Surgical treatment of hilar cholangiocarcinoma in the new era: the Asan experience
Surgical treatment of hilar cholangiocarcinoma in the new era: the Asan experience
复制标题
DOI：
10.1007/s00534-009-0204-5
复制
发表时间：
2010-07-01
影响因子：
3
通讯作者：
Ko, Gi Young
中科院分区：
文献类型：
--
作者：
Lee, Sung Gyu;Song, Gi Won;Ko, Gi Young
根治性切除和最小化住院死亡率是肝门部胆管癌患者长期生存的唯一机会。肝门部胆管癌的切除率因联合肝切除术而增加，但该手术技术要求高，且仍与显著的发病率和死亡率相关，必须仔细权衡长期生存的机会。2001年1月至2008年12月期间，350例肝门部胆管癌患者接受了探查，目的是潜在的治愈性切除，其中302例（86.3%）在蔚山大学医学部峨山医学中心肝胆外科和肝移植部门切除。联合肝切除268例（88.7%）。行半肝切除257例，保留肝实质切除11例。在268例肝切除患者中，40例（14.9%）与门静脉切除相关。为控制术前胆管炎和降低术后肝功能衰竭的风险，329例患者术前应用内镜和/或经皮经肝穿刺引流胆管减压和门静脉栓塞术（94.0%）350例探索患者和91例168例扩大肝切除术（右半肝切除154例，右三肝切除9例，左三肝切除5例）中，肝切除率为54.2%。肝门部胆管癌未行肝移植作为主要治疗手段，5例（1.7%）手术切除后院内死亡，1例术后肝功能衰竭行肝移植成功。严重并发症23例（7.0%），总发病率为43%。在302例切除中，214例（70.9%）为根治性切除（R 0），88例（29.1%）为姑息性切除（R1）。切除术后1、3和5年的总生存率（包括院内死亡）在R 0组中分别为84.6%、50.7%和47.3%，在R1组中分别为69.9%、33.3%和7.5%。扩大半肝切除术的5年生存率为36.4%，明显优于保留肝实质切除术的10.5%。淋巴结转移和手术失败是影响术后生存率的两个重要预测因素（P < 0.001）。2例血管受累的患者同时行肝动脉和门静脉重建，术后3年存活，术前胆道减压和门静脉栓塞使我们能够减少与肝门部胆管癌扩大切除术相关的院内死亡。大部分半肝切除术由于治愈性切除的可能性高于单纯胆管切除术和保留肝实质的肝切除术，因此生存率较高，但仍有一定的死亡率。如果获得无肿瘤切除边缘，则可以安全地进行不太广泛的手术，并且对于肿瘤分期不太晚期的老年患者是有益的。
Both curative resection and minimized in-hospital mortality offer the only chance of long-term survival in patients with hilar cholangiocarcinoma. The reported resectability rates for hilar cholangiocarcinoma have increased by virtue of combined major hepatectomy, but this procedure is technically demanding and still associated with a significant morbidity and mortality that must be carefully balanced against the chances of long-term survival.Between January 2001 and December 2008, 350 patients with hilar cholangiocarcinoma underwent exploration for the purpose of potentially curative resection, of whom 302 (86.3%) were resected in the Department of Hepato-Biliary Surgery and Liver Transplantation, Asan Medical Center, University of Ulsan College of Medicine. Combined hepatectomy was carried out in 268 (88.7%) of 302 resected patients. Major hemihepatectomy and parenchyma-preserving hepatectomy were performed in 257 and 11 patients, respectively. Portal vein resection was associated in 40 (14.9%) of 268 hepatectomized patients. To control preoperative cholangitis and reduce risk of postoperative hepatic failure, biliary decompression through endoscopic and/or percutaneous transhepatic drainage and portal vein embolization were preoperatively applied in 329 (94.0%) of 350 explored patients and in 91 (54.2%) of 168 extended hepatectomized patients (154 right hemihepatectomy, 9 right trisectionectomy, 5 left trisectionectomy), respectively. Liver transplantation was not performed as primary treatment for hilar cholangiocarcinoma.There were 5 cases (1.7%) of in-hospital death after resection and 1 postoperative liver failure that was successfully treated with liver transplantation. Major complications were encountered in 23 patients (7.0%), and the overall morbidity rate was 43%. In 302 resections, 214 (70.9%) were curative resections (R0) and 88 (29.1%) were palliative resections (R1). The overall 1-, 3- and 5-year survival rates after resection, including in-hospital deaths, were 84.6, 50.7 and 47.3% in the R0 group and 69.9, 33.3 and 7.5% in the R1 group, respectively. The 5-year survival rate of extended hemihepatectomy of 36.4% was better than that of parenchyma-preserving hepatectomy at 10.5%. Two significant predictive factors adversely affecting survival after resection were lymph node metastasis and incurability of surgery (P < 0.001). Two patients with vascular involvement who underwent concomitant hepatic artery and portal vein reconstruction are alive after more than 3 years.Preoperative biliary decompression and portal vein embolization enabled us to reduce in-hospital deaths associated with extended hepatectomy for hilar cholangiocarcinoma. Major hemihepatectomy offers an increased survival because of the higher possibility of curative resection than bile duct resection alone and parenchyma-preserving hepatectomy, but it still carries a certain mortality. Less extensive procedures can be conducted safely and are beneficial for aged patients in poor condition with a less advanced tumor stage if tumor-free resectional margins are obtained.