2 patients. Hepatic function indicators including total bilirubin, direct bilirubin, alkaline phosphatase,gamma-glutamyl-transferase, alanine aminotransferase and aspartate aminotransferase were significantly decreased after operation (t=7.799, 8.445, 5.697, 6.633, 4.469, 4.140, P<0.05). Two patients died perioperatively, with the mortality rate of 5.3%(2/38). The main postoperative complications included bile leakage and hepatic function insufficiency, with the incidences of 28.9%(11/38) and 21.1%(8/38), respectively. Postoperative histopathological findings included 31 patients with invasive adenocarcinoma, 5 patients with nodular adenocarcinoma, 1 patient with mucinous adenocarcinoma and 1 patient with adenosquamous carcinoma. The overall 1-, 2-, 3-year survival rates were 66%, 37% and 21%, and the median survival time was 22.0 months. There were significant differences in the survival rates between patients who received R0 resection and those with R1/R2 resection, and between patients with N0 and N1/N2 stage (χ2=4.516, 10.397, P<0.05). The results of multivariate analysis showed that positive margin and lymph node metastasis were prognostic indicators.
    Conclusions  Concomitant precise hemihepatectomy has significantly improved the radical resection rate and the efficacy of treatment for hilar cholangiocarcinoma. Comprehensive preoperative imaging examination and hepatic function test are important for the assessment for resectability of hilar cholangiocarcinoma. Selective preoperative biliary drainage are key points to decrease postoperative morbidity and morality.

     

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