原位肝移植联合胰头及十二指肠根治性切除治疗肝门部胆管癌一例

Combined extended radical resections and orthotopic liver transplantation for the treatment of hilar cholangiocarcinoma: one case report

目的评价原位肝移植联合胰头及十二指肠根治性整块切除(Whipple法)治疗Ⅳ型肝外胆管癌的可行性。方法对1例Ⅳ型(Bismuth-Corlette分型)肝外胆管癌侵犯肝内二级胆管及胆总管胰腺段的患者,实施原位肝移植联合胰头及十二指肠根治性切除手术(HPLTX)。术后应用他克莫司(FK506)+甲泼尼龙二联免疫抑制方案;给予拉米夫定+大剂量乙型肝炎免疫球蛋白静脉滴注抗病毒治疗。采用免疫组织化学法检测病肝中肝细胞蛋白、癌胚抗原、胆管上皮细胞角蛋白(CK9、CK17)的表达。结果病肝标本病理诊断为浸润型低分化胆管癌。患者移植肝功能恢复顺利,血清甲胎蛋白、癌胚抗原、肿瘤相关抗原(CA19-9、CA125)均降至正常范围,未见肿瘤复发。结论实施HPLTX可提高肝门部Ⅳ型胆管癌手术R0切除率,可获得较好的预后。

Objective To evaluate the surgical technique and outcome of the extended radical resections for hilar cholangiocarcinoma. Methods A patient with Bismuth-Corlette type IV Klatskin＇s tumor, which invaded the secondary intrahepatic bile duct and the pancreatic portion along the common bile duct, underwent the HPLTx. And then, the digest cannel was reconstructed according to the Child＇s methods. By using immunohistochemistry, the expression of cytokeratin9, 17, CEA and hepatocyte protein was detected. After operation, the irnmunosuppressive agents consisting of Tacrolimus and steroids were given; lamivudine and HBIg were used to prevent HBV from recurrence. Results Pathologic examination revealed low differentiated adenocarcinoma and immunohistochemistry stains confirmed the positive expression of cytokeratin9 and 17, carcinoembryonic antigen, and the negative expression of hepatocyte protein. Neither the margins of resection nor periductal lymph nodes were pathologically involved. She was currently alive for 17 months after the operation, the liver graft function was within normal range, and the patient was back to the previous work without any evidence of recurrent cancer. The tumor marker in plasma was decreased to the controllable level. Conclusion The HPLTx may he the treatment choice for unresectable Klatskin＇s tumor and provide the higher rate of radical resection and better prognosis.