原发性肝内胆管结石合并胆管癌

Primary hepatolithiasis complicating cholangiocarcinoma

目的总结原发性肝内胆管结石合并胆管癌的临床特征、诊断方法、治疗手段及预后。方法回顾性分析北京大学第三医院1958年6月至2011年3月收治的原发性肝内胆管结石合并胆管癌709例的临床资料。结果709例原发性肝内胆管结石合并胆管癌20例（2．8％），获得随访17例，随访率为85％，中位随访时间2（0—15）年。胆管癌诊断前原发性肝内胆管结石病程15±11年（3～38年）。有胆管炎的14例，其中重症胆管炎11例。合并肝脓肿12例，肝硬化或门静脉高压症15例。术前辅助检查提示合并胆管癌诊断的依次为CT、MRCP、B超、肿瘤标志物等。胆管癌的术前临床诊断率为55％（11／20）。行胆管癌根治术4例，姑息性手术7例，探查活检术6例，非手术治疗3例。根治术后1例失访，其余3例均存活，目前存活时间分别为1年1例，5年2例。姑息性手术7例，术后失访2例，存活时间1年2例，3年1例，5年1例。未切除者存活时间均未超过1年。结论对于原发性肝内胆管结石病例有以下情况者应提高警惕，（1）病史较长、有胆管炎。（2）合并肝硬化。（3）影像学提示胆管壁增厚或肝内占位病变。（4）肿瘤标志物升高。这些提示发生胆管癌的可能性大。对这些病例应严格定期随访，以便早期发现，获得根治切除者预后较好。

Objective To summarize the clinical features, diagnosis, treatment and prognosis of hepatolithiasis complicating cholangiocarcinoma. Methods From June 1958 to March 2011, 709 cases of hepatolithiasis were admitted to Department of General Surgery, Peking University Third Hospital. The cases concomitant with cholangiocarcinoma were reviewed. Results 20 of 709 （2. 8% ） hepatolithiasis cases developed cholangiocarcinoma. 17 cases （ 85 %, 17/20） were followed-up for 2 years （0 - 15 years）. The hepatolithiasis course before the malignant diagnosis was 15 ＋ 11years （3 -38 years）. 14 cases had frequent episodes of cholangitis, 15 cases had liver cirrhosis. Preoperative diagnosis was established by CT, MRCP, B-ultrasound and tumor markers in 55% （11/20） cases. 4 cases underwent radical resection, 7 received palliative resection, 9 cases received conservative treatment. In radical resection, one lost to follow-up, one survived one year, two for 5 years. In palliative resection, 2 lost to follow-up, two survived one year, one survived 3 years, one for 5 years. None in conservative group survived more than one year. Conclusions Cholangiocarcinoma developed from hepatolithiasis with a long history, frequent cholangitis, liver cirrhosis, especially in cases with imige showing thickness of bile duct or mass and rising tumor markers （ CA19-9, CA125, CEA）. The cases undergoing radical resection may have a favorable prognosis.