中晚期肝门部胆管癌诊治15例

摘要

目的: 探讨中晚期肝门部胆管癌的外科治疗方式选择, 提高手术切除率和疗效.

方法: 对2001-10/2004-12收治的15例中晚期肝门部胆管癌的外科治疗方式和随访结果进行回顾性分析, 其中中期7例(Bismuth IIIa型4例, IIIb型3例), 晚期(IV型)8例.

结果: 手术切除10例, 非手术胆道支架内引流5例(IV型5例). 随访14例(14/15, 93.3%), 手术切除组随访10例, 中位生存期14.2 mo(16 d-32.3 mo); 非手术胆道支架内引流组随访4例, 中位生存期3.8 mo(1.3-7.2 mo); 两组中位生存期差异显著(t= 2.802, P<0.05).

结论: 对于中晚期肝门部胆管癌, 联合肝切除的姑息性肝门部胆管癌切除可显著延长患者生存期、提高生活质量, 必要时辅以"架桥式"肝管空肠内引流对提高手术切除率、降低术后胆漏发生率具有重要作用.

关键词: 肝门; 胆管癌; 根治性切除; 姑息性切除; "架桥式"肝管空肠内引流

Diagnosis and treatment for advanced hilar cholangiocarcinoma: an analysis of 15 cases

Zong-Ming Zhang, Hai-Lin Xing, Gang Li, Kai Liu, Jian-Ping Zhu, Yan-Ming Su, Hua Zhong, Jin-Xing Guo

Zong-Ming Zhang, Gang Li, Jian-Ping Zhu, Yan-Ming Su, Hua Zhong, Jin-Xing Guo, Digestive Medical Center, the First Affiliated Hospital of Tsinghua University, Beijing 100016, China

Hai-Lin Xing, Kai Liu, the First Department of General Surgery, Tongji Hospital, Tongji University, Shanghai 200065, China

Correspondence to: Zong-Ming Zhang, Digestive Medical Center, the First Affiliated Hospital of Tsinghua University, Beijing 100016, China. zhangzongming@mail.tsinghua.edu.cn

Received: August 26, 2005
Revised: September 2, 2005
Accepted: September 5, 2005
Published online: September 28, 2005

Abstract

AIM: To evaluate the efficacy of the surgical treatment for advanced hilar cholangiocarcinoma in order to enhance the resection rate and the curative effect.

METHODS: A retrospective analysis was performed on the data of 15 patients underwent surgical treatment for advanced hilar cholangiocarcinoma, including 7 mid-term cases (4 for Bismuth type IIIa, 3 for IIIb) and 8 late-term cases (Bismuth type IV).

RESULTS: Ten patients underwent successful resection, and 5 received non-surgical internal biliary stent drainage, of which 14 patients were followed-up (93.3%, 14/15), including all the 10 cases in the surgical resection group with the median survival time of 14.2 mo (16 d-32.3 mo). The median survival time for the patients received internal biliary stent drainage was 3.8 mo (1.3-7.2 mo), which was significantly different from that for the patients received surgical resection (t = 2.802, P < 0.05).

CONCLUSION: Palliative resection combined with hepatectomy can significantly prolong the survival time of the patients with advanced hilar cholangiocarcinoma. Internal drainage through hepatico-jejunal bridge can enhance the surgical resection rate and decrease the occurrence rate of postoperative biliary fistula.

Key Words: Hilar cholangiocarcinoma; Radical resection; Palliative resection; Internal drainage through hepatico-jejunal bridge

0 引言

肝门部胆管癌(hilar cholangiocarcinoma, HCC), 又称Klatskin瘤[1], 是指位于肝总管、左右肝管汇合部和左右肝管的癌, 约占肝外胆管癌的58%-75%. 根据Bismuth分型[2,3], 将其III型、IV型分别称为中、晚期HCC. 由于HCC早期临床表现不明显, 多数患者就诊时已处于中晚期, 手术切除率低, 术后复发率高, 预后差, 是目前胆道外科面临的一大难题[4-7]. 我院2001-10/2004-12收治中晚期HCC 15例, 现对其外科治疗方式和随访结果进行回顾性分析, 总结报告如下.

1 材料和方法

1.1 材料

我院2001-10∕2004-12收治的中晚期HCC患者15例, 男性6例, 女性9例, 年龄43-83岁, 平均70.2±11.7岁. 临床表现以皮肤、巩膜黄疸为首发症状者13例(86.7%), 皮肤瘙痒9例(60%), 陶土色大便8例(53.3%).

1.2 方法

1.2.1 实验室检查: 血清CA19-9 231.4±158.7 kU/L CEA 14.8±1.6 µg/L. 血清总胆红素(TB)213.9±125.7 µmol/L, 直接胆红素(DB)139.3±83.7 µmol/L, 谷丙转氨酶(ALT)2 062.1±968.5 nkat/L, 碱性磷酸酶(ALP)8 293.3±5 222.7 nkat/L, γ-谷氨酰转肽酶(γ-GT)11 965.7±7 639.9 nkat/L.

1.2.2 影像学检查: 全组病例均行B型超声检查, 提示肝弥漫性肿大、肝内胆管扩张、肝门部肿物. 13例行CT检查, 显示肝门部胆管占位性病变、肝内胆管扩张. 14例行磁共振胰胆管成像(MRCP)检查, 显示肝门部胆管阻塞、肝内胆管扩张. 9例经内镜逆行性胰胆管造影(ERCP)检查, 显示梗阻部位位于肝门部, 呈鸟嘴状或截断征改变.

1.2.3 临床分型: 根据影像学检查和手术所见, 按Bismuth分型标准[2,3], 判定IIIa型4例, IIIb型3例, IV型8例.

统计学处理 采用SPSS 10.0软件, 对手术切除组和非手术胆道支架引流组的中位生存期差异进行t检验, 检验水准α =0.05.

2 结果

2.1 治疗方式

手术切除10例, 切除率66.7%(10/15), 其中: (1)根治性切除3例(IIIa型1例, IIIb型2例): 行右/左肝管和汇合部肿瘤及以下胆管切除、胆囊切除、肝十二指肠韧带骨骼化, 左、右肝管集合成形、肝管空肠Roux-en-Y吻合术, 联合肝方叶切除2例; 左半肝切除1例. (2)姑息性切除4例(IIIa型3例, IIIb型1例), 因肿瘤侵犯门静脉分叉行姑息性右/左肝管和汇合部肿瘤切除、胆囊切除, 左、右肝管集合成形、肝管空肠Roux-en-Y吻合术, 联合肝方叶切除3例. (3)姑息性切除加"架桥式"肝管空肠内引流3例(IV型3例), 因肿瘤侵犯门静脉分叉或左、右分支, 行姑息性左、右肝管和汇合部肿瘤切除、胆囊切除, 在左、右肝管集合成形困难或不满意情况下, 将T管长臂或硅胶管一端置入肝管并缝合固定, 另一端置入空肠并造隧道固定, 完成"架桥式"肝管空肠Roux-en-Y吻合术, 联合肝方叶切除3例. 非手术胆道支架内引流5例, 均为IV型, 其中经内镜逆行性胆道支架内引流(ERBD)3例, 经皮肝穿刺胆道支架内引流(PTBD)2例.

全组手术切除或非手术胆道支架内引流病例, 均无胆漏发生.

2.2 病理检查

10例手术切除病例中, 高分化腺癌5例, 中分化腺癌2例, 低分化腺癌3例.

2.3 生存情况

2005-02/2005-04对全组病例进行随访, 获得随访资料14例, 随访率93.3%(14/15), 平均生存期为11.2 mo. 手术切除组随访10例, 中位生存期14.2 mo(16 d-32.3 mo); 非手术胆道支架内引流组随访4例, 中位生存期3.8 mo(1.3-7.2 mo); 两组中位生存期差异显著(P<0.05, t = 2.802).

3 讨论

3.1 提高早期诊断水平

肝门部胆管癌起病隐匿, 症状缺乏特异性, 就诊时多数已处于中晚期, 因此提高早期诊断水平具有重要现实意义. 根据本组病例的血生化和影像学检查结果, 对上腹部疼痛不适、食欲不振、乏力、消瘦、皮肤瘙痒的患者应考虑到该病的可能, 积极的血清肝功能、CA19-9、CEA检查能提示恶性梗阻性黄疸的可能, B超、CT、MRCP多能明确该病诊断, ERCP可进一步确诊并了解肿瘤的确切部位和大小.

按Bismuth所建议的分型方法[2,3], 根据胆管受累范围, 将肝门部胆管癌分型如下: I型: 肿瘤位于肝总管, 但未侵犯分叉部及左右肝管; II型: 肿瘤自肝总管侵犯左、右肝管分叉部; III型: 肿瘤自肝总管侵犯单侧一级肝管分支(IIIa型: 侵犯右肝管; IIIb型: 侵犯左肝管); IV型: 肿瘤同时侵犯肝总管和左右肝管. 本研究将上述III型、IV型分别称为中、晚期肝门部胆管癌.

3.2 根治性切除

肝门部胆管癌的治疗仍以根治性切除为首选[8-10], 要求完全切除肿瘤及其上方胆管1 cm以上, 并对肝十二指肠韧带进行骨骼化清扫, 但由于其解剖位置的特殊性, 易于侵犯肝门区重要血管和肝实质, 因此根治性切除率很低. 本组根治性切除3例(切除率30%), 其中联合肝方叶切除2例、左半肝切除1例, 表明联合肝切除对于提高中晚期肝门部胆管癌的根治性切除率具有重要作用. 新近, 有学者为了提高根治性切除率, 采用联合肝叶和胰十二指肠切除、扩大肝右三叶切除等扩大手术, 尽管有生存5年的病例[11], 但由于伴有较高的手术死亡率和并发症发生率, 该种"激进"的手术方式尚值得商榷[12], 其作用有待于总结更多的病例作出评价.

3.3 姑息性切除

中晚期肝门部胆管癌患者, 多因肿瘤侵犯肝门区重要血管而失去根治性切除机会, 姑息性切除就显得非常重要, 其主要目的在于尽可能解除胆管癌阻塞肝门造成的肝内胆汁淤积, 要求尽可能切除肿瘤、通畅胆道引流, 即使肿瘤上方胆管切缘达不到无瘤原则, 也会对提高患者术后生活质量、延长生存时间起到积极的促进作用. 对于侵犯肝门血管的肝门部胆管癌, 有学者认为除了切除肿瘤外, 还需全部或部分切除受侵犯的血管, 并重建或修补血管[13]; 但也有学者持相反态度, Launois et al[14] 报告的肝门部胆管癌切除率为49.4%, 对于侵犯门静脉或其分支的中晚期患者, 切除受侵血管的1, 3, 5年生存率无明显提高.

3.4 "架桥式"肝管空肠内引流

肝门部胆管癌根治性切除后胆道重建较难, 其主要困难在于肝胆管壁较薄, 减压后肝胆管较细, 胆肠吻合难以满意完成, 且易发生胆漏. 本组3例IV型肝门部胆管癌患者, 术中探查发现肿瘤侵犯门静脉而施行姑息性切除, 并将肿瘤上方的肝管尽可能切除1 cm以上, 在将左、右肝管的主分支开口集合成形后, 因肝管成形后的管壁短、薄, 周围肝组织软、脆, 难以完成肝管-空肠吻合, 将T管长臂或硅胶管一端置入肝管并缝合固定, 另一端置入空肠并造隧道固定, 完成"架桥式"肝管空肠Roux-en-Y吻合术, 术后胆道引流通畅、且无胆漏发生. 该"架桥"术式的成功实施, 对于扩大姑息性切除范围、提高手术切除率、降低术后胆漏发生率具有重要作用, 有待积累更多病例.

3.5 非手术胆道支架内引流

该方法是微创性治疗方法之一, 是应用介入放射学技术, 通过PTC或ERCP将导丝送入肝内胆管或胆总管, 并使其通过肿瘤占据的狭窄部位, 再沿导丝将胆道内支架输送器送至狭窄部位的远端, 然后选择合适的可展性支架通过支架输送器置入胆道狭窄部位, 置入后约两周, 胆道黏膜逐渐覆盖支架, 保持支架的稳定和持续性张力, 引流效果较好, 胆汁不丢失, 患者生活质量高于外引流术者, 适用于肝门部胆管癌晚期, 患者全身情况差, 估计肿瘤不能切除或难以耐受剖腹探查者, 不失为晚期肝门部胆管癌的可供选择的较理想治疗手段之一[15]. 本组5例IV型肝门部胆管癌, 经内镜逆行性胆道支架内引流3例, 经皮肝穿刺胆道支架内引流2例, 尽管中位生存期仅为3.8个月, 但术后黄疸明显下降, 全身严重瘙痒症状减轻或消失, 能适量进饮食, 生活质量明显提高.

备注

电编:张勇 编辑:王瑾晖 审读:张海宁

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