腹腔镜肝门部胆管癌根治术的临床疗效

Clinical efficacy of laparoscopic radical resection of hilar cholangiocarcinoma

目的探讨腹腔镜肝门部胆管癌根治术(LRHCCA)的临床疗效。方法采用回顾性描述性研究方法。收集2014年5月至2022年6月河北医科大学第二医院收治的211例行LRHCCA患者的临床病理资料;男135例,女76例;年龄为(63±8)岁。观察指标:(1)手术情况。(2)术后情况。(3)随访情况。正态分布的计量资料以x±s表示,偏态分布的计量资料以M(Q1,Q3)或M(范围)表示。计数资料以绝对数或百分比表示。采用Kaplan‑Meier法计算生存率并绘制生存曲线。结果(1)手术情况。211例患者均顺利完成LRHCCA,手术时间为350(300,390)min,术中出血量为400(200,800)mL,术中输红细胞为2.0(0.0~15.0)U。211例患者中,10例行门静脉切除重建,门静脉血管切缘均为阴性,手术时间为(400±53)min,术中出血量为1200(800~3000)mL,术中输红细胞为5.5(4.0~15.0)U。(2)术后情况。211例患者中,BismuthⅠ型63例、BismuthⅡ型65例、BismuthⅢa型22例、BismuthⅢb型26例、BismuthⅣ型35例;R_(0)切除率为95.73%(202/211);胆管腺癌202例,其中低分化7例、中低分化189例、中高分化3例、高分化3例;胆管黏液腺癌8例,均为低分化;胆管内乳头状肿瘤伴上皮高级别异型增生1例;Ⅰ期24例、Ⅱ期98例、ⅢA期30例、ⅢB期34例、ⅢC期19例、ⅣA期6例。211例患者中,术后发生胆瘘25例、术后腹腔感染11例、术后出血3例(均为胆瘘后吻合口周围出血)、胃排空障碍2例、急性肝衰竭1例;术后非计划再手术7例,其中3例行急诊手术止血,4例因严重腹腔感染行腹腔探查清创引流;围手术期死亡3例,其中1例急性肝衰竭,1例全身感染、多器官衰竭,1例下肢深静脉血栓脱落、急性肺栓塞;术后住院时间为(15±5)d,其中行门静脉切除重建患者术后住院时间为(17±4)d;住院费用为(11.7±1.7)万元。(3)随访情况。211例患者中,188例获得随访,随访时间为21(4~36)个月,中位生存时间为22个月,术后1、2、3年生存率分别为90.9%、43.1%、18.7%,结论具备丰富腹腔镜手术经验的临床医师并对患者进行严格手术评估下行LRHCCA安全、可行,近期疗效满意。

Objective To investigate the clinical efficacy of laparoscopic radical resection of hilar cholangiocarcinoma(LRHCCA).Methods The retrospective and descriptive study was constructed.The clinicopathological data of 211 patients who under LRHCCA in the Second Hospital of Hebei Medical University from May 2014 to June 2022 were collected.There were 135 males and 76 females,aged(63±8)years.Observation indicators:(1)surgical situations;(2)postoperative situations;(3)follow-up.Measurement data with normal distribution were represented as Mean±SD,and measurement data with skewed distribution were represented as M(Q1,Q3)or M(range).Count data were described as absolute numbers or percentages.The Kaplan-Meier method was used to calculate survival rate and draw survival curve.Results(1)Surgical situations.All 211 patients underwent LRHCCA successfully,with the operation time as 350(300,390)minutes,volume of intraoperative blood loss as 400(200,800)mL,and intraoperative red blood cell transfusion as 2.0(range,0−15.0)U,respectively.As partial portal vein invasion,10 of 211 patients underwent portal vein resection and reconstruction.Results of intraoperative histopathology examination showed negative margin of portal vein.The operation time,volume of intraoperative blood loss,intraoperative red blood cell transfusion of the 10 patients was(400±53)minutes,1200(range,800−3000)mL,5.5(range,4.0−15.0)U,respectively.(2)Postoperative situations.Of the 211 patients,there were 63 cases of the Bismuth typeⅠ,65 cases of the Bismuth typeⅡ,22 cases of the Bismuth typeⅢa,26 cases of the Bismuth typeⅢb,35 cases of the Bismuth typeⅣ.The R_(0)resection rate was 95.73%(202/211).There were 202 patients identified as adenocarcinoma of the bile duct,including 7 cases with poorly differentiated tumor,189 cases with moderate to poorly differentiated tumor,3 cases with moderate to well differentiated tumor,3 cases with well differentiated tumor.There were 8 patients with poorly differentiated biliary mucinous adenocarcinoma,1 patient with intraductal papillary neoplasm with high-grade epithelial dysplasia.There were 24 cases of stageⅠ,98 cases of stageⅡ,30 cases of stageⅢA,34 cases of stageⅢB,19 cases of stageⅢC,6 cases of stageⅣA.Of the 211 patients,there were 25 cases with postoperative biliary fistula,11 cases with postoperative abdominal infection,3 cases with postoperative bleeding as anastomotic bleeding after biliary fistula,2 cases with postoperative gastric emptying disability,1 case with postoperative acute liver failure.There were 7 patients undergoing postoperative unplanned reoperation,including 3 cases with emergency operation for hemostasis,4 cases with abdominal exploration debridement and drainage for severe abdominal infection.There were 3 cases dead during perioperative period,including 1 case of acute liver failure,1 case of systemic infection and multiple organ failure,1 case of exfoliated deep venous thrombosis of lower extremities and acute pulmonary embolism.The postoperative duration of hospital stay was(15±5)days of the 211 patients and(17±4)days of patients undergoing portal vein resection and reconstruction.The cost of hospital stay of the 211 patients was(11.7±1.7)ten thousand yuan.(3)Follow-up.Of the 211 patients,188 patients were followed up for 21(range,4‒36)months.The median survival time of 188 patients was 22 months,and the postoperative 1-,2-and 3-year survival rate was 90.9%,43.1%and 18.7%,respectively.Conclusion LRHCCA is safe and feasible,with satisfactory short-term effect,under the coditions of clinicians with rich experience in laparoscopic surgery and patients with strict surgical evaluation.