Experomental and clinical studies to increase curability and safety of surgery for hilar cholangiocarcinoma

*临床研究*(1)术前通过胆道引流管、经皮肝胆管镜、选择性血管造影、经皮肝门静脉造影、肝静脉造影等胆道造影可准确诊断肿瘤程度。这反过来又导致了合理的手术程序。(2)神经周围浸润对胆管癌患者的生存有深远的影响，表明彻底的骨化切除是达到治疗目的的必要条件。(3)我们发展了一种新的经皮经肝门静脉栓塞入路，即同侧入路，使栓塞左、右三段门静脉成为可能。门静脉栓塞术有可能增加肝门部胆管癌大肝切除术的安全性和扩大适应症。(4)在透视控制下，经直接前路行多路选择性胆管手术治疗肝门部胆管癌的技术已经建立。这种积极的引流对于预防和/或治疗肝汇合处恶性胆管梗阻患者的节段性胆管炎是必不可少的。*实验研究*以下结果是用大鼠或小鼠实验证明的。(1)胆外引流与内引流不同，不抑制部分肝切除术后胆汁淤积肝的再生。(2)胆道感染，尤其是伴有梗阻性黄疸，可显著损害肝脏线粒体功能。胆道引流对改善受损功能绝对有效。(3)选择性胆道梗阻时，肝非积胆叶和积胆叶的线粒体功能也下降。这意味着整个胆道系统的胆道引流是有益的。(4)脂质乳剂在全肠外营养中的应用有助于肝部分切除术后的肝再生。(5)从DNA聚合酶和线粒体基因表达变化的角度来看，门脉分支结扎术诱导肝细胞在非结扎叶增殖的方式与肝部分切除术相似。(6)门静脉分支结扎诱导非结扎肝叶肝细胞增殖，与梗阻性黄疸无关。(7)二丁基cAMP对炎性肝损伤的保护作用与肝脏中IL-10产生的增加有关。少

*Clinical Research*(1) Preoperative accurate diagnosis of cancer extent was achievable using cholangiography throgh biliary drainage catheter, percutaneous transhepatic cholangioscopy, selective angiography, pcrcutaneous transhepatic portography and hepatic venography. This, in turn led to rational surgical prcoedures. (2) Perineural lnvasion proved to have a profound impact on survival of the patients with bile duct carcinoma, indicating that thorough skeletonization resection is essential for curative intent. (3) We developed a new approach of percutaneous transhepatic portal vein cmbolization, the ipsilateral approach, which made it possible to embolize the right or left trisegment portal vein. Portal vein cmbolization had the potential to increase safety of and to extend indication of major hepatectomy for hilar cholangiocarcinoma. (4) Technique of multiple selective biliary for hilar cholangiocarcinoma was well established by the direct anterior approach under fluoroscopic control … More . This aggressive drainage was essential for preventing and/or treating segmental cholangitis in patients with malignant biliary obstruction at the hepatic confluence.*Experimental Research*The following resukts were demonstrated experimentally using rats or mioe. (1) External bilisry drainage, unlike internal drainage, does not suppress regcenration of cholestatic liver after partial hepatectomy. (2) Biliary infection, especially associated with obstructive jaundice, injures hepatic mitochondrial function markedly. Biliary drainage is definitely effective in improving the impaierd function. (3) Under a condition of selective biliary obstruction, hepatic mitochondrial function is decreased also in the non-cholestatic lobe, as well as the cholestatic lobc. This implies that biliary drainage of the entire biliary system is beneficial. (4) An application of lipid emulsion to total parenteral nutrition is useful for hepatic regeneration after partial hepatectomy. (5) Portal branch ligation induces hepatocyte proliferation in the non-ligated lobe in a way similar to partial hepatectomy, from the viewpoint of changes in DNA polymerases and mitochondrial gene expression. (6) Portal branch ligation induces hepatocyte proliferation in the non-ligated lobe, irrespective of obstructive jaundice. (7) An increment in IL-10 production in the liver is involved in the protective effect of dibutyryl cAMP on inflammatory liver injury. Less