【作者】 张剑；

【导师】 王剑明；

【作者基本信息】 华中科技大学 ， 普通外科学， 2014， 博士

【摘要】 目的肝门部胆管癌(Hilar Cholangiocarcinoma, HC)恶性程度高、易侵犯肝门区血管、胆道及肝实质,解剖复杂、手术难度大、且对放疗及化疗不敏感,故根治性手术是目前唯一有效的治疗手段。为减少手术并发症,提高远期生存率,我们提倡采取外科一体化治疗,包括：完备的术前管理,精确的术前评估,合理的手术规划以及积极的手术策略。对2009.7-2014.2我们单治疗组收治的92例HC患者进行回顾性总结、归纳,浅析肝门部胆管癌的一体化治疗。方法回顾性分析2009.7-2014.2在我们单治疗组就治的92例HC患者的临床资料,其中2009.7-2010.7收治15例患者,2010.8-2011.8收治17例患者,2011.9-2012.9收治25例,2012.10-2014.2收治35例,呈逐年增长趋势。92例患者中,84例患者行PTCD减黄,67例患者胆红素降至正常水平后检测ICG,其中2012.10-2014.2的35例HC患者在薄层CT和MRCP基础上建立3D评估,显示肿瘤与血管、胆道的三维关系,并进行虚拟的手术方式规划及可切除性评估,后与术中实际情况对比。记录患者的手术方式及患者转归。结果1.92例HC患者中,2009.7-2010.7收治15例患者,2010.8-2011.8收治17例患者,2011.9-2012.9收治25例,2012.10-2014.2收治35例,呈逐年增长趋势。根据Bismuth标准分型,Ⅰ型1例、Ⅱ型1例、Ⅲa型32例、Ⅲb型44例、Ⅳa型6例、Ⅳb型8例。2.92例患者入院时胆红素平均水平为：TB(334.3±146.5)μmol/L,DB(174.8±71.1) μmol/L,7例患者因入院时胆红素在正常范围、1例患者因反复B超检查示肝内胆管不扩张未行PTCD引流,余84例行B超引导下PTCD引流,部分多次或多点穿刺,其中穿刺左叶胆管27例,穿刺右叶胆管39例,同时穿双侧18例,成功率100%,67例胆红素减至正常患者的减黄时间为7-50天,平均(15+5)天,57例胆红素减至正常的手术患者术前复查胆红素较入院明显下降：TB (24.3±9.2)μmol/L, DB (8.1±4.9)μmol/L。3.92例患者中,67例患者待胆红素降至完全正常后检测ICG,具体结果如下：56例ICGR15m<10%(53例手术,3例放弃手术),11例ICGR15m>10%(4例手术,7例放弃手术)。25例患者未检测ICG,具体结果如下：11例手术患者因胆红素未降至正常未测ICG。14例拒绝检测ICG(7例手术,7例放弃手术)。除17例放弃手术患者外,72例患者均接受不同类型的联合肝脏切除术,3例行开关手术。4.92例患者中,2012.10-2014.2收治的35例3D评估患者Bismuth分型如下：Ⅰ型1例、Ⅱ型1例、Ⅲa型7例、Ⅲb型13例、Ⅳa型6例、Ⅳb型7例,29例术后Bismuth分型与术前3D成像判断一致,准确率为90.6%；围肝门部解剖分型如下：A型29例,占82.9%；B型6例,占17.1%；未见C、D、E型；右侧胆管的解剖变异分型如下：Supraportal型27例,占77.1%, Infraportal型8例,占22.9%；左侧胆管的解剖变异分型如下：Ⅰ型8例,占22.8%,Ⅱ型27例,占77.1%,Ⅲ型0例,占0%；胆管平均预留孔数3.1孔；评估肝动脉解剖变异率为14.3%,受侵犯准确率为87.5%；评估门静脉解剖变异率为5.7%,受侵犯准确率为84.4%,可切除性评估准确率为93.8%。32例手术患者虚拟手术规划如下：16例患者行左半肝切除,13例患者行右半肝切除,3例行左三肝切除。其中5例患者与实际手术存在差异,准确率84.4%。5.92例患者中,经充分术前准备后,58例行根治术,14例行小范围肝切除+肝门部胆管整形+胆肠吻合术,3例行开关手术,17例因个人因素放弃手术。58例根治性手术患者中,34例行左半肝切除,其中联合部分尾状叶切除13例,联合全尾状叶切除7例；20例行右半肝切除术,其中联合部分尾状叶切除9例,联合全尾状叶切除3例；4例行左三肝切除,其中联合部分尾状叶切除1例,联合全尾状叶切除2例。3例分别因为肿瘤侵犯胆总管胰腺段、13a淋巴结及胰头联合HPD,2例联合肝右动脉切除+大隐静脉架桥术,4例联合门静脉切除重建术(3例联合门静脉右支切除重建术,1例联合门静脉左支切除重建术)。术后病理证实：胆囊腺癌1例,高分化腺癌18例,中分化腺癌35例,低分化腺癌21例。6.手术时间波动在310-580min,平均手术时间为394±38min；术中失血量波动在180-1650ml,平均失血量为449±98ml；对于术中输血量,浓缩红细胞波动在400-1200ml,平均值为643±102ml,新鲜冰冻血浆波动在200-800ml,平均值为416ml±50ml。7.术后并发症具体为：5例胆漏,11例腹腔积液,0例腹腔出血,0例腹腔感染,并发症率为21.3%；1例因急性心肌梗死在住院期间死亡,围手术期死亡率1.3%。术后平均住院时间(18±3)天。8.除1例院内死亡患者外,余74例出院患者随访结果如下：15例复查示转移,其中1例转移至残余肝脏的患者于术后7个月死亡,2例患者发生胆道感染再次入院,20例患者失访,37例患者目前随访健在,继续随访中。结论1、肝门部胆管癌的外科一体化治疗是指在PTCD引流、肝脏储备功能及3D评估等一套完整的术前管理体系的基础上进行根治性手术切除,可改善HC围手术期处理,增加患者对手术的耐受性,预测可切除性并做出准确的手术规划,在此基础上进行根治性手术切除,可减少手术并发症并提高远期生存率。2、在肝切除的基础上,联合门静脉伴／不伴肝动脉切除并重建使HC手术方式变得更富有挑战性,患者的外科疗效及长期存活率得到很大改善,建议在大型医疗中心对肝门部胆管癌在完备的管理体系下采取积极的手术策略以提高疗效。更多还原

【Abstract】 ObjectiveThe hilar cholangiocarcinoma is a kind of highly malignancy carcinoma. It was easily invasived to vascular, bile duct around hilar hepatic and liver parenchyma which coursed difficult for the surgery, what’s more the carcinoma was insensitive toradio-and chemo-therapy. HC radical resection is considered as to be the best treatment for hilar cholangiocarcinoma. To reduce surgical complications and improve long-term survival, we advocated the integration of surgical treatment, including:comprehensive preoperative management, accurate preoperative evaluation, surgical planning and rational aggressive surgical strategy.We analyzed the data of92patients in our surgical team with HC from Jul.2009to Feb.2014and discuss the experience of integration treatment for HC.MethodsWe made the retrospectively analyzing for the data of92patients with HC between Jul.2009to Feb.2014,15patients between Jul.2009to Jul.2010,17patients between Aug.2010to Aug.2011,25patients between Sep.2011to Sep.2012,35patients between Oct.2012to Feb.2014. The cases of HC we treated was increasing year by year. In the92patients with HC,84cases had performed PTCD and67cases reduce jaundice back to normal and detected ICG before surgery. In the35patients with HC between Oct.2012to Feb.2014, we also made the ICG test and3D evaluation which based on CT and MRCP to clear the relationship between the tumor with blood vessel and biliary tract. Then we did virtual operation plan to evaluated the resectablation for each patient. At last we compared to the actual situation during operation, recorded the surgical approach and outcome. Result1. In the92patients with HC,15patients between Jul.2009to Jul.2010,17patients between Aug.2010to Aug.2011,25patients between Sep.2011to Sep.2012,35patients between Oct.2012to Feb.2014. The cases of HC we treated was increasing year by year.And accroing to the Bismuth-Corlette classification,there were1case for type I,1case for type II,32cases for Ⅲa,44cases for Ⅲb,6cases for IVa and8cases for IVb.2.The TB of the92patients is (334.3±146.5) mmol/L while DB is (174.8±71.1) mmol/L when hospitalized.7patients whose bilirubin was in the normal range and1patient whose B-ultrasonic test showed no intrahepatic bile duct dilatation did not undergo PTCD drainage.84patients were performed PTCD under the guide of B ultrasound.27cases punctured on the bile duct of left lobe,39on the right and18cases on both sides. All the PTCD performents were successed. The whole process in the67cases whose TB was down to the normal reduced jaundice cost7to50days, with the average is15±5days and the bilirubin levels of the57patients with surgery showed a dramatic decrease with the TB was (24.3±9.2) mmol/L and DB was (8.1±4.9) mmol/L before operation.3. In the92patients,67patients detected ICG when the bilirubin were completely normal. The results were as follow:56cases ICGR15m were<10%(53cases with surgery,3cases without surgery),11cases ICGR15m>10%(4cases with surgery,7cases without surgery),25cases didn’t detected ICG, the results were as follow:11cases with surgery for their bilirubin cannot returned to normal,14cases refused to detect ICG(7cases with surgery,7cases without surgery).17cases forgo surgery.72patients were received combination of different types of liver resection.3patients did on-off surgery.4. In the92patients, through3D evaluation of35cases between Oct.2012to Feb.2014, there were1case for type I,1case for type II,7cases for Ⅲa,13cases for Ⅲb,6cases for IVa and7cases for IVb,3D evaluation of29cases was the same as actural, the accuracy of Bismuth-Corlette classification was90.6%. Anatomical classification of perihilar bile ducts as follow:29A type(82.9%),6B type(17.1%), no type C、D、E. Anatomical classification of right bile ducts as follow:27Supraportal type(77.1%),8Infraportal type(22.9%). Anatomical classification of left bile ducts as follow:8Type Ⅰ(22.8%),27Type Ⅱ(77.1%).The number of bile duct orifices in the cut end of the hilar plate was3.1. Anatomic variation rate of hepatic artery was14.3%. Hepatic artery infringement evaluation was87.5%. Anatomic variation rate of portal vein was5.7%. Portal vein infringement is84.4%, and resectable evaluation was93.8%. Virtual operation plans for32surgical patients were as follows:16cases were performed left liver resection,13cases were right half liver resection and3cases were third left liver resection. Only5cases had different surgery with virtual plans. So the accuracy was84.4%.5. In the92patients, after well preparation,58cases underwent radical operation;14cases underwent small scale hepatic resection, hilar bile duct plastic and bile duct intestinal anastomosis;3cases underwent on-off surgery.17patients gave up surgery. Among58patients who accepted radical operation,34cases underwent left liver resection,13combined resection of part of the caudate lobe,7combined resection of all the caudate lobe;20cases underwent right liver resection,9combined resection of part of the caudate lobe,3combined resection of all the caudate lobe; and4patients underwent third left liver resection,1combined resection of part of the caudate lobe,2combined resection of all the caudate lobe.3cases underwent Hepatopancreatoduodenectomy.2cases underwent right hepatic artery resection.4cases underwent portal vein resection. Pathologically confirmed:1case of gallbladder adenocarcinoma,18cases of adenocarcinoma, moderately differentiated adenocarcinoma in35cases,21cases of poorly differentiated adenocarcinoma.6. The operation time fluctuations in the310-580min and the mean was394±38min. Intraoperative blood loss around in180-1650ml and the mean was449±98ml, For intraoperative blood transfusion, red blood cells around400to1200ml, with an average of643±102ml, fresh frozen plasma around200to800ml, with an average of416ml±50ml.7. Postoperative complications:5cases of bile leakage,11cases of ascites,0cases of abdominal bleeding,0cases of abdominal infection Complication rate was21.3%;One case died for acute myocardial infarction died during hospitalization, perioperative mortality of1.3%.The mean postoperative hospital stay (18±3) days.8. Except for one case died in hospital The follow-up results for the other74cases as follows:15cases showed metastasis, Which is metastasis to the residual liver and the patient died7months after surgery,2cases occurred biliary tract infection,20patients were lost to follow37patients follow-up currently alive, we will keep to follow up.Conclusion1. The integration surgical treatment of hilar cholangiocarcinoma means radical resection based on a set of completely preoperative management system including PTCD, liver functional reserve estimation,3D evaluation, and so on. It can improve perioperative treatment of HC patients, increase the patient’s tolerance to surgery, help to predict resectable, and contribute to make surgical planning more accurate. Baesed on this treatment, performing radical surgery can reduce surgical complications and improve the long-term survival of patients with HC.2. Liver resection combined with portal vein (with or without hepatic artery) resection and rebuild made the HC operation became more challenging. At the same time, surgical curative effect and long-term survival rate of the patients is greatly improved. By the comprehensive management system, more aggressive operation strategy is suggested to in a large medical center.更多还原