肝门部胆管癌的可切除性评估

Research progress on resectability assessment of hilar cholangiocarcinoma

肝门部胆管癌（HCC）因其解剖位置特殊，手术难度大且并发症多，术前详尽的评估十分重要。B超、CT、MRI可以提供肿瘤的位置、血管侵犯及远处转移的相关情况，为手术切除提供重要信息。内镜逆行胰胆管造影术（ERCP）及经皮肝胆管造影术（PTC）在评估肿瘤位置、长度的同时，还可行治疗性胆汁引流。磁共振胰胆管成像（MRCP）在辨别肿瘤范围上，与PTC及ERCP具有相同的准确性，且并发症较少。外科手术的主要目的是获得R0切除，术前可切除性评估主要根据肿瘤累及胆管范围、肿瘤侵犯肝门区血管情况、肝叶萎缩程度、淋巴转移和神经丛浸润情况。肝门部胆管癌根治性切除往往需要联合大范围的肝切除，精确评估剩余肝功能储备对于手术策略和规划非常重要。术前胆管引流适用于胆管炎、长期持续性黄疸（直接胆红素水平〉200μmol／L）、营养不良、肝容积〈全部肝容积40％的患者。门静脉栓塞术减少了HCC扩大肝切除术后的远期并发症，当残肝容积〈30％～40％，可考虑行门静脉栓塞术。

Hilar cholangiocarcinoma （HCC） resection is a difficult and complicated surgery with high complication risk because of the special anatomic position. The detailed preoperative assessment is very important. Ultrasound （US）, computed tomography （CT） and magnetic resonance imaging （MRI） can provide important information on the tumor location, vascular invasion and distant metastasis, which is necessary for the resection. Endoscopic retrograde cholangiopancreatography （ERCP） and percutaneous transhepatic cholangiography （PTC） can be used to determine the tumor location and size, and achieve bile drainage. Magnetic resonance Cholangiopancreatolography （MRCP） as a noninvasive examination with fewer complications has comparable accuracy in identifying tumor extent with PTC and ERCP. The ultimate goal of surgical treatment is R0 resection. Preoperative resectablility evaluation mainly depends on the bile duct involvement, hilar vessels invasion, extent of hepatic lobe atrophy, lymphatic metastasis and nerve plexus infiltration. HCC radical resection often demands extended liver resection and accurate assessment of the residual liver function is very important for clinical strategy. Preoperative biliary drainage could be conducted in patients with cholangitis, long-term refractory jaundice （direct bilirubin level 〉 200 μmol/L）, poor nutrition status and residual liver volume 〈 40% of the total liver volume. Portal vein embolization decreases the long-term complications for HCC patients with enlarged liver resection. Portal vein embolization can be considered when residual liver volume 〈 30% -40%.