术前内镜引流在疑似可切除的肝门部胆管恶性肿瘤患者外科治疗中的价值

The value of preoperative endoscopic drainage in the surgical treatment of patients with malignant tumor of the hilar bile duct which has the possibility to resection

目的探讨术前内镜引流在疑似可切除的肝门部胆管恶性肿瘤患者外科治疗中的价值。方法我院在2010．1—2014．12期间，对收治入院的肝门部胆管恶性肿瘤患者进行全面的术前影像学评估，将评估后的病人分成3组：肿瘤可切除组；肿瘤肯定不能切除组；肿瘤疑似可切除组。可切除组采用手术治疗，肯定不能切除组采用内镜治疗（内镜治疗不成功者采用PTCD），对疑似可切除组采用术前内镜引流，1—2天后再行剖腹探查手术，术中探查能够切除肿瘤者则予以切除，不能切除者则直接关腹。本文主要对疑似可切除这一组病人（共17例）的临床资料进行回顾性分析和总结。结果本组17例中，男11例，女6例，年龄46～63岁，平均年龄52岁。术前Bismuth分型：Ⅱ型2例，Ⅲ型11例，Ⅳ型4例。术前影像学评估均不能确定肿瘤能否切除，外科手术前1～2天行内镜鼻胆管引流术（ENBD，11例）或内镜下塑料支架置入术（ERBD，6例）。术中探查提示：胆囊癌侵及肝门部胆管3例，均行姑息性胆囊切除术；肝癌侵及肝门部胆管4例，行左半肝切除联合右肝管空肠R—Y内引流术1例，3例行肿瘤活检术；原发性胆管癌10例，行根治性切除2例，姑息性切除2例，余6例仅行肿瘤活检。7例病人术后1～2周将鼻胆管引流改为塑料支架引流。全组1患者出院时均无胆道外引流管，黄疸有效缓解率为100％。结论对疑似可切除的肝门部胆管恶性肿瘤患者术前I一2天先行内镜引流，既可增加该类病人外科手术切除的机会，也可有效避免对术中明确不能切除的患者实施“U”型管外引流，从而最大限度地提高该类病人的生活质量。

Objective To investigate the value of preoperative endoscopic drainage in the surgical treatment of patients with malignant tumor of the hilar bile duct which has the possibility to resection. Methods Comprehensive preoperative imaging evaluation was performed in patients with hilar cholangiocareinoma admitted to our hospital in 2010.1 to 2014.12. The assessed patients were divided into 3 groups： tumor resectable group; cannot resectable group; borderline resectable group. Resectable group was treated by operation, cannot resectable group by endoscopic （PTCD after endoscopic treatment failed）. The exploratory laparotomy was performed in the borderline group after endoscopic drained several days. If we have the ability to remove it we perform, or we close the abdominal cavity. We retrospectively analyzed and summarized the clinical data of patients which have the possibility to be resected（ 17 cases） in this paper. Results Among the 17 cases, 11 male and 6 female, the age were 46 - 63 years old, the average age was 52. Bismuth classification： type Ⅱ in 2 cases, type Ⅲ in 11 cases and type IV in 4 cases. Endoscopic nasobiliary drainage （ENBD, 11 cases） or endoscopicretrograde biliary drainage （ERBD ,6 cases）were performed before surgical operation in the borderline group which were evaluated by the preoperative imaging evaluation 1 - 2 days. The intraoperative exploration shows 3 cases of gallbladder carcinoma invalding hilar bile duct were treated with palliative eholecystectomy ;4 cases of liver cancer invalding hilar cholangiocarcinoma, only 1 was per- formed by left liver resection and right hepaticojejunostomy in R-Y , the other were by biopsy;10 cases of primary bile duct carcinoma, 2 cases were performed by radical resection,2 cases by palliative resection, the other only by biopsy. Plastic biliary stenting drainage replaced ENBD 1 - 2 weeks after operation in these 7 patients of biopsy. All patients were discharged with none external drainage tube except the bile duet drainage tube, and the rate of jaundice regression was 100%. Conclusion Endoscopic drainage to the borderline reseetable hilar bile duct malignant tumor patients before operation 1 - 2 days can increase the opportunity of surgical resection, and also be effective to avoid the external drainage of ＂U＂ type tube in the unresectable patients. So as to maximize the quality of life in these patients.