MANAGEMENT STRATEGIES IN RESECTION FOR HILAR CHOLANGIOCARCINOMA
MANAGEMENT STRATEGIES IN RESECTION FOR HILAR CHOLANGIOCARCINOMA
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DOI：
10.1097/00000658-199201000-00005
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发表时间：
1992-01-01
影响因子：
9
通讯作者：
DIAMOND, T
中科院分区：
文献类型：
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作者：
BISMUTH, H;NAKACHE, R;DIAMOND, T
自1960-1990年间，122例肝门部胆管癌行手术治疗，其中23例行手术切除。单纯局部切除10例(43%)。肝切除累及继发胆管或肝实质13例(57%)，其中扩大右肝切除3例，右肝切除1例，扩大左肝切除6例，左肝切除2例，左叶切除1例。在其他三个病例中，进行了全肝切除和肝移植，但这些都不包括在切除的结果分析中。仅2例(8.7%)出现明显的手术并发症，手术死亡率为0。4例肉眼未能完全切除肿瘤(肉眼根治性切除率15.6%)。9例手术切除标本组织学检查边缘无肿瘤(镜检根治率为9/122；7.4%)。10例组织学检查发现切缘内含肿瘤。1年总生存率为87%，2年总生存率为63%，3年总生存率为25%(中位生存期24个月)。切除切缘游离的患者的生存率和无复发率优于切除切缘受累或肉眼可见残留病变的患者。7例患者获得了潜在的根治性切除，手术切缘为阴性且至今未复发：2例I型病变采用局部切除；2例IIIb型病变采用左肝切除+1节段切除，1例IV型病变采用左肝切除+1节段切除；2例IIIa型病变采用右肝切除右肝切除+1段切除。这些结果表明，如果获得无组织学切除切缘，切除可以提高肝门部胆管癌的存活率，且发病率最低，死亡率为零。为了达到这一目的，根据我们的经验和解剖学方面的考虑，我们建议对每一种类型的病变采取以下手术：I型为局部切除；II型为局部切除+1节段切除；IIIa和b型为局部切除+1节段切除，右肝或左肝切除；IV型为肝切除+肝移植。
Between 1960 and 1990, resection was performed in 23 of 122 patients who underwent surgical treatment for hilar cholangiocarcinoma. Local excision of the lesion alone was performed in 10 cases (43%). Hepatic resection for tumor extending to the secondary bile ducts or hepatic parenchyma was performed in 13 cases (57%): extended right hepatectomy (3), right hepatectomy (1), extended left hepatectomy (6), left hepatectomy (2), and left lobectectomy (1). In three other cases, resection by total hepatectomy and liver transplantation was performed, but these were not included in the analysis of results for resection. Significant operative complications occurred in only two cases (8.7%), and the operative mortality rate was zero. In four cases, complete excision of the tumor could not be achieved macroscopically (macroscopic curative resection rate 19/122; 15.6%). In nine cases, the margins of the resected specimens were free from tumor on histologic examination (microscopic curative resection rate, 9/122; 7.4%). In 10 cases, the resection margins were found to contain tumor on histologic examination. The overall survival rate was 87% at 1 year, 63% at 2 years, and 25% at 3 years (median survival, 24 months). The survival and freedom from recurrence rates for patients with free resection margins was superior to that for patients with involved resection margins or residual macroscopic disease. A potentially curative resection, with histologically negative margins and no recurrence to date, was achieved in seven patients using the following procedures: local excision for two type I lesions; left hepatectomy plus excision of segment 1 for two type IIIb lesions and one type IV lesion; right hepatectomy and right hepatectomy plus excision of segment 1 for two type IIIa lesions. These results indicate that improved survival in hilar cholangiocarcinoma can be achieved by resection, with minimal morbidity and zero mortality rates, if histologically free resection margins are obtained. To achieve this, we recommend the following procedures for each type of lesion, based on our experience and on anatomic considerations: local excision for type I; local excision plus resection of segment 1 for type II; local excision, resection of segment 1, and right or left hepatectomy for types IIIa and b; hepatectomy plus liver transplantation for type IV.