目的 提出胆管囊状扩张症的临床分型及针对不同分型的治疗策略和手术方法.方法 回顾性分析1993年6月至2010年6月解放军总医院收治的434例胆管囊状扩张症患者的临床资料.收集和重新分析患者腹部CT、MRI、MRCP和胆道造影检查结果,根据胆管囊状扩张病变累及胆管树的部位及范围,结合其临床病理特征、发病因素及适用的手术方式提出一种新的胆管囊状扩张症的临床分型;分析新分型中不同胆管囊状扩张症的临床表现、手术方式、围手术期结果、随访结果等资料,针对不同分型胆管囊状扩张症制订治疗策略和手术方法.率的比较采用x2检验,理论频数＜5或总观测频数＜ 30时,采用Fisher确切概率法.结果 根据囊状扩张病变累及胆管树的部位及病理特征将其分为5种类型:(1)A型:周围肝管型肝内胆管囊状扩张.A1型:囊状扩张病变局限分布于部分肝段;A2型:囊状扩张病变弥漫分布于全肝.(2)B型:中央肝管型肝内胆管囊状扩张.B1型:单侧肝叶中央肝管囊状扩张;B2型:囊状扩张病变同时累及双侧肝叶主肝管及左、右肝管汇合部.(3)C型:肝外胆管型胆管囊状扩张.C1型:囊状扩张病变未累及胰腺段胆管;C2型:囊状扩张病变累及胰腺段胆管.(4)D型:肝内外胆管型胆管囊状扩张.D1型:囊状扩张病变累及单叶中央肝管和肝外胆管;D2型:囊状扩张病变累及双侧肝叶中央肝管和肝外胆管.(5)E型:壶腹胆管型胆管囊状扩张.本组434例胆管囊状扩张症患者中,A型24例(A1型17例、A2型7例),B型13例(B1型10例、B2型3例),C型300例(C1型56例、C2型244例),D型96例(D1型17例、D2型79例),E型1例.24例A型患者中,14例伴有先天性肝纤维化,16例合并多囊肾病,区别于其他各型患者.手术方式:24例A型患者中,17例A1型患者行部分肝切除术,3例A2型患者行肝移植,1例A2型患者行囊状扩张病变穿刺引流术,3例A2型患者采用非手术治疗;13例B型患者中,12例患者行肝切除术,1例患者合并胆管癌,采用非手术治疗;300例C型患者中,286例患者行肝外囊状扩张病变切除+胆管空肠吻合术,14例患者因囊状扩张胆管恶变行胆管癌根治性切除术;96例D型患者中,35例患者行肝外胆管囊状扩张病变切除+肝切除(肝内胆管囊状扩张病变累及的部分肝组织)+胆管空肠吻合术,59例患者仅行肝外囊状扩张病变切除术,1例D1型和1例D2型患者伴有胆管癌,行根治性切除术;1例E型患者行EST治疗.399例患者获得随访,随访时间l～15年,平均随访57个月.33例患者出现胆管空肠吻合口狭窄和(或)结石.24例患者并发胆管癌,其中15例患者于随访期内死亡.46例患者因复发性胆管炎伴有吻合口狭窄或结石、肿瘤实施再次手术治疗(胆管空肠再吻合术、内镜下胆管取石术、胆管癌根治性切除术等).其余患者无相关临床症状或偶发轻度的胆管炎,经对症治疗缓解.D型患者中联合肝切除者与仅行肝外胆管囊状扩张病变切除者的症状缓解率、狭窄和(或)结石复发率、再手术率分别为88.2％(30/34)、8.8％ (93/34)、11.8％ (4/34)和64.4％(38/59)、28.8％(17/59)、35.6％ (21/59),两者比较,差异有统计学意义(P＜0.05).结论 新的胆管囊状扩张症分型基于囊状扩张病变累及胆管树的部位及其病理特征,对于不同分型的胆管囊状扩张症选择不同的治疗策略和手术方法具有明确的指导作用.
目的 提齣膽管囊狀擴張癥的臨床分型及針對不同分型的治療策略和手術方法.方法 迴顧性分析1993年6月至2010年6月解放軍總醫院收治的434例膽管囊狀擴張癥患者的臨床資料.收集和重新分析患者腹部CT、MRI、MRCP和膽道造影檢查結果,根據膽管囊狀擴張病變纍及膽管樹的部位及範圍,結閤其臨床病理特徵、髮病因素及適用的手術方式提齣一種新的膽管囊狀擴張癥的臨床分型;分析新分型中不同膽管囊狀擴張癥的臨床錶現、手術方式、圍手術期結果、隨訪結果等資料,針對不同分型膽管囊狀擴張癥製訂治療策略和手術方法.率的比較採用x2檢驗,理論頻數＜5或總觀測頻數＜ 30時,採用Fisher確切概率法.結果 根據囊狀擴張病變纍及膽管樹的部位及病理特徵將其分為5種類型:(1)A型:週圍肝管型肝內膽管囊狀擴張.A1型:囊狀擴張病變跼限分佈于部分肝段;A2型:囊狀擴張病變瀰漫分佈于全肝.(2)B型:中央肝管型肝內膽管囊狀擴張.B1型:單側肝葉中央肝管囊狀擴張;B2型:囊狀擴張病變同時纍及雙側肝葉主肝管及左、右肝管彙閤部.(3)C型:肝外膽管型膽管囊狀擴張.C1型:囊狀擴張病變未纍及胰腺段膽管;C2型:囊狀擴張病變纍及胰腺段膽管.(4)D型:肝內外膽管型膽管囊狀擴張.D1型:囊狀擴張病變纍及單葉中央肝管和肝外膽管;D2型:囊狀擴張病變纍及雙側肝葉中央肝管和肝外膽管.(5)E型:壺腹膽管型膽管囊狀擴張.本組434例膽管囊狀擴張癥患者中,A型24例(A1型17例、A2型7例),B型13例(B1型10例、B2型3例),C型300例(C1型56例、C2型244例),D型96例(D1型17例、D2型79例),E型1例.24例A型患者中,14例伴有先天性肝纖維化,16例閤併多囊腎病,區彆于其他各型患者.手術方式:24例A型患者中,17例A1型患者行部分肝切除術,3例A2型患者行肝移植,1例A2型患者行囊狀擴張病變穿刺引流術,3例A2型患者採用非手術治療;13例B型患者中,12例患者行肝切除術,1例患者閤併膽管癌,採用非手術治療;300例C型患者中,286例患者行肝外囊狀擴張病變切除+膽管空腸吻閤術,14例患者因囊狀擴張膽管噁變行膽管癌根治性切除術;96例D型患者中,35例患者行肝外膽管囊狀擴張病變切除+肝切除(肝內膽管囊狀擴張病變纍及的部分肝組織)+膽管空腸吻閤術,59例患者僅行肝外囊狀擴張病變切除術,1例D1型和1例D2型患者伴有膽管癌,行根治性切除術;1例E型患者行EST治療.399例患者穫得隨訪,隨訪時間l～15年,平均隨訪57箇月.33例患者齣現膽管空腸吻閤口狹窄和(或)結石.24例患者併髮膽管癌,其中15例患者于隨訪期內死亡.46例患者因複髮性膽管炎伴有吻閤口狹窄或結石、腫瘤實施再次手術治療(膽管空腸再吻閤術、內鏡下膽管取石術、膽管癌根治性切除術等).其餘患者無相關臨床癥狀或偶髮輕度的膽管炎,經對癥治療緩解.D型患者中聯閤肝切除者與僅行肝外膽管囊狀擴張病變切除者的癥狀緩解率、狹窄和(或)結石複髮率、再手術率分彆為88.2％(30/34)、8.8％ (93/34)、11.8％ (4/34)和64.4％(38/59)、28.8％(17/59)、35.6％ (21/59),兩者比較,差異有統計學意義(P＜0.05).結論 新的膽管囊狀擴張癥分型基于囊狀擴張病變纍及膽管樹的部位及其病理特徵,對于不同分型的膽管囊狀擴張癥選擇不同的治療策略和手術方法具有明確的指導作用.
목적 제출담관낭상확장증적림상분형급침대불동분형적치료책략화수술방법.방법 회고성분석1993년6월지2010년6월해방군총의원수치적434례담관낭상확장증환자적림상자료.수집화중신분석환자복부CT、MRI、MRCP화담도조영검사결과,근거담관낭상확장병변루급담관수적부위급범위,결합기림상병리특정、발병인소급괄용적수술방식제출일충신적담관낭상확장증적림상분형;분석신분형중불동담관낭상확장증적림상표현、수술방식、위수술기결과、수방결과등자료,침대불동분형담관낭상확장증제정치료책략화수술방법.솔적비교채용x2검험,이론빈수＜5혹총관측빈수＜ 30시,채용Fisher학절개솔법.결과 근거낭상확장병변루급담관수적부위급병리특정장기분위5충류형:(1)A형:주위간관형간내담관낭상확장.A1형:낭상확장병변국한분포우부분간단;A2형:낭상확장병변미만분포우전간.(2)B형:중앙간관형간내담관낭상확장.B1형:단측간협중앙간관낭상확장;B2형:낭상확장병변동시루급쌍측간협주간관급좌、우간관회합부.(3)C형:간외담관형담관낭상확장.C1형:낭상확장병변미루급이선단담관;C2형:낭상확장병변루급이선단담관.(4)D형:간내외담관형담관낭상확장.D1형:낭상확장병변루급단협중앙간관화간외담관;D2형:낭상확장병변루급쌍측간협중앙간관화간외담관.(5)E형:호복담관형담관낭상확장.본조434례담관낭상확장증환자중,A형24례(A1형17례、A2형7례),B형13례(B1형10례、B2형3례),C형300례(C1형56례、C2형244례),D형96례(D1형17례、D2형79례),E형1례.24례A형환자중,14례반유선천성간섬유화,16례합병다낭신병,구별우기타각형환자.수술방식:24례A형환자중,17례A1형환자행부분간절제술,3례A2형환자행간이식,1례A2형환자행낭상확장병변천자인류술,3례A2형환자채용비수술치료;13례B형환자중,12례환자행간절제술,1례환자합병담관암,채용비수술치료;300례C형환자중,286례환자행간외낭상확장병변절제+담관공장문합술,14례환자인낭상확장담관악변행담관암근치성절제술;96례D형환자중,35례환자행간외담관낭상확장병변절제+간절제(간내담관낭상확장병변루급적부분간조직)+담관공장문합술,59례환자부행간외낭상확장병변절제술,1례D1형화1례D2형환자반유담관암,행근치성절제술;1례E형환자행EST치료.399례환자획득수방,수방시간l～15년,평균수방57개월.33례환자출현담관공장문합구협착화(혹)결석.24례환자병발담관암,기중15례환자우수방기내사망.46례환자인복발성담관염반유문합구협착혹결석、종류실시재차수술치료(담관공장재문합술、내경하담관취석술、담관암근치성절제술등).기여환자무상관림상증상혹우발경도적담관염,경대증치료완해.D형환자중연합간절제자여부행간외담관낭상확장병변절제자적증상완해솔、협착화(혹)결석복발솔、재수술솔분별위88.2％(30/34)、8.8％ (93/34)、11.8％ (4/34)화64.4％(38/59)、28.8％(17/59)、35.6％ (21/59),량자비교,차이유통계학의의(P＜0.05).결론 신적담관낭상확장증분형기우낭상확장병변루급담관수적부위급기병리특정,대우불동분형적담관낭상확장증선택불동적치료책략화수술방법구유명학적지도작용.
Objective To suggest a new clinical classification of the cystic dilatation of bile duct (CDBD),and to design the treatment modality according to different classifications.Methods The clinical data of 434 patients with CDBD who were admitted to the Chinese PLA General Hospital from June 1993 to June 2010 were retrospectively analyzed.The data of computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) were collected.A new clinical classification of CDBD was proposed based on the site,pathological features,pathogenic factors of CDBD and relevant surgical procedures.The clinical condition,surgical procedure,treatment efficacy and results of follow-up of CDBD patients based on the new classification were analyzed,and then proper surgical treatment method for patients with different types of CDBD was suggested.The data were analyzed using the chi-square test,and Fisher exact probability was applied when the theoretical frequency ＜ 5 or the observed frequency ＜ 30.Results CDBD was classified into 5 types according to the pathological features and the location of cystic dilation in the biliary tree:(1) Type A:cystic dilatation of the peripheral biliary tree was limited to the intrahepatic bile ducts.This type could be s1ubdivided into type A1 (cystic dilation of the bile duct was limited to one hepatic lobe or several segments) and type A2 (cystic dilation of the bile duct was diffused to entire intrahepatic biliary tree).(2) Type B:cystic dilation of central large intrahepatic bile duct above the hilar convergence.Commonly the disease presented a single localized form limited to one hepatic lobe (type B1),and cystic dilation in hilar convergence or in bilobar central bile ducts (type B2) was rare.(3) Type C:cystic dilation of the extrahepatic bile duct.According to whether the intrapancreatic bile duct was involved,this type could be divided into type C1 (without intrapancreatic bile duct involvement) and C2 (with intrapancreatic bile duct involvement).(4) Type D:cystic dilation involving both the intra-and extrahepatic bile ducts.According to the range of involvement,this type could be divided into type D1 (cystic dilation limited to one lobe) and D2 (cystic dilation expanded to bilobar bile ducts).(5) Type E:Cystic dilation of the distal common bile duct.Of the 434patients,there were 24 patients with type A CDBD (type A1:17 patients,type A2:7 patients),13 patients with type B (type B1:10 patients,type B2:3 patients),300 patients with type C (type C1:56 patients,type C2:244 patients),96 patients with type D (type D1:17 patients,type D2:79 patients),and 1 patient with type E.In 24 patients with type A CDBD,14 were found with congenital hepatic fibrosis and 16 with polycystic kidney disease.Of the 24 patients with type A CDBD,17 patients with type A1 received partial hepatectomy,3 patients with type A2 received liver transplantation,1 patient with type A2 received puncture and drainage of cystic lesions,and 3 patients with type A2 received non-surgical treatment.Thirteen patients were with type B CDBD,12 received hepatectomy and 1 with cholangiocarcinoma received non-surgical treatment.Of the 300 patients with type C CDBD,286 received cystectomy and Roux-en-Y cholangiojejunostomy,and 14 received radical resection of cholangiocarcinoma.Of the 96 patients with type D CDBD,35 received extrahepatic cystectomy + lobectomy +Roux-en-Y cholangiojejunostomy,59 received extrahepatic cystectomy without hepatectomy,1 with type D1 and 1with type D2 received radical resection of cholangiocarcinoma.One patient with type E CDBD received endoscopic papillectomy.A total of 399 patients followed up for 1-15 years,and the mean follow-up time was 57 months.Thirty-three patients were complicated with anastomotic stricture and (or) biliary stone.There were 24 patients complicated with cholangiocarcinoma,and 15 of whom died during the follow-up.Forty-six patients received re-operation (re-anastomosis of bile duct and jejunum,choledochoscopic stone removal,radical resection of cholangiocarcinoma,and et al) because of recurrent cholangitis,anastomotic stricture,biliary stone or tumor.Other patients were free of biliary symptoms or with accidental mild cholangitis and received symptomatic treatment.The rates of symptom remission,structure and (or) biliary stone and reoperation were 88.2％ (30/34),8.8％ (3/34) and 11.8％ (4/34) in patients who received extrahepatic cystectomy + hepatectomy,and 64.4％ (38/59),28.8％ (17/59) and 35.6％ (21/59) in patients who received extrahepatic cystectomy,and with significant difference (P ＜ 0.05).Conclusion The new clinical classification of CDBD based on the location of cystic dilation in the biliary tree and its pathological features could help to make a suitable surgical plan for clinical treatment.
