MRCP在肝门部胆管癌术前分型中的作用

The Value of Type Determination with MRCP in Surgical Management of Hilar Cholangiocarcinoma

目的探讨磁共振胰胆管成像(MRCP)对肝门部胆管癌患者进行术前分型的可行性及其在临床术前评估中的价值。资料与方法参照Bismuth分型法,对33例经病理证实的肝门部胆管癌患者进行术前分型,并与手术探查结果及术式相对照。借助MRCP图像测量病变上缘至肝内胆管二级分支之间扩张的胆管长度,同时观察肝门部胆管汇合方式,并且与术中胆肠吻合方式对照。结果(1)MRCP对肝门部胆管癌术前分型准确性达97%。Ⅰ+Ⅱ型与Ⅲb型和Ⅲa型之间手术切除率无显著性差异(P>0.05),而Ⅳ型的手术切除率明显低于Ⅰ+Ⅱ型及Ⅲb型(P<0.05)。(2)Ⅰ+Ⅱ型手术切除率高,MRCP示病灶上缘至肝内胆管二级分支之间扩张胆管长度在0.5～1cm之间。(3)17例显示了肝门部胆管解剖及变异情况,其中右后叶肝管汇入肝总管及右后叶肝管汇入左肝管具有重要临床意义。结论(1)MRCP可对肝门部胆管癌进行较准确的术前Bismuth分型,且对临床外科制定手术方案具有重要参考价值。(2)依据MRCP图像对肝门部胆管癌病灶上方可游离胆管长度的测量可作为术前评估胆肠吻合可能性的可靠依据。(3)术前MRCP显示的肝门部胆管汇合方式对临床手术的成功具有重要作用,可提示临床避免术中误伤胆管。

Objective To discuss the feasibility and value of type determination with MRCP in surgical management of hilar cholangiocarcinoma. Materials and Methods According to the Bismuth type determination, 33 cases with hilar cholangiocarcinoma were divided into types Ⅰ , Ⅱ , Ⅲ a, Ⅲ b, Ⅳ. The results of type determination were compared with the surgical and pathological results. The operative methods for each type were compared. The length from the bile duct above the lesion to its second branch on MRCP was measured, the confluence of the hepatic hilar bile ducts by MRCP were observed, and compared with the pattern of the biliary enteric anastomoses and the management to the bile ducts in surgery. Results （ 1 ） The accurate rate of type determination with MRCP was 97%. The excision rate of type Ⅰ ＋ Ⅱ was not markedly different from that of type Ⅲa＋ Ⅲb （ P 〉 0.05）. However, the excision rate of types Ⅳ was significantly lower than those of types Ⅰ ＋ Ⅱ , Ⅲ b（ P 〈 0.05）. （2） The excision rate of types Ⅰ ＋ Ⅱ was high, the length from the bile duct above the lesion to its second branch was 0.5 - 1cm in those cases. （3）MRCP could clearly depict the anatomy and variations of hepatic hilar bile ducts in 17 cases, two patterns of the variation of the hepatic hilar bile ducts displayed on MRCP had important clinical significance, one was drainage of right posterior duct into common hepatic duct, the another was that right posterior duct emptied into left hepatic duct. Conclusion （ 1 ） MRCP could accurately make the preoperative classification of HC, MRCP is useful in making the operative regimens for hilar cholangiocarcinoma in surgery. （2） The length from the bile duct above the lesionto its main branch could be measured on MRCP, and the length is an important factor in the choice of biliary enteric anastomoses. （3） The pattern of the confluence of hepatic hilar bile ducts displayed on MRCP is an important factor in surgery planning, attention should be paid to avoid injuring the bile duct.