肝门部胆管癌术后复发与手术方式的关系

Post-operative recurrence of hilar cholangiocarcinoma and its relation to the operative pattern after resection of hilar cholngiocarcinoma

目的提高肝门部胆管癌的远期疗效.方法回顾1978～2003年330例肝门部胆管癌的手术切除率、并发症、死亡率、5年生存率及随访40例不同术式的切除后复发情况.结果肝门部胆管癌切除率从前阶段(1998年前)53.6%提高到后阶段的61.1%(P＜0.05),并发症发生率由9.3%上升到30.0%(P＜0.01),死亡率略有上升但统计学无差别(P＞0.05).对40例行根治切除术病人术后随访5年,其不同切除术式的肿瘤复发情况为:肝十二指肠韧带骨骼化切除伴方叶切除及伴左半肝切除者术后100%复发,伴右三肝叶切除者66.6%复发,复发处在肝尾叶.伴肝叶切除及尾叶切除者复发率为25%,与不伴尾叶切除者复发率比较有统计学差别(P＜0.01),伴尾叶切除与不伴尾叶切除5年存活率有明显统计学差别(P＜0.01).结论肝门部胆管癌Bismuth分类中Ⅱ型以上者必须行肝尾叶切除及肝十二指肠韧带骨骼化切除,Ⅲa,Ⅲb期除尾叶切除外,加扩大右肝或左肝切除甚至右、左三叶切除更好.此时切除前,应行切除侧门静脉栓塞及胆管引流术,门静脉受累段切除、肝动脉切除重建应慎重选择.

Objective To improve the long-term results of surgical resection for patients with hilar cholangiocarcinoma. Methods The resection rate, complication, mortality, five year survival rate and the recurrences of tumors resected in various patterns in 40 cases were reviewed in 330 patients with hilar cholangiocareinoma from 1978 to 2003.Results The resection rate of the hilar cholangiocareinoma rose from 53.6% of the previous stage （before 1998） to 61. 1% in the later stage （ P 〈 0.05） and the percontage of complication from 9.3 % before 1998 to 30.0% （ P 〈 0.01 ） after 1998. The mortality rose slightly, but there was no statistical difference （ P 〉 0.05）. The recurrence rote in 40 patients after resection through follow-up for 5 years was as follows： the postoperative recurrence rate was 100% in which the skeletonized hapatoduodenal ligament combined with the quadrate lobe and left lobe was excised; the postoperative recurrenoe rate was 66.6% in which the skeletenized hepatoduodenal ligament combined with the right three lobes was excised and the site of the recurrence was at the caudate lobe of the pancreas. The recurrenco rate in patients undergoing lobectomy combined with resection of the caudate lobe was 25% There was statistical difference, as compared with the recurrence rote of the patients without caudate lobeetomy （ P 〈 0.01 ）. There was obvious statistical difference in the 5-year survival rate after caudate lobectomy or without caudate lobectomy （ P 〈 0.01）. Conclusion Resection of the caudate lobe of the liver and the skeletonized hepatoduodenal ligament should be performed in patients with hilar cholangiocarcinoma above type Ⅱ of the Bismuth classification. It is better to extend right or left hepatectomy and even the right and left three lobectomy except for caudate lobectomy in type Ⅲa, and Ⅲb stage. The pertal vein embolization of the affected side and drainage of the bile duct should be performed precperatively. Besides, the involved segnent of the pertal vein should be excised, but the reconstruction of the resected hepatic artery should be selected cautiously.