389例肝门部胆管癌外科治疗回顾性分析——单中心11年经验总结

Retrospective analysis of surgical treatment for 389 patients with hilar cholangiocarcinoma: a single-center 11-year experience

目的探讨肝门部胆管癌的外科治疗及其预后影响因素。方法回顾性分析2003年1月至2013年12月西安交通大学第一附属医院收治的389例肝门部胆管癌患者临床资料。患者均签署知情同意书,符合医学伦理学规定。其中男208例,女181例;平均年龄(59±12)岁。合并胆管炎22例,肝内胆管结石5例,胆囊结石7例。分析患者治疗方式及疗效。率的比较采用χ~2检验,生存分析采用Kaplan-Meier法和Log-rank检验。结果根治性切除132例,姑息性切除134例,姑息性减黄治疗123例。2008~2013年根治切除率和联合半肝切除率分别为56%(104/187)和31%(58/187),明显高于2003~2007年的35%(28/79)和6%(5/79)(χ~2=9.04,18.73;P<0.05)。联合半肝切除患者中,术前减黄组肝功能不全发生率为26%(6/23),明显低于未减黄组的45%(18/40)(χ~2=4.58,P<0.05)。术前减黄组胆道感染发生率为35%(8/23),明显高于未减黄组的8%(3/40)(χ~2=7.54,P<0.05)。姑息性减黄治疗患者中,ERCP组术后胆管炎发生率为38%(16/42),明显高于经皮经肝穿刺胆管引流术(PTBD)组的14%(10/71)(χ~2=8.59,P<0.05)。单纯根治性切除患者术后1、2、3年总体生存率分别为72%、40%、23%,联合半肝切除相应为81%、46%、31%,两组总体生存率差异有统计学意义(χ~2=4.68,P<0.05)。TNM分期、切缘残留肿瘤细胞及淋巴结转移与根治性切除患者预后相关(χ~2=24.66,80.31,57.81;P<0.05)。结论近年肝门部胆管癌根治性切除率提高,术前减黄可降低联合半肝切除患者肝功能不全发生率。与PTBD相比,ERCP姑息性减黄治疗具有胆道感染发生率低的优势。联合半肝切除患者生存优于单纯根治性切除。

Objective To investigate the surgical treatments and prognostics influencing factorsfor hilar cholangiocarcinoma.Methods Clinical data of389patients with hilar cholangiocarcinomawho were admitted to the First Affiliated Hospital of Xi'an Jiaotong University between January2003and December2013were retrospectively analyzed.The informed consents of all patients wereobtained and the local ethical committee approval was received.Among them,208cases were male and181were female,aged(59±12)years old on average.Twenty-two cases were combined with cholangitis,5with intrahepatic biliary calculi and7with cholecystolithiasis.The treatment methods and curative effects were analyzed.The rates were compared by Chi-square test.The survival analysis was conductedby Kaplan-Meier method and Log-rank test.Results Radical resection was performed in132cases,palliative resection in134cases and palliative jaundice reduction in123cases.The radical resection rateand combined hemihepatectomy rate was respectively56%(104/187)and31%(58/187)between2008and2013,significantly higher than35%(28/79)and6%(5/79)between2003and2007(χ2=9.04,18.73;P<0.05).Among the patients with combined hemihepatectomy,the incidence of hepatic insufficiency inthe preoperative jaundice reduction group was26%(6/23),significantly lower than45%(18/40)in thenon-jaundice reduction group(χ2=4.58,P<0.05).The incidence of biliary tract infection in the preoperativejaundice reduction group was35%(8/23),significantly higher than8%(3/40)in the non-jaundice reductiongroup(χ2=7.54,P<0.05).Among the patients with palliative jaundice reduction treatment,the incidence ofcholangitis in the ERCP group was38%(16/42),significantly higher than14%(10/71)in the percutaneoustranshepatic biliary drainage(PTBD)group(χ2=8.59,P<0.05).The postoperative1,2,3-year overallsurvival rate was respectively72%,40%,23%in the patients with simple radical resection,and wascorrespongdingly81%,46%and31%in the patients with combined hemihepatectomy,and significantdifference was observed in the overall survival rate between two groups(χ2=4.68,P<0.05).The TNMstage,residual tumor cells at incisal margin and lymph node metastasis were correlated with the prognosisof patients with radical resection(χ2=24.66,80.31,57.81;P<0.05).Conclusions Radical resection rateof hilar cholangiocarcinoma has been increased in recent years.Preoperative jaundice reduction can reduceincidence of hepatic insufficiency in patients with combined hemihepatectomy.Compared with PTBD,ERCP palliative jaundice reduction has the advantage of lower biliary tract infection rate.The survival rateof patients with combined hemihepatectomy is better than that of patients with simple radical resection.