肝门部胆管癌手术切除方式选择和淋巴结清扫的临床应用分析

Combined caudate lobectomy radical resection and lymph node dissection for hilar cholangiocarcinoma

目的探讨不同手术切除方式和淋巴结清扫范围治疗肝门部胆管癌的临床应用及影响预后的因素。方法回顾性分析2008年2月至2017年2月北京大学人民医院肝胆外科肝门部胆管癌患者的临床资料及随访结果。对比不同手术方式和淋巴结清扫范围术中及术后情况等。结果手术方式上联合尾状叶切除手术方式与未联合尾状叶切除在R0切除率[72.2%(13/18)比43.9%(18/41)]、手术时间[(433±136)min比(302±122)min]、术中出血量[(1789±1091)ml比(776±755)ml]及术后并发症发生率[66.7%(12/18)比36.6%(15/41)]比较,差异均有统计学意义(均P<0.05)。扩大淋巴结清扫患者中位生存时间长于区域淋巴结清扫患者(33个月比13个月),差异有统计学意义(P<0.05)。单因素及多因素分析显示术前血清CA199水平,镜下切缘状况及肿瘤TNM分期与预后显著相关(PvO.05)。结论联合尾状叶切除可提高R0切除率。针对性进行淋巴结清扫有助于延长患者生存期。镜下切缘状况、术前CA199和肿瘤TNM分期是肝门部胆管癌患者预后的独立危险因素。

Objective To investigate the clinical efficacy and prognostic factors for combined caudate lobectomy radical resection plus broad lymph node dissection in patients of hilar cholangiocarcinoma.Methods The clinical data and follow-up results of patients with hilar cholangiocarcinoma surgically treated from Feb 2008 to Feb 2017 were retrospectively analyzed.Result The R0 resection rate[72.2%(13/18)vs 43.9%(18/41)],operation time[(433±136)min vs(302±122)min],intraoperative blood loss[(1789±1091)ml vs(776±755)ml]and postoperative complication rate[66.7%(12/18)vs 36.6%(15/41)]were significantly higher in the hepatic lobe combined with caudate lobe resection group than that without caudate lobe resection group(P< 0.05).The median survival time of patients with enlarged lymph node dissection was longer than that of patients with regional lymph node dissection(33 months vs 13 months,P<0.05).Univariate and multivariate analysis showed that the preoperative serum CAI99 level>1000 U/ml,the degree of microscopic margin and tumor TNM stage were significantly correlated with the prognosis of the patients(P<0.05).Conclusion Combined with caudate lobe resection can improve R0 resection rate.Targeted lymph node dissection helps prolong survival.The degree of microscopic margin,preoperative CA199 and TNM staging are independent risk factors for the prognosis of patients with hilar cholangiocarcinoma.