肝门部胆管癌根治性切除术中应考虑的解剖学问题

Anatomy problems in the radical resection for hilar cholangiocarcinoma

目的探讨影响肝门部胆管癌根治性切除的解剖学相关因素。方法回顾性分析1984年1月至2008年12月安徽医科大学附属第一医院普外科收治的52例肝门部胆管癌行根治性切除（R0）患者的影像学资料、临床分型、病理特征、手术方式及随访结果，并结合文献进行统计学分析。结果52例患者中，按照Bismuth—Codette分型，I型5例、Ⅱ型12例、Ⅲa型6例、mb型16例、Ⅳ型13例。联合肝叶切除24例，其中联合肝方叶切除6例、联合左半肝切除15例、联合右半肝切除1例、联合尾状叶部分切除2例；另外联合肝动脉切除4例。围手术期死亡2例（3．8％），发生术后并发症16例（30．8％）。术后1、3、5年生存率分别为78．8％、36．4％、12．1％。术前总胆红素〉340μmol／L的患者并发症的发生率明显增加，与〈170μmol／L的患者比较差异有统计学意义（P〈0．05）。结论肝门部胆管癌应根据术中肿瘤的解剖学累及范围判断能否进行根治性切除手术，尤其应特别考虑肝叶切除范围、血管切除与重建等解剖学因素，获得R0根治性切除的患者预后明显改善。

Objective To analyze the clinical data, surgical strategies and results from the patients with hilar cholangiocarcinoma （HCCA）, and to explore the anatomic factors related to the radical resection. Methods The data from 52 patients with HCCA who underwent radical resection between January 1984 to December 2008 were investigated retrospectively, which included clinical diagnosis, Bismuth-Corlette classification, pathologic features, surgical procedures and follow-up results. Results According to the Bismuth-Corlette classification, 5, 12,6, 16 and 13 patients belonged to type Ⅰ , Ⅱ , Ⅲ a, Ⅲ b and IV respectively. There were 24 cases underwent combined hepatic lobectomy. The 1-,3- and 5-year survival rates were 78.8% ,36.4% and 12. 1% respectively. Postoperative complications rate was 30. 8% with the 3.8% mortality rate. The frequency of surgical complications was significantly higher in patients with higher level of serum total bilirubin （ 〉 340 μmol/L） than that in patients with a relatively lower one （ 170 μmol/L） before operation（ P 〈 0. 05 ）. Conclusions Some anatomical factors should be considered during the radical resection of hilar cholangiocarcinoma, especially evaluation of potential hepatectomy, resection of caudate lobe, hepatic artery resection and/or reconstruction. The prognosis of the patients underwent Ro radial resection could be significantly improved.