肝部分切除联合肝十二指肠韧带骨骼化治疗肝门部胆管癌

Partial hepatectomy with skeletonization of the hepatoduodenal ligament for hilar cholangiocarcinoma

目的 总结应用肝部分切除联合肝十二指肠骨骼化治疗肝门部胆管癌的临床经验。方法 回顾 1999年 1月～ 2 0 0 1年 12月手术治疗 6 7例肝门胆管癌的临床资料。结果 6 7例患者中 6 5例手术切除 ,4 9例根治性切除 (2 2例肝十二指肠韧带骨骼化切除 ,2 7例联合部分肝切除 )。根据Bismuth分型 ,Ⅰ、Ⅱ型行骨骼化切除 ,Ⅲa型行右半肝加右尾叶切除 ,Ⅲb型行左半肝加左尾叶切除 ,IV型中行右半肝加全尾叶 3例切除 ,左半肝加全尾叶 9例切除 ,方叶切除者 2例。 2例外院曾行部分肿瘤切除加肝门胆管空肠吻合术者 ,我们再次行左半肝加全尾叶切除加右肝管空肠吻合术根治肿瘤。8例患者行肿瘤部分切除加肝内胆管支撑加肝门胆管空肠吻合。 13例患者行门静脉部分切除 ,2 7例患者切除肝动脉。 2 4例患者术后无并发症发生 ,2 0例发生了严重并发症。后者中 14例经治疗后康复 ,余 6例患者术后 7、12、14、4 2、5 7、89d死于肝功能衰竭、心源性休克、腹内大出血、消化道大出血。术后 30d病死率 4 5 % ,根治性手术后患者中位生存期 16个月 (1个月～ 4 1个月 ) ,姑息治疗者为 7个月 (1个月～ 16个月 )。结论 肝部分切除联合肝十二指肠韧带骨骼化可用以根治肝门部胆管癌 。

Objective To sum up author's experience and to define the role of partial hepatectomy with skeletonization resection in the treatment of hilar cholangiocarcinoma Methods Between January 1999 and December 2001,67 patients underwent exploration in our hospital The clinical records of these patients were reviewed Results Sixty five (97%) patients underwent surgical resection Forty nine patients (73%) had curative resection [22 skeletonization resection(SR),and the other 27 undergone SR combined with partial hepatectomy] According to the Bismuth Corlett classification,tumors were classified into four types SR was performed in type Ⅰ(5 cases) and type Ⅱ(17 cases) Right lobectomy with right caudate lobectomy was performed in type Ⅲa(6 cases),left lobectomy with left caudate lobectomy in type Ⅲb(15 cases) Right lobectomy with whole caudate lobectomy(3 cases),left lobectomy with whole caudate lobectomy(9 cases),and quadrate lobectomy(2 cases) were undertaken in type Ⅳ We successfully did SR and left lobectomy with whole caudate lobectomy in 2 patients(3%) who had suffered palliative biliary cancer resection and cholangiojejunostomy before Eight patients(12%) had local resection of the tumor with Roux en Y hepaticojejunostomy reconstruction and intrahepatic bile ducts support Two patients(3%) had palliative biliary drainage Combined portal vein resection was performed in 13(20%) patients and hepatic artery resection in 27(40 3%) Twenty four(35 8%) patients had no postoperative complications,and 20(30 2%) patients developed major complications Of the 20 patients with major complications 14 recovered; the remaining 6 patients died of liver renal failure with other organ failure or of heart attack,intraabdominal bleeding,and gastrointestinal bleeding in 7,12,14,42,57,or 89 days after surgery Thirty days operative mortality was 4 5% The median survival of patients with curative resection was 16 months(ranging from 1 to 41 months),while the median survival with palliative operation was 7 months (ranging from 1 to 16 months) Conclusions Partial hepatectomy with skeletonization resection for hilar cholangiocarcinoma can be performed with acceptable morbidity and mortality For curative treatment of hilar cholangiocarcinoma,Caudate lobectomy is always recommended in Bismuth type Ⅲ/Ⅳ