207例肝门部胆管癌外科手术的疗效分析

Clinical efficacy of surgical treatment for hilar cholangiocarcinoma： a report of 207 cases

【摘要】目的探讨肝门部胆管癌的不同根治性手术的疗效。方法回顾性分析2007年6月至2012年6月第三军医大学西南医院收治的207例肝门部胆管癌患者的临床资料。BismuthI型患者行肿瘤局部切除或半肝联合尾状叶切除术；BismuthⅡ型和病变局限于一级胆管内的部分Ⅲa、Ⅲb型及Iv型患者行哑铃式切除术；其余病变侵犯二级胆管的ma、mb型及Ⅳ型患者根据术中情况行半肝或扩大半肝联合尾状叶切除术。通过本所临床研究中心进行电话随访和门诊随访，术后每3个月随访1次。随访时问截至2012年12月。率或构成比的比较采用，检验或Fisher确切概率法，Kaplan—Meier法绘制生存曲线，生存分析采用Log—rank检验。结果207例患者中，124例行根治性切除术，其中14例行局部肿瘤切除术（未切除肝叶），23例行哑铃式切除术，87例行联合肝叶和（或）尾状叶切除术；49例患者行姑息性切除术；34例患者行单纯胆道引流术。4例患者于围手术期死亡。行哑铃式切除术、左半肝联合尾状叶切除术和右半肝联合尾状叶切除术患者的并发症发生率分别为21．7％（5／23）、46．6％（27／58）和48．3％（14／29），行哑铃式切除术患者的并发症发生率显著低于左半肝联合尾状叶切除术和右半肝联合尾状叶切除术（∥=4．42，3．90，P〈0．05）。170例患者获得有效随访，112例行根治性切除术的患者中位生存时间为26．5个月，1、3、5年生存率分别为75．9％（85／112）、42．9％（24／56）、28．9％（11／38）；38例行姑息性切除术的患者中位生存时间为8．5个月，1、3年生存率分别为31．6％（12／38）、0；20例行单纯胆道引流术的患者中位生存时间为4．0个月，1年生存率为0。行根治性切除术患者的生存率优于行姑息性切除术（∥=65．32，P〈0．05）；单纯胆道引流术和手术治疗患者的生存率比较，差异有统计学意义（∥=99．97，P〈0．05）。112例行根治性切除术的患者中，10例行局部肿瘤切除术的患者中位生存时间为47．0个月，1年生存率为10／10，随访结束时生存4例；23例行哑铃式切除术的患者中位生存时间为32．0个月，1、3年生存率分别为95．7％（22／23）、7／15，生存时问〉5年者6例；54例行左半肝或扩大左半肝联合尾状叶切除术的患者中位生存时间为27．6个月，1、3年生存率分别为42．1％（24／57）、38．7％（12／31），生存时间〉5年者9例，随访结束时生存3例；25例行右半肝或扩大右半肝联合尾状叶切除术的患者中位生存时间为28．3个月，l、3年生存率分别为45．8％（11／24）、6／15，生存时间〉5年者6例，随访结束时生存2例。35例行半肝联合尾状叶切除术的患者（BismuthI、Ⅱ型和肿瘤未侵犯二级胆管的BismuthⅢa、Ⅲb型患者）中位生存时间为32．0个月，1、3、5年生存率分别为91．4％（32／35）、45．8％（11／24）、5／16，与行哑铃式切除术患者的生存率比较，差异无统计学意义（z。0．17，P〉0．05）。有淋巴结转移患者的5年生存率为4／19，低于无淋巴结转移患者的30．4％（7／23），两者比较，差异有统计学意义（x2=23．40，P〈0．05）。结论联合肝叶切除及规范淋巴结清扫能够提高肝门部胆管癌患者的手术疗效。

Objective To investigate the efficacy of different radical surgical procedures for the treatment of hilar cholangiocarcinoma. Methods The clinical data of 207 patients with hilar cholangiocarcinoma who weretreated at the Southwest Hospital from June 2007 to June 2012 were retrospectively analyzed. Local resection or hemihepatectomy combined with caudate lobectomy was applied to patients with Bismuth type I hilar cholangio- carcinoma; dumbbell type radical resection was applied to patients with Bismuth type 1] hilar cholangiocarcinoma or some patients with type ma, mb and 1V hilar cholangiocarcinoma; hemihepatectomy or extended hemihepatec- tomy combined with caudate lobectomy was applied to patients with Bismuth type m a, m b and 1V hilar cholangio- carcinoma. The patients were followed up every 3 months postoperatively till December 2012. All data were analyzed using the chi-square test or Fisher exact probability test, the survival curve was drawn by Kaplan-Meier method, and the survival was analyzed using the Log-rank test. Results Of the 207 patients, 124 received radical resection, including 14 received local resection, 23 received dumbbell type resection, 87 received lobectomy ＋ caudate lobectomy, 49 received palliative resection; 34 received biliary drainage. Four patients died perioperatively. The incidences of complications of dumbbell type radical resection, left hemihepatectomy ＋ caudate lobectomy, right hemihepatectomy ＋ caudate lobectomy were 21.7% （5/23）, 46.6% （27/58） and 48.3% （ 14/29）, respec- tively. The incidence of complications after dumbbell type radical resection was significantly lower than left hemi- hepatectomy ＋ caudate lobectomy and right hemihepatectomy ＋ caudate lobectomy （X2 = 4. 42, 3.90, P 〈 0.05 ）. One hundred and seventy patients were followed up. The median survival time of the 112 patients who received radical radical resection was 26.5 months, and the 1-, 3-, 5-year survival rates were 75.9% （85/112） , 42.9% （24/56） and 28.9% （ 11/38）, respectively. The median survival time of the 38 patients who received palliative resection was 8.5 months, and the 1-, 3-year survival rates were 31.6% （12/38） and 0. The survival time of 20 patients who received biliary drainage was 4.0 months, and the 1-year survival rate was 0. The survival rate of patients who received radical resection was significantly higher than those who received palliative resection （X2= 65.32, P 〈 0.05 ）. There was a significant difference in the survival rate between patients who received surgical treatment and those who received biliary drainage （X2=99. 97, P 〈0.05）. Of the 112 patients who received radical resection, the median survival time of 10 patients who received local resection of tumor was 47.0 months, the 1-year survival rate was 10/10, and 4 patients survived at the end of the follow-up; the median survival time of 23 patients who received dumbbell type radical resection was 32.0 months, and the 1-, 3-year survival rates were 95.7% （22/23） and 7/15, and the survival time of 6 patients was longer than 5 years; the median survival time of 54 patients who received left hemihepatectomy or extended left hemihepatectomy ＋ caudate lobectomy was 27.6 months, and the 1-, 3-year survival rates were 42.1% （24/57） and 38.7% （ 12/32）, and the survival time of 9 patients was longer than 5 years, 3 patients survived at the end of the follow-up; the median survival time of 25 patients who received right hemihepatectomy or extended right hemihepatectomy ＋ caudate lobectomy was 28.3 months, and the 1-, 3-year survival rates were 45.8% （11/24） and 6/15, and the survival time of 6 patients was longer than 5 years, 2 patients survived at the end of follow-up. The median survival time of 35 patients （patients with Bismuth type ｜, II hilar cholangiocarcinoma and Bismuth HI a and m b hilar cholangiocarcinoma which did not invade the secondary bile duct） who received hemihepatectomy ＋ caudate lobectomy was 32.0 months, and the 1-, 3-, 5-year survival rates were 91.4% （32/35）, 45.8 % （11/24） and 5/16, which were not different from the survival rate of patients who received dumbbell type radical resection （X2 = 0. 17, P 〉 0.05 ）. The 5-year survival rate of patients with lymph node metastasis was 4/19, which was significantly lower than 30.4% （7/23） of patients without lymph node metastasis （X2 = 23.40, P 〈 0.05）. Conclusion Joint lobectomy and standardized lymph node dissection could help to improve the efficacy of surgical treatment for patients with hilar cholangiocarcinoma.