肝门部胆管癌外科治疗的单中心经验

Surgical treatment for perihilar cholangiocarcinoma:a single-center experience

目的探讨肝门部胆管癌(pCCA)外科治疗的策略和效果。方法回顾性收集2014年1月至2021年12月在中山大学孙逸仙纪念医院胆胰外科接受以根治性切除为目的手术治疗的81例pCCA患者的病历资料。男性50例、女性31例,年龄(62.5±11.5)岁(范围:26~83岁)。就诊时合并黄疸75例,其中60例术前行胆道引流。患者术前1周内血清胆红素水平[M(IQR)]为44.3(41.9)μmol/L(范围:8.0~344.2μmol/L);术前行门静脉栓塞20例。术前通过影像学检查评估Bismuth-Corlette分型,Ⅰ型3例、Ⅱ型6例、Ⅲa型21例、Ⅲb型27例、Ⅳ型24例。主要研究指标为总体生存时间,次要研究指标为无复发生存时间、术后并发症发生率、术后90 d内病死率。采用Kaplan-Meier法计算术后生存时间并绘制生存曲线,采用Log-rank检验进行生存比较,并采用Cox比例风险模型分析pCCA患者的独立预后因素。结果81例pCCA患者中,行大范围肝切除术67例,其中大范围肝切除联合胰十二指肠切除术3例;34例联合肝门部血管切除重建(单纯门静脉切除重建术18例、单纯肝动脉切除重建术9例、门静脉和肝动脉联合切除重建7例);获得R0切除43例。手术时间(627±136)min(范围:565~940 min),术中出血量400(455)ml(范围:200~2800 ml)。围手术期病死率为3.7%(3/81)。根据Clavien-Dindo并发症分级系统,术后Ⅲ~Ⅳ级并发症发生率为23.4%(19/81)。随访截至2022年9月,随访时间为34.0(24.2)个月(范围:0.4~103.6个月)。排除3例围手术期死亡患者,余78例患者的中位生存时间为36.10个月(95%CI:18.23~42.97个月),1、3、5年总体生存率分别为85.3%、46.8%、28.7%。41例R0切除患者的中位生存时间为47.83个月(95%CI:36.90~58.80个月),37例R1、R2切除患者的中位生存时间为20.47个月(95%CI:10.52~30.58个月)。70例R0和R1切除患者的中位无复发生存时间为24.50个月(95%CI:12.15~31.85个月),1、3、5年无复发生存率分别为65.2%、45.7%、29.9%。41例R0切除患者的中位无复发生存时间为38.57个月(95%CI:21.50~55.63个月),29例R1切除患者的中位无复发生存时间为10.83个月(95%CI:2.82~19.86个月)。结论根治性手术切除是治疗pCCA的首选方法,术前精准评估和充分准备可减少手术并发症,积极的手术治疗可提高根治性切除率而使患者获得较好的生存受益。

Objective To investigate surgical strategies and the corresponding benefits for patients with perihilar cholangiocarcinoma(pCCA).Methods A total of 81 patients with pCCA who underwent radical excision in the Department of Biliary and Pancreatic Surgery of Sun Yat-Sen Memorial Hospital between January 2014 and December 2021 were retrospectively collected.The cohort consisted of 50 male and 31 female patients,with an age of(62.5±11.5)years(range:26 to 83 years).Seventy-five cases were diagnosed with jaundice,60 of whom received preoperative biliary drainage,while 20 patients received portal vein embolization.Their serum bilirubin level within one week before the operation(M(IQR))was 44.3(41.9)μmol/L(range:8.0 to 344.2μmol/L).Preoperative imaging examinations were performed to evaluate the Bismuth-Corlette type of pCCA,showing 3,6,21,27,and 24 cases of Bismuth-Corlette typeⅠ,Ⅱ,Ⅲa,Ⅲb,andⅣ,respectively.The primary outcome was overall survival(OS),and the secondary outcomes were relapse-free survival(RFS),90-day postoperative morbidity and 90-day postoperative mortality.OS and RFS were estimated using the Kaplan-Meier method and compared by the Log-rank test.Significant prognostic factors were determined using univariate and multivariable Cox proportional hazard regression analyses.Results In the cohort of 81 pCCA patients,67 cases(82.7%)underwent major hepatectomy while 3 cases received major hepatectomy combined with pancreaticoduodenectomy.Thirty-four patients underwent hepatectomy combined with vascular resection and reconstruction(18 cases of portal vein resection and reconstruction alone;9 cases of hepatic artery resection and reconstruction alone;7 cases of combination of portal vein and hepatic artery resection and reconstruction).Margin negative(R0 excision)were achieved in 53.1%(43/81)of these patients.The operation duration was(627±136)minutes(range:565 to 940 minutes),and the intraoperative blood loss was 400(455)ml(range:200 to 2800 ml).The 90-day postoperative mortality was 3.7%(3/81).Grade 3-4 postoperative morbidity was 23.4%(19/81)according to the Clavien-Dindo classification of surgical complications.Up to the last follow-up at September 2022,the follow-up time was 34.0(24.2)months(range:0.4 to 103.6 months).Three patients who died within 90 days after surgery were excluded from the survival analysis.The median OS was 36.10 months(95%CI:18.23 to 42.97 months)and the 1-,3-and 5-year OS rates were 85.3%,46.8%and 27.3%,respectively.The median OS of 41 patients with negative margins was 47.83 months(95%CI:36.90 to 58.80 months)and that of 37 patients with positive margins was 20.47 months(95%CI:10.52 to 30.58 months).The median RFS of 70 patients with R0 and R1 resection was 24.50 months(95%CI:12.15 to 31.85 months)and the 1-,3-and 5-year RFS rates were 65.2%,45.7%and 29.9%,respectively.The median RFS of 41 patients with R0 resection was 38.57 months(95%CI:21.50 to 55.63 months)and that of 29 patients with R1 resection was 10.83 months(95%CI:2.82 to 19.86 months).Conclusions The primary therapy for pCCA is radical surgical resection.A precise preoperative evaluation and sufficient preparation can reduce postoperative morbidity.Surgical treatment can achieve a better survival outcome by increasing the radical resection rate.