ObjectiveTo summarize a patient diagnosed as Bismuth type Ⅲa hilar cholangiocarcinoma who unerwent the curative surgery combined with partial portal vein resection and reconstruction+hilar bile duct formation+Roux-en-Y choledochojejunostomy, meanwhile we reviewed the current status of surgical treatment of hilar cholangiocarcinoma at home and abroad.MethodsTo retrospectively summarized and analyzed the clinical data of one case of Bismuth type Ⅲa hilar cholangiocarcinoma. The preoperative total bilirubin of this patient was 346.8 μmol/L, and this patient underwent the curative surgery combined with partial portal vein resection and reconstruction+hilar bile duct formation+Roux-en-Y choledochojejunostomy after reducing jaundice by percutaneous transhepatic biliary drainage (PTBD). Then we retrieved domestic and foreign related literatures.ResultsOperative time of this patient was about 290 min and intraoperative bleeding was about 350 mL. No intraoperative blood transfusion occurred. The results of pathological examination showed middle-differentiatied adenocarcinoma of hilar bile duct with negative tumor margins and no regional lymph node metastasis (0/14). The postoperative recovery was uneventful with hospital stay time of 9 days and without any complication. The patient had been followed-up in the outpatient department for 3 years,and was generally in good condition. The evidence of recurrence or metastasis wasn’t found.ConclusionsPre-operative biliary drainage can improve the safety of operation and reduce the incidence of postoperative complications, extend liver resection for the patient with Bismuth type Ⅲa hilar cholangiocarcinoma, which can improve R0 resection rate and extend postoperative survival.
目的 对肝门胆管癌外科治疗疗效进行评价。 方法 回顾分析2007年3月－2012年3月收治的156例肝门胆管癌患者的临床资料。按手术方式将患者分为手术切除组（n=45）、胆道引流组（n=78）和姑息治疗组（n=33），并对住院期间并发症发生率、病死率及生存时间等进行分析。 结果 156例患者根治性切率为23.1%不同治疗方式住院期间病死率差异无统计学意义（P＜0.05）；手术治疗组与姑息治疗组并发症发生率差异有统计学意义（P＜0.05）。手术切除组、胆道引流组、姑息治疗组的1、3、5年累积生存率分别为64.4%、17.8%、0.0%；40.2%、12.6%、12.6%；17.7%、7.1%、0.0%，手术切除组生存情况明显好于其他两组（P＜0.05）。 结论 不建议所有患者术前均引流可减黄，且可以不过分强调R0切除。胆道引流可一定程度改善预后，但近远期胆道感染相关并发症发生率较高。
Objective To explore favorable factors of reducing incidence of postoperative liver failure after radical resection of Bismuth-Corlette type Ⅳ hilar cholangiocarcinoma in condition of hyperbilirubinemia. Methods All the clinical data of one patient with Bismuth-Corlette type Ⅳ hilar cholangiocarcinoma underwent radical resection in June 2017 in the West China Hospital of Sichuan University were collected. The preoperative total bilirubin level of this patient was 470.3 μmol/L, the patient didn’t receive preoperative biliary drainage. The preoperative jaundice time and cholangitis were calculated accurately. A 3D imaging system for quantitative evaluation of the liver was used to reconstruct the images with contrast-enhanced CT images of this patient. And the total liver volume and the future liver remnant volume (FLRV) were calculated. Finally, 6 months of follow-up were conducted after surgery. Results The exact jaundice time was 20 d and there was no preoperative cholangitis. The postoperative FLRV accounted for about 70%. No postoperative liver failure occurred. No recurrence of tumor and death of patient occurred after 6 months of follow-up. Conclusions Radical resection of hilar cholangiocarcinoma in condition of hyperbilirubinemia is not an absolute contraindication for surgery, but indications should be strictly controlled. For special patient whose jaundice with short duration, no preoperative cholangitis and a high FLRV may be treated with directly radical surgery to prevent for losting the best time of surgery.
ObjectiveTo explore the treatment and prognostic factors of typeⅢhilar cholangiocarcinoma. MethodsThe data of 170 cases of typeⅢhilar cholangiocarcinoma treated in our hospital from Jan. 2002 to Dec. 2011 were retrospectively analyzed. ResultsAmong these 170 patients of typeⅢhilar cholangiocarcinoma, 109 patients underwent surgical exploration in which 60 patients underwent resection and the remaining 49 patients were found unresectable and underwent U-tube or metallic stent drainage. Sixty one patients were preoperatively assessed as unresectable in which 14 patients underwent percutaneous transhepatic cholangial drainage and the remaining 47 patients refused any surgical intervention. Results of Cox proportional hazard model showed that residual tumor status (HR=4.621, 95% CI:1.907-11.199, P=0.001), lymph node metastasis (HR=2.792, 95% CI:1.393-5.598, P=0.004), and hepatectomy (HR=3.003, 95% CI:1.373-6.569, P=0.006) were independent prognostic factors which associated with patients in resection group. Besides, treatmentR0 resection (HR=0.177, 95% CI:0.081-0.035, P < 0.001), no treatment (HR=5.568, 95% CI:2.733-11.342, P < 0.001)] and vascular invasion (HR=1.667, 95% CI:1.152-2.412, P=0.007) were prognostic factors associated with all patients. ConclusionsTreatment and vascular invasion are the most important predictors of prolonging survival associated with typeⅢhilar cholangiocarcinoma. Besides, R0 resection including hepatectomy without lymph nodes metastasis is feasible in the majority of patients with resectable hilar cholangiocarcinoma.
目的 探讨不能切除的肝门胆管癌的治疗方法。方法 1992年1月至1997年1月采用胆肠桥式吻合术治疗该病12例。结果 该术式简单、实用、减黄效果满意。结论 胆肠桥式吻合是治疗不能切除的肝门胆管癌的较理想术式之一。
【摘要】 目的 探讨老年肝门胆管癌的围手术期处理方法。 方法 回顾性分析1992年6月-2004年10月收治的60岁以上的肝门胆管癌患者临床资料。 结果 78例患者合并有多脏器储备功能改变，施行手术切除12例，外引流手术11例，内引流手术55例。17例出现并发症，以肺部感染、肝肾功能衰竭和吻合口瘘为多见。根治性切除、 姑息性切除和姑息性引流组手术后中位生存时间分别为12、8、5个月。 结论 肝门胆管癌的手术复杂，创伤大，对老年患者更容易产生心肺功能异常及各种并发症；但通过围手术期内合理、充分的综合治疗措施，仍能取得较好的治疗效果。【Abstract】 Objective To investigate the perioperative therapy for the elder patients with hilar cholangiocarcinoma. Methods The clinical data of over 60 years old patients with hilar cholangiocarcinoma who were treated in the hospital from June 1992 to October 2004 were retrospectively analyzed. Result Seventy-eight patients with multiple organs liver functional changes, 12 patients received surgical excision, 11 patients received external drainage surgery, 55 patients received internal drainage surgery. Postoperative complications occurred in 17 patients, wost of which were lung infection, liver and kidney failure and anastomotic leakage. The median survival time were 12, eight and five months for the patients who received radical resection, palliative resection and drainage, respectively. Conclusions The surgical treatment for hilar cholangiocarcinoma is complicated with major surgical trauma. The postoperative complication and the cardio-pulmonary dysfunetion are easily happened especially in the aged patients. Intensive supportive therapy is needed all over the course.
ObjectiveTo investigate the value of diffusion weighted imaging (DWI) combined with three-dimensional volumetric interpolated breath-hold examination (3D-VIBE) in evaluating metastatic lymph nodes secondary to hilar cholangiocarcinoma. MethodsFrom July 2009 to March 2011, DWI examination was performed in 37 patients with hilar cholangiocarcinoma, which was compared with 3D-VIBE sequences. The morphological characteristics and distribution were analyzed for metastatic and nonmetastatic lymph nodes. Signal intensity (SI) was measured on DWI images and apparent diffusion coefficient (ADC) was calculated for each lymph node. The SI of lymph nodes (SILN） and liver (SIliver) were also measured and the ratio of SI was calculated. The ADC and the ratio of SI were compared between metastatic and nonmetastatic lymph nodes. ResultsThere were fifty-nine groups of lymph nodes in 37 patients with hilar cholangiocarcinoma, fifty-one groups were revealed in both DWI and 3D-VIBE sequences, and eight groups were only demonstrated in one sequence (P=0.070). The short diameters were (1.05±0.42) cm and (0.78±0.22) cm on 3D-VIBE images for metastatic and nonmetastatic lymph nodes, respectively (P=0.030). The ADC value in metastatic lymph nodes was (1.64±0.3)×10-3 mm2/s, which was significantly lower than that in nonmetastatic lymph nodes 〔(2.28±0.79)×10-3 mm2/s〕 on DWI images (P=0.033). There were no significant differences in SILN/SIliver between metastatic and nonmetastatic lymph nodes on images of portal venous phase and 3 min delayed contrast-enhanced phase. ConclusionsDifferences of ADC and short diameter can provide valuable information to differentiate metastatic lymph nodes with nonmetastatic lymph nodes. When combined with 3D-VIBE sequence, DWI is more effective in evaluating metastatic lymph nodes secondary to hilar cholangiocarcinoma.
ObjectiveTo explore clinical manifestation, diagnosis and treatment of IgG4 sclerosing cholangitis developed postoperative gastroduodenal hemorrhage, so as to improve awareness and treatment of this disease. MethodThe clinical data of a case of IgG4 sclerosing cholangitis misdiagnosed as the hilar cholangiocarcinoma which developed postoperative gastrointestinal hemorrhage in this hospital were analyzed retrospectively. ResultsThis patient was misdiagnosed as the hilar cholangiocarcinoma and accepted the radical resection, while the postoperative pathology proved to be the IgG4 sclerosing cholangitis. One month later, the patient developed the acute gastrointestinal hemorrhage and it was resolved by using the endovascular embolization. ConclusionsPreoperative distinguishing IgG4 sclerosing cholangitis from hilar cholangiocarcinoma can avoid an unnecessary surgery. Endovascular intervention is both a useful measure of diagnosis and treatment for gastroduodenal pseudoaneurysm. Attention should be paid to arterial protection during process of arterial osteogenesis in hepatobiliary operation.
ObjectiveTo discuss the treatment methods and outcome of hilar cholangiocarcinoma. MethodsFrom January 2002 to December 2008, 81 cases of hilar cholangiocarcinoma were retrospectively analyzed. ResultsAmong 81 patients, there were 55 males and 26 females, ages were from 38 to 72 years with an average age 57.5 years. In BismuthCorlette classification, 5 cases were type Ⅰ, 15 cases type Ⅱ, 14 cases type Ⅲa, 14 cases type Ⅲb, 33 cases type Ⅳ, according to the preoperative results of MRCP, but the classification of 15 cases were not consistent to the preoperative results (5 cases type Ⅱ, 8 cases type Ⅲ, 2 cases type Ⅳ) according to the results of intraoperative exploration. The rates of complications of radical operation, palliative operation, internal biliary drainage, and external biliary drainage were 54.5%(12/22), 58.8%(10/17), 23.8%(5/21), and 66.7%(14/21), respectively. The rate of complications of internal biliary drainage was lower than that of the other three methods (Plt;0.01), there were no significant differences among the other three methods. The 1, 2, 3, and 5year survival rates of 22 patients with radical operation, 17 patients with palliative operation, 21 patients with internal biliary drainage, 21 patients with external biliary drainage were 75.0%, 60.0%, 38.3%, 2.6%; 72.7%, 26.5%, 4.2%, 0; 50.5%, 15.8%, 2.2%, 0; 30.6%, 8.5%, 0, 0, respectively. The median survival time was 29.5 months, 13.8 months, 10.5 months, and 8.3 months, respectively. Survival rate of radical operation was higher than that of palliative operation (χ2=14.20, P=0.000 3), palliative operation was higher than that of internal biliary drainage (χ2=4.50, P=0.040 5), and internal biliary drainage was higher than that of external biliary drainage (χ2=4.45, P=0.040 1). ConclusionsThe BismuthCorlette classification is a guide to the required surgery, but the results of intraoperative exploration decides the final classification and operative method. Radical resection is the main related factors influencing the therapy efficacy of hilar cholangiocarcinona. Basinstyle anastomosis and T type supportingtube is the first choice of palliative operation. External drainage, to the full, is avoided.