44例肝门部胆管癌的手术治疗体会

Surgical Treatment Experiences of 44 Cases of Hilar Cholangiocarcinoma

目的探讨肝门部胆管癌手术治疗中的要点与难点,以及不同的治疗方式对于手术预后的影响。方法回顾性分析2010年1月~2013年12月间44例肝门部胆管癌患者的临床资料并进行总结。44例患者中,Bismuth分型Ⅰ型（癌肿局限于肝总管,左右肝管汇合部尚通畅）2例（4.5%）,Ⅱ型（癌肿累及左右肝管汇合部）7例（15.9%）,Ⅲ型（癌肿扩展至肝内右肝管或左肝管）23例（52.3%）,Ⅳ型（癌肿累及肝内左右肝管及其2级分支）12例（27.3%）。病理结果 ：中高分化腺癌28例（63.6%）,中分化腺癌11例（25%）,低分化腺癌5例（11.4%）。其中行根治性手术组29例（65.9%）,行姑息性手术组13例（29.5%）,另2例（4.5%）仅行单纯剖腹探查、开关术。结果在术前胆道引流的12例患者中,经2周左右胆汁外引流后,总胆红素（total bilirubin,TBIL）、碱性磷酸酶、谷氨酰转氨酶均较减黄手术前明显下降（P〈0.05）,丙氨酸转氨酶虽然数值上也有所下降,但无统计学差异（P〉0.05）。根治性切除组的29例患者存活时间为（24.55±8.21）个月,其中8例生存时间〉15个月,4例生存时间〉27个月。姑息性手术组的13例患者存活时间为（8.53±3.057）个月,最长17个月。根治性切除组存活时间明显长于姑息性手术组（P〈0.05）。结论肝门部胆管癌的手术治疗十分重要,充分的手术评估与准备,仔细的探查、术中精准肝切除技术的运用,有助于提高肝门部胆管癌根治性切除率,并减少术后并发症。

Objective To investigate the key points and difficulties of the surgical treatment of hilar cholangiocarcinoma,as well as different treatment modalities for surgical prognosis. Methods A retrospective analysis was carried out of the demographic characteristics,surgical records and outcome in 44 patients with hilarcholangiocarcinoma undergoing surgical resections or palliative surgical procedures for the period of January2010 to December 2013. There were 2 cases（ 4. 5%） of BismuthⅠ,7cases（ 15. 9%） of BismuthⅡ,23 cases（ 52. 3%） of Bismuth Ⅲ and 12 cases（ 27. 3%） of BismuthⅣ. There were 12 cases underwent preoperative jaundice reduction. Results In the 12 cases of preoperative jaundice reduction,the total bilirubin,alkaline phosphatase,glutamine transaminase significantly decreased after 2 weeks of biliary drainage（ P〈0. 05）. The survival time of 29 cases of the radical resection group was（ 24. 55 ± 8. 21） months,including eight cases of survival time 〉15 months,and four patients survived 〉27 months. The survival time of 13 cases of palliative surgery group was（ 8. 53 ± 3. 057） months,up to 17 months. The mean survival time of the radical resection group was significantly longer than that of the palliative surgery group（ P〈0. 05）. Conclusion Radically extended surgical resection for hilar cholangiocarcinoma is necessary to obtain improved patient survival. It isthe key points of the fully operative evaluation and preparation,careful intraoperative exploring,and accurate liver resection techniques to improve rates of radical resection and reduce complications for hilar cholangiocarcinoma patients.