肝管汇合变异在肝门胆管癌手术中的价值

The Significance of the Variation of Hepatic Biliary Confluence in the Treatment for Hilar Cholangiocarcinoma

目的:评价肝管汇合变异在肝门胆管癌治疗中的价值。方法:对2002年1月～2007年3月本院就诊的肝门胆管癌(或肝门部胆管癌)患者行术前磁共振胰胆管显影(MRCP)检查,发现存在左、右肝管汇合方式变异患者24例,其中16例评价有潜在手术切除可能的患者行手术探查,对该16例患者的资料进行回顾性分析。结果:16例患者术前MRCP检查发现的肝管汇合变异均经手术证实,MRCP诊断肝管汇合方式变异的准确性为100%;16例患者中右后叶支直接汇入左肝管7例(43.8%),呈"三叉戟"状5例(31.3%),右后叶支直接汇入肝总管2例(12.5%),右前叶支直接汇入左肝管2例(12.5%);手术切除9例(56.3%),其中R0切除5例(31.3%),R1切除3例(18.8%),R2切除1例(6.3%);术后发生并发症2例,1例患者死于术后胆漏。结论:肝门胆管癌患者中肝管汇合变异较常见,术前MRCP检查能较准确的发现这种变异;有些肝管汇合变异是对手术有利的,通过合理的手术入路,利用这些变异,能提高部分患者、尤其是Ⅲ和Ⅳ型等高位胆管癌患者手术切除的成功率,并有利于选择合适的胆肠吻合方式及避免术中胆道误损伤,提高手术切除的安全性。

Objective： To evaluate the significance of the variation of hepatic biliary confluence in the treatment of hilar cholangiocarcinoma. Methods： Patients with hilar cholangiocarcinoma treated in our hospital from January 2002 to March 2007 underwent magnetic resonance cholangiopancreatography （MRCP） examination, Twenty-four patients had variations of hepatic biliary confluence, including 16 patients who had potential for successful resection and underwent surgery. The clinical data of these 16 patients were retrospectively analyzed. Results： The variations of hepatic biliary confluence showed by preoperative MRCP examination in the 16 patients were supported by observations during surgery. The accuracy of MRCP in determining the type of variation was 100%. The right posterior duct fusing with the left hepatic duct was seen in 7 patients （43.8%）, the so-called ＂trident confluence＂ was seen in 5 patients （31.3%）, the right posterior duct directly fusing with the common bile duct was observed in 2 patients （12.5%）, and the right anterior duct fusing with the left hepatic duct occurred in 2 patients （12.5%）. Surgical resection was conducted in 9 patients （56.3%）, of which 5 patients （31.3%） had R0 resection, 3 patients （18.8%） had R1 resection and 1 patient （6.3%） had R2 resection. Two patients （12.5%） suffered from postoperative complications and 1 died of biliary leakage. Conclusion： Hepatic biliary confluence is very common in hilar cholangiocarcinoma, and preoperative MRCP is an effective way to detect these variations. Some variations are beneficial and suitable surgical procedures can increase the resection rate of some hilar cholangiocarcinomas, especially Bismuth type Ⅲ-Ⅳ. Some variations are helpful for surgeons who need to select an appropriate method of biliary-enteric anastomosis while avoiding injury of the bile duct during surgery.