全肝门切除重建与门静脉切除重建在肝门胆管癌治疗中的比较研究

Evaluations of total hilar en bloc resection and reconstruction in comparison with portal vein resection and reconstruction in treatment of perihilar cholangiocarcinoma

目的比较全肝门切除重建(THERR)与单纯门静脉切除重建(PVRR)治疗肝门胆管癌(PHC)的临床效果。方法回顾性分析2013年6月至2019年12月宁波市医疗中心李惠利医院肝胆胰外科连续收治的101例PHC患者资料,其中接受肝切除联合THERR 14例[男性6例、女性8例,年龄(64.3±9.7)岁],接受肝切除联合PVRR 19例[男性11例、女性8例,年龄(63.8±8.6)岁]。两组患者一般资料、临床病理学特征、手术切除数据和术后近远期结果的比较采用t检验、χ²检验或Fisher确切概率法;采用Kaplan-Meier法进行生存分析并行Log-rank检验。结果两组患者年龄、性别比例及术前胆道引流比例的差异均无统计学意义(P值均>0.05)。THERR组以扩大的左半肝切除为主(10/14,P=0.010),PVRR组以扩大的右半肝切除为主(12/19,P=0.001)。THERR组手术时间[(586±158)min]长于PVRR组[(453±88)min](t=3.087,P=0.004),持续肝门阻断时间[(32.5±7.3)min]长于PVRR组[(12.4±3.8)min](t=10.325,P<0.01)。THERR组1例术后9 d死于肝功能衰竭,另13例术后1、3、5年总体生存率分别为84.9%、57.1%、37.0%,PVRR组19例1、3、5年总体生存率分别为81.9%、37.8%、30.2%,两组差异无统计学意义(χ²=0.150,P=0.698)。结论与PVRR在PHC切除术中的作用相比,THERR应用于经选择的需同时行肝动脉和PVRR的PHC切除术,特别是需行肝右动脉和门静脉右支重建以保留右半肝的PHC切除术是可行的。

Objective To evaluate the feasibility and efficacy of total hilar en bloc resection and reconstruction(THERR)and portal vein resection and reconstruction(PVRR)in treatment of perihilar cholangiocarcinoma(PHC).Methods Data of a total of 101 consecutive patients with PHC who underwent bile duct resection with various types of hepatectomies from June 2013 to December 2019 at Department of Hepatopancreatobiliary,Lihuili Hospital were retrospectively analyzed.Patients who underwent PHC resection combined with THERR or PVRR were identified and grouped accordingly.Fourteen patients(6 males,8 females,aged(64.3±9.7)years old)underwent hepatectomy combined with THERR,19 patients(11 males,8 females,aged(63.8±8.6)years old)underwent hepatectomy combined with PVRR.Indications and surgical procedures of THERR and PVRR were reported.The clinicopathological characteristics and operation data,as well as the short and long-term outcomes of patients of the two groups were compared by Student′s t-test and theχ^(2) test or Fisher exact test,respectively.The actual survivals rates were calculated by using the Kaplan-Meier method,and compared using the Log-rank test.Results There were no statistically significant differences between the two groups in respect to age,sex and whether they had preoperative biliary drainage or not.The types of combined hepatectomy carried out predominately between the two groups were statistically different with the left side being predominant in the THERR group(10/14,P=0.010)and right side in PVRR group(12/19,P=0.001).There were no significant differences between the two groups in respect to whether they received preoperative portal vein embolization,intraoperative blood loss,curative degree,number of lymph node dissections,and whether there was lymphatic metastasis or not.However,both the times of operation and continuous Pringle maneuver were statistically longer in the THERR group((586±158)minutes and(32.5±7.3)minutes)than those in the PVRR group((453±88)minutes and(12.4±3.8)minutes),respectively(t=3.087,P=0.004;t=10.325,P<0.01).One patient in the THERR group died of liver failure 9 days postoperative,the cumulative 1-,3-and 5-year survival rates were 84.9%,57.1%and 37.0%for the THERR group and 81.9%,37.8%and 30.2%for the PVRR group,respectively.There was no statistically significant differences between the two groups(χ²=0.150,P=0.698).Conclusions Compared to the role of PVRR in the treatment of PHC,THERR is a novel and technically demanding procedure that is feasible in selected patients for the treatment of advanced PHC with invasion of both the hepatic artery and portal vein.However,due to the small size of this primary study,the value of THERR needs further evaluation.