联合肝动脉切除重建的肝门部胆管癌根治术技术要点

Key hepatic artery resection skills in radical operation of hilar cholangiocarcinoma

目的总结对于进展期肝门部胆管癌患者行肝脏切除联合动脉切除重建的处理经验。方法回顾性分析2008年1月-2013年12月我院收治的15例行肝门部胆管癌根治联合肝动脉切除重建的进展期肝门部胆管癌患者的临床资料，总结其手术情况及预后。结果15例中，肝右动脉与肝固有动脉端端吻合5例，肝右动脉与胃、十二指肠动脉端端吻合3例，肝右动脉与肝左动脉端端吻合1例，肝右动脉与肝右动脉端端吻合1例，肝右后与肝右后端端吻合1例，肝固有动脉与门静脉端侧吻合3例，肝右动脉与门静脉端侧吻合1例，其中4例同时联合门静脉切除重建。本组根治性切除（R0切除）11例，非根治性切除（R1切除）4例。3例术后出现胆瘘，1例出现胆瘘合并腹腔内感染，1例出现腹腔内感染，1例出现上消化道出血，均经保守治疗痊愈。2例于术后因肝功能衰竭死亡。术后4例肿瘤复发，时间为6～26个月，平均复发期为17．5个月；其中1例（25％）为R0切除，3例（75％）为R1切除。术后6个月、1年、3年生存率分别为85．6％、78．6％、33．7％。结论对于动脉受侵犯的肝门部胆管癌患者行肝脏切除联合动脉切除重建，可提高根治切除率并可改善患者预后。熟练掌握血管吻合技巧可大大降低术后并发症发生率。

Objective To summary the experiences in liver resection with artery resection in patients with progressive hilar cholangiocarcinoma. Methods Clinical data about 15 patients with progressive hilar cholangiocarcinoma admitted to our hospital from January 2008 to December 2013 for liver resection with artery resection were retrospectively analyzed. Their outcomes after operation were summarized. Results Of the 15 patients, 5 underwent end to end anastomosis of the right hepatic artery with the hepatic proper artery, 3 end to end anastomosis of the right hepatic artery with the gastroduodenal artery, 1 end to end anastomosis of the right hepatic artery with the left hepatic artery, 1 end to end anastomosis of the right hepatic artery with the right hepatic artery, 1 end to end anastomosis of the right posterior hepatic artery with the right posterior hepatic artery, 3 end to side anastomosis of the hepatic proper artery with the portal vein, 1 end to side anastomosis of the right hepatic artery with the portal vein, 4 comb ined portal vein resection and reconstruction. Of the 15 patients, 11 underwent radical resection and 4 received non-radical resection. Biliary fistula was found in 3 patients, biliary fistula with intra-abdominal infection in 1 patient, intra-abdominal infection in 1 patient, upper gastrointestinal hemorrhage in 1 patient. All patients were cured by conservative treatment except 2 died of liver failure after operation. Of the 4 patients with their tumor relapsed 6 -26 months （17.5 months） after operation, 1 （25%） underwent radical resection and 3 （75%） received non-radical resection. Their 6- month, 1- and 3- year survival rate was 85.6%, 78.6%, and 33.7%, respectively. Conclusion Liver resection with artery resection in patients with hilar cholangiocarcinoma with their artery involved can improve their radical resection rate and prognosis. Skilled vascular anastomosis can greatly reduce the incidence of complications after operation.