肝内胆管癌术前评估要点

Key points of preoperative evaluation of intrahepatic cholangiocarcinoma

肝内胆管癌(ICC)是发病率仅次于肝细胞癌的原发性肝癌,其恶性程度高,预后差。近年来,ICC的发病率逐步上升。根治性手术切除是目前可能使病人获得长期生存最有效的治疗方式,但根治性切除率低、术后复发率高仍是外科医生和ICC病人共同面临的巨大阻碍。然而由于ICC发病隐匿和恶性程度高的特性使很多病人初诊时便丧失了手术治疗的机会。因此,早期筛查、准确临床诊断、充分术前评估及完备精准的手术方案是手术赖以顺利实施的保障。癌胚抗原(CEA)和CA19-9对ICC的诊断具有一定价值。影像学检查是诊断ICC的最重要手段。腹部超声是临床第一线的早期筛查手段;CT和MRI是临床上用于ICC最常用的影像学检查。三维重建技术为术前残肝体积预估,手术方案制定提供更直接更精准的信息。建立能准确预测ICC预后的分期系统非常重要。术前减黄是否需要尚存争议。残肝体积和肿瘤是否转移是判断手术可切除性的两个要点。腹腔镜探查、腹腔镜超声检查及术中快速冷冻活检是判断是否可实施根治性切除的重要手段。

Intrahepatic cholangiocarcinoma(ICC) is the second most common primary liver cancer with high malignancy and poor prognosis,and its incidence is gradually on the rise all over the world. Radical resection is currently the most effective treatment and may lead to a long-term survival.The low rate of radical resection and high rate of postoperative recurrence remain the greatest obstacles faced by both surgeons and ICC patients. Moreover,the high grade of malignancy with insidious onset results in some patients lost the opportunity of surgery at the initial diagnosis. Early screening,accurate clinical diagnosis,adequate preoperative evaluation and complete and accurate surgical programming are the guarantee for smooth implementation of surgery.Carcinoembryonic antigen(CEA) and CA19-9 are valuable in the diagnosis of ICC. Radiological techniques are critical for ICC diagnosis and assessment,of which ultrosonography is recommended the first line examination for early screening;whereas CT and MRI are the most useful modalities for comprehensive evaluation. Three-dimensional reconstruction provides more direct and accurate support for liver remnant assessment and surgery planning. It is still controversial for preoperative bile duct drainage. Estimated liver remnant and metastasis are two main concerns for a radical resection.Laparoscopic exploration,intraoperative ultrasonography and frozen pathological examination are three important modalities for an R0 resection evaluation.