肝门空肠扣式吻合术治疗Ⅲ型和Ⅳ型肝门部胆管癌

Button-like Cholangiojejunostomy in the Treatment of Type Ⅲ and Ⅳ Hilar Cholangiocarcinoma

目的探讨肝门空肠扣式吻合术治疗Ⅲ型和Ⅳ型肝门部胆管癌的可行性及其疗效。方法对2010年1月至2011年6月行肝门空肠扣式吻合术的12例晚期肝门部胆管癌患者的疗效及近期并发症进行回顾性分析。其中男性7例,女性5例;平均年龄59.83(39～78)岁。患者主要临床表现为黄疸、上腹部钝痛等。血清总胆红素升高12例(100%),10例直接胆红素升高。肿瘤标志物检查,CA199异常(>27U/ml)12例(100%),CEA异常(>5 U/ml)7例(58.33%),CA125异常(>35 U/ml)4例(33.33%)。所有患者均行B超、CT/MRCP检查,均显示肝内胆管扩张,肝门部占位。根据Bismuth-Corlette分型,Ⅲa型3例,Ⅲb型3例,Ⅳ型6例。均行肝门部胆管癌切除,将残留的5支左右胆管断端与空肠襻行胆管空肠扣式吻合术。结果所有患者术后血清总胆红素均明显下降,术后引流有效率100%。术后发生吻合口胆瘘1例,切口感染2例,肺部感染2例,无围手术期死亡病例。2例患者分别于术后3、5个月死于多器官功能衰竭,1例于术后10个月死于肿瘤复发广泛转移,其余均健在。结论对晚期肝门部胆管癌应持积极的手术态度,肝门空肠扣式吻合术能提高Ⅲ型和Ⅳ型肝门部胆管癌切除率,是一种可行的治疗方法。

Objective To discuss the feasibility of the surgical technique with button-like cholangiojejunostomy in the treatment for type Ⅲ or Ⅳ hilar cholangiocarcinoma.Methods The clinical outcomes and the short-term complications were analyzed retrospectively in 12 patients from January 2010 to June 2011 with advanced hilar cholangiocarcinoma treated with button-like cholangiojejunostomy.There were 7 cases of male and 5 cases of female with 39 to 78 years old.The main clinical features were jaundice,blunt upper abdominal pain,and etc.The serum total bilirubin elevated in all cases,and the direct bilirubin elevated in 10 cases.The detection of tumor markers showed elevated CA199 in 12 cases,elevated CEA in 7 cases and elevated CA125 in 4 cases.Intrahepatic bile duct dilatation and hilar space-occupying were obtained by the ultrasound and CT/MRCP.According to the Bismuth-Corlette classification,there were 3 of type Ⅲa,3 of type Ⅲb and 6 of type Ⅳ.All the cases underwent resection of the hilar cholangiocarcinoma with Roux-en-Y button-like cholangiojejunostomy.Results The efficacy of biliary drainage in 12 patients was 100%.1 case suffered from the biliary leakage after Roux-en-Y cholangiojejunostomy.No death occurred in the period of perioperation.There were 3 cases died at the third,fifth and tenth months after operation respectively,and the others all survived.Conclusion A positive attitude should be kept to the surgical treatment for advanced hilar cholangiocarcinoma.It can increase the resection rate of the button-like cholangiojejunostomy for the type Ⅲ and Ⅳ hilar bile duct carcinoma,and is recommended as a viable treatment method.