不同部位肝外胆管癌特点和手术治疗预后效果观察

Characteristics and prognosis of surgical treatment for extrahepatic bile duct cancer in different locations

目的探讨不同部位肝外胆管癌的特点和手术治疗预后效果。方法选取2007年1月至2017年1月间葫芦岛市中心医院龙湾院区收治的435例肝外胆管癌患者,根据胆管癌部位分为肝门胆管癌组290例和胆总管下端癌组145例。对两组患者的胆管条件、血管情况和功能性肝实质充分保留情况进行评估,对具备行根治性切除的可能性进行判断,肝门胆管癌组Ⅰ型、Ⅱ型、Ⅲa和Ⅲb型及Ⅳ型患者分别接受单纯胆管骨骼化切除、骨骼化切除附加尾叶切除、肿瘤联合尾状叶及左右半肝切除及联合半肝切除治疗,胆总管下端癌组患者均接受胰十二指肠切除术治疗。治疗后,比较两组患者的术后肿瘤复发转移时间、最终死亡时间、无瘤生存时间及总生存时间。结果肝门胆管癌组165例患者术后并发症:感染55例,胆汁瘘15例,胆管炎15例,肝衰竭5例。1年生存率为62.2%,2年生存率为35.1%,3年生存率为27.0%。肿瘤直径≥3cm者总生存时间短于<3cm者;有淋巴结转移、肝脏侵犯和血管侵犯患者的总生存时间短于无淋巴结转移、肝脏侵犯和血管侵犯患者;随着Bismuth分型、改良T分期和AJCC分期的提升,患者总生存时间逐渐缩短,差异均有统计学意义(均P<0.05)。不同糖类抗原CA19-9水平和病理类型患者的总生存时间比较,差异无统计学意义(P>0.05)。肿瘤直径≥3cm患者的无瘤生存时间显著短于<3cm患者,有淋巴结转移和肝脏侵犯患者的无瘤生存时间均短于无淋巴结转移和肝脏侵犯的患者,随着Bismuth分型、改良T分期和AJCC分期的提升,患者的无瘤生存时间均逐渐缩短,差异均有统计学意义(均P<0.05)。不同CA19-9水平、病理类型和血管侵犯患者的无瘤生存时间比较,差异无统计学意义(P>0.05)。胆总管下端癌组70例患者术后并发症:感染55例,胰瘘15例,1年生存率为37.5%。随着AJCC分期提升,患者总生存时间逐渐缩短(P<0.05);不同肿瘤直径、CA19-9水平、病理类型和胰腺侵犯患者的总生存时间比较,差异无统计学意义(P>0.05)。不同肿瘤直径、CA19-9水平、病理类型、AJCC分期和胰腺侵犯患者的无瘤生存时间比较,差异无统计学意义(P>0.05)。两组患者根治术后总生存时间、根治术后无瘤生存时间、非手术治疗总生存时间和总生存时间比较,差异均无统计学意义(P>0.05)。结论不同部位肝外胆管癌根治性切除手术治疗,效果均较好,预后可用AJCC分期评估。

Objective To observe the characteristics and prognosis of surgical treatment for extrahepatic bile duct cancer in different locations. Methods A total of 435 patients with extrahepatic bile duct cancer treated at Longwan Campus,Huludao Central Hospital from January 2007 to January 2017 were selected. According to the locations of bile duct cancer,the patients were classified into patients with hilar cholangiocarcinoma（ 290 patients） and with carcinoma at the lower end of the common bile-duct（ 145 patients）. The conditions of bile duct,blood vessels and retention of functional hepatic parenchyma were evaluated. The possibility of having radical resection was judged. Patients with type Ⅰ,Ⅱ,Ⅲa,Ⅲb and Ⅳhilar cholangiocarcinoma underwent single skeletonization resection of bile duct,skeletonization resection plus caudate lobe resection,tumor resection plus caudate lobe resection,left and right hemihepatectomy and combined hepatectomy,respectively. Patients with carcinoma at the lower end of the common bile-duct underwent duodenopancreatectomy. Time to postoperative recurrence and metastasis and death,and tumor-free survival and overall survival were compared. Results Among 165 patients with hilar cholangiocarcinoma,infection occurred in 55 patients,fistulas in 15 patients,cholangitis in 15 patients and liver failure in 5 patients. The 1-year,2-year and 3-year survival was 62. 2%,35. 1% and 27. 0%,respectively. The overall survival in patients with tumors of ≥ 3 cm was significantly shorter than patients with tumors of 3 cm（ P〈0. 05）. The overall survival was significantly shorter in patients with lymph node metastasis,liver invasion and vascular invasion than in patients without lymph node metastasis,liver invasion and vascular invasion（ P〈0. 05）. With the enhancement of Bismuth type,modified T and AJCC staging,the overall survival gradually shortened（ all P〈0. 05）. There was no significant difference in the overall survival among patients with different CA19-9 levels and pathological features（ P〈0. 05）. The disease-free survival was significantly shorter in patients with tumors of ≥ 3 cm than patients with tumors of 〈3 cm（ P〈0. 05）. The disease-free survival were significantly shorter in patients with lymph node metastasis and liver involvement than in patients without（ P〈0. 05）. With the enhancement of Bismuth type,modified T and AJCC staging,the disease-free survival gradually shortened（ all P〈0. 05）. There was no significant difference in the disease-free survival among patients with different CA19-9 levels,pathological features and vascular invasion（ P〉0. 05）. Among 70 patients with carcinoma at the lower end of the common bile-duct,infection occurred in 55 patients and pancreatic fistula occurred in 15 patients. The 1-year survival was 37. 5%. With the process of AJCC staging,the overall survival was gradually shortened（ P〈0. 05）. There was no significant difference in the overall survival among patients with different CA19-9 levels,pathological features and pancreas invasion（ P〉0. 05）. There was no significant difference in postoperative overall survival,disease-free survival and non-operation survival between the two groups（ P〉0. 05）. Conclusion The efficacy of radical resection for extrahepatic bile duct cancer is good without regarding to locations and the prognosis can be evaluated by AJCC staging.