CAJ | 학술논문

手术切除是目前治疗肝门部胆管癌最有效的手段,切除范围不足是术后肿瘤复发的主要因素之一.近年来国内外趋于实施扩大的根治性切除,能够提高远期生存率,但大范围肝叶切除的主要风险是术后发生肝功能衰竭.本文报道一种既保证足够的肝内外胆管切除范围、又最大限度地减少肝组织切除的肝门部胆管癌根治性切除术式.该术式的切除范围包括肝Ⅳb段、右肝蒂前部分肝Ⅴ段的肝组织,左右肝管、分叉部、肝外胆管及尾状叶(肝Ⅰ段),同时行肝门区血管骨髂化及至少包括第2站淋巴结的清扫.因所切除组织整体上形似哑铃状,我们称之为“哑铃”式肝门部胆管癌根治术.手术指征:(1) BisnuthⅡ型肝门部胆管癌,以及部分肿瘤局限于一级肝管内的Ⅲa、Ⅲb型肝门部胆管癌；(2)无门静脉分叉部或左右支受侵；(3)第3站淋巴结无转移；(4)无肝内或远处组织器官转移.本研究23例患者完成该术式,术前多数患者TBil＞ 300 μmol/L,均未行PTCD或胆管内支架引流.平均手术时间为355 min.术中平均出血量为350 ml.患者1、3年无瘤生存率分别为95.7％(22/23)和7/15.其结果表明:该术式适宜于我国目前条件下BismuthⅡ型肝门部胆管癌及部分肿瘤局限于一级肝管内的Ⅲa型或Ⅲb型的患者.
수술절제시목전치료간문부담관암최유효적수단,절제범위불족시술후종류복발적주요인소지일.근년래국내외추우실시확대적근치성절제,능구제고원기생존솔,단대범위간협절제적주요풍험시술후발생간공능쇠갈.본문보도일충기보증족구적간내외담관절제범위、우최대한도지감소간조직절제적간문부담관암근치성절제술식.해술식적절제범위포괄간Ⅳb단、우간체전부분간Ⅴ단적간조직,좌우간관、분차부、간외담관급미상협(간Ⅰ단),동시행간문구혈관골가화급지소포괄제2참림파결적청소.인소절제조직정체상형사아령상,아문칭지위“아령”식간문부담관암근치술.수술지정:(1) BisnuthⅡ형간문부담관암,이급부분종류국한우일급간관내적Ⅲa、Ⅲb형간문부담관암；(2)무문정맥분차부혹좌우지수침；(3)제3참림파결무전이；(4)무간내혹원처조직기관전이.본연구23례환자완성해술식,술전다수환자TBil＞ 300 μmol/L,균미행PTCD혹담관내지가인류.평균수술시간위355 min.술중평균출혈량위350 ml.환자1、3년무류생존솔분별위95.7％(22/23)화7/15.기결과표명:해술식괄의우아국목전조건하BismuthⅡ형간문부담관암급부분종류국한우일급간관내적Ⅲa형혹Ⅲb형적환자.
Surgical resection is considered to be the most effective therapy for hilar cholangiocarcinoma.Inadequate excision range is the main reason for recurrence after surgery.Extended radical resection provides better long-term survival,however,it may also increase the risk of liver failure because of the extensive hepatic resection.In present study,we showed a new operation which could excise enough length of bile ducts and avoid large volume hepatic tissue resection.The excision extension includes:segment Ⅰ,Ⅳb and partial Ⅳ,left,right and furcation of hepatic duct,extrahepatic ducts,skeletonization of hilar vessels,and dissection of at least second station lymph nodes.As the tissue resected resembles a dumbbell,this surgical technique is named dumbbell type radical resection.The operative indications include:(1) hilar cholangiocarcinoma,Bithmuth Ⅱ and Bithmuth Ⅲ with tumor limited in left or right hepatic ducts ; (2) Without portal invasion; (3) Without third station lymph node metastasis; (4) Without liver or distant organ metastasis.Twenty-three patients had undergone this operation sucessfully.Most patients have high total bilirubin levels (more than 300 μmol/L) and have not received percutaneous transhepatic cholangial drainage or biliary drainage.The average operation time was 355 minutes,and average volume of blood loss during operation was 350 ml.The total survival rate was 65.2％.One-year tumour free survival rate was 95.7％ (22/23),and three-year tumor free survival rate was 7/15.The results indicated that dumbbell type radical resection was feasible for hilar cholangiocarcinoam of Bismuth Ⅱ and Bismuth Ⅲ with tumor limited in left or right hepatic ducts.