腹腔镜下中下段胆管癌根治术中联合肝动脉切除重建的疗效与安全性：附3例报告（附视频）

背景与目的：中下段胆管癌临床上主要以下段胆管癌多见，下段胆管癌一般采用胰十二指肠切除术，中段胆管癌可以采用胰十二指肠切除术或胆管癌根治、胆肠吻合术。中下段胆管癌因胆管紧邻肝动脉和门静脉，因此更容易发生门静脉侵犯，因肝动脉有动脉外鞘，因此肝动脉受侵犯相对较少，但一旦侵犯，因为涉及肝动脉切除吻合重建，具有较高技术难度，常需联合肝动脉切除重建才能实现R0切除。目前肝动脉切除重建在临床逐渐成熟，但腹腔镜下完成肝动脉切除重建经验缺乏，需要进一步积累。因此，本研究对3例完成腹腔镜下联合肝动脉切除重建的胆管癌患者的临床资料进行回顾性分析并评估短期结果，以期为临床实践提供初步经验。方法：回顾性分析2021年11月—2022年11月中国人民解放军陆军军医大学第二附属医院肝胆外科的3例行联合肝动脉切除重建的中下段胆管癌根治术患者的临床资料。结果：3例患者中女性1例，男性2例，年龄分别为61、65、69岁；病例1为胆管中段癌，因肿瘤侵犯右肝动脉和门静脉，且胆管下端切缘阴性，行联合右肝动脉切除重建、门静脉切除重建、胆管癌切除、胆肠吻合术、肝门部胆管整形术、淋巴结清扫术；病例2为胆管下段癌，因肿瘤侵犯替代右肝动...

Efficacy and safety of combined hepatic artery resection and reconstruction in laparoscopic radical surgery for middle and lower bile duct cancers: a report of 3 cases (with video)

Background and Aims In clinical practice, lower bile duct cancers are more commonly encountered among cancers in the middle and lower segments of the bile ducts. Lower bile duct cancers are generally treated with pancreaticoduodenectomy, while middle bile duct cancers can be managed with pancreaticoduodenectomy, radical resection of bile duct cancer, and choledochojejunostomy. Bile duct cancers in the middle and lower segments are more prone to invasion of the portal vein due to their proximity, whereas invasion of the hepatic artery is relatively less common due to its adventitial sheath. However, when hepatic artery invasion occurs, it poses higher technical challenges as it often requires combined hepatic artery resection and reconstruction to achieve R₀ resection. Although hepatic artery resection and reconstruction are gradually becoming more mature in practice at present, there is a lack of experience in performing laparoscopic hepatic artery resection and reconstruction, and further accumulation is needed. Therefore, this study retrospectively analyzed the clinical data of three patients who underwent laparoscopic combined hepatic artery resection and reconstruction and evaluated the short-term results, so as to provide preliminary experience for clinical practice.Methods The clinical data of three patients undergoing radical surgery combined with laparoscopic hepatic artery resection and reconstruction for middle and lower bile duct cancers in the Department of Hepatobiliary Surgery of the Second Affiliated Hospital of the Army Medical University from November 2021 to November 2022 were retrospectively analyzed.Results Among the three patients, there was one female and two males, aged 61, 65, and 69 years, respectively. Case 1 with a middle bile duct cancer underwent combined resection and reconstruction of the right hepatic artery and portal vein, bile duct cancer resection, bilioenterostomy, hilar cholangioplasty, and lymph node dissection, due to tumor invasion of the right hepatic artery and portal vein, and negative margins at the lower end of the bile duct. Case 2 had a lower bile duct cancer with tumor invasion of the replaced right hepatic artery and portal vein, and underwent combined resection and reconstruction of the replaced hepatic artery, portal vein, and laparoscopic pancreaticoduodenectomy (LPD). Case 3 had a lower bile duct cancer with tumor invasion at the gastroduodenal artery and hepatic artery bifurcation, and underwent laparoscopic combined hepatic artery resection and reconstruction along with LPD. After operation, case 2 developed a grade B pancreatic fistula with abdominal infection, which was improved after 12 d of treatment and was discharged after tube removal. Cases 1 and 3 both recovered well without pancreatic fistula or bile leakage, and follow-up examinations showed good blood supply to the hepatic artery. None of the three cases required unplanned readmission within 30 d. During follow-up, case 2 showed tumor marker elevation and recurrence 13 months after operation, while cases 1 and 3 showed no tumor recurrence at 1 year after operation.Conclusion When middle and lower bile duct cancers are concurrently associated with invasion of the portal vein and hepatic artery, simultaneous hepatic artery/replaced right hepatic artery resection and reconstruction during portal vein resection can be performed to improve the resection rate of bile duct cancer, which is safe, feasible, and effective.