Ⅳ型肝门部胆管癌的治疗体会

Treatment Experience of Type Ⅳ Hilar Cholangiocarcinoma

目的探讨Ⅳ型肝门部胆管癌的初步治疗经验。方法收集2008年4月至2011年4月期间四川大学华西医院肝胆胰外科1个医疗组收治的20例Ⅳ型肝门部胆管癌患者的临床资料,对其术中及术后结果进行分析。结果 20例中行手术切除15例,切除率为75%。其中行根治性切除术10例,非根治性切除术5例;行左三肝+尾叶切除(右前右后肝管成形、肝管-空肠吻合+空肠-空肠Roux-en-Y吻合术)7例,行扩大右半肝切除+尾叶切除(左外左内肝管成形、肝管-空肠吻合+空肠-空肠Roux-en-Y吻合术)6例,行肝方叶切除(左外内、右前后肝管分别整形后行2个胆-肠吻合术)2例;其中2例因总胆红素>400 mmol/L而先行经皮肝穿刺胆管引流(PTCD)和门静脉栓塞(PVE)后再手术,1例行根治性切除术,另1例行非根治性切除术。不能切除者5例,其中3例因发生肝脏及远处广泛转移,行术中PTCD,另2例因肿瘤侵犯门静脉左右支,行术中T管引流、联合术后PTCD。行手术切除者术后1年生存率为100%,术后生存时间1～3年,平均1.5年;肿瘤未切除者生存3～6个月,平均4.2个月。本组无一例围手术期死亡。结论对于Ⅳ型肝门部胆管癌,术前应精确评估,力争切除肿瘤,解除胆管梗阻;如不能一期切除则行PTCD和PVE,力争二期切除。

Objective To explore primary surgical treatment experience of typeⅣ hilar cholangiocarcinoma.Methods From April 2008 to April 2011,20 patients with type Ⅳ hilar cholangiocarcinoma were enrolled into the same surgical group in Department of Hepatobiliary and Pancreatic Surgery of West China Hospital of Sichuan University.The intra-and post-operative results were analyzed.Results The total resection rate was 75%,which was consisted of 10 cases of radical excision and 5 cases of non-radical excision.Seven patients received left hepatic trisegmentectomy and caudate lobe resection including anterior and posterior right hepatic duct reconstruction,hepatojejunostomy,and Roux-en-Y jejunojejunostomy.Six patients received enlarged left hepatic trisegmentectomy and caudate lobe resection including left intrahepatic and extrahepatic duct reconstruction,hepatojejunostomy,and Roux-en-Y jejunojejunostomy.Two patients received quadrate lobe resection including two cholangioenterostomies after anterior and posterior right hepatic duct reconstruction,and left intrahepatic and extrahepatic duct reconstruction.After percutaneous transhepatic cholangial drainage（PTCD） and portal vein embolization（PVE）,two patients with total bilirubins 400 mmol/L received radical excision and non-radical excision,respectively.Three patients only received PTCD during operation due to wide liver and distant metastasis,and two patients received T tube drainage during operation and postoperative PTCD due to left and right portal vein involvement.All 15 patients who received lesion resection survived more than one year,whereas another five patients whose lesions can not been resec ted only survived from 3 to 6 months with the mean of 4.2 months.No death occurred during the perioperative period.Conclusions For patients with type Ⅳ hilar cholangiocarcinoma,preoperative evaluation and tumor resection shall conducted so as to relieve obstruction of biliary tract,otherwise PTCD and PVE prior to the final lesion resection shall be performed.