Prognostic factors and long term outcome after surgery for hilar cholangiocarcinoma. Univariate and multivariate analysis

Aim of the study was to evaluate the surgical strategy for the treatment of the hilar cholangiocarcinoma, focusing on the clinicopathological factors influencing the outcome. Between January 2001 and December 2003 23 patients out of 33 underwent surgery for hilar cholangiocarcinoma. All patients underwent resection of the extrahepatic biliary duct. This was the only treatment in patients with Bismuth-Corlette type I cholangiocarcinoma, or in patients not suitable for hepatic resection. In the other cases, resection of extrahepatic bile duct was associated to right or left hepatectomy. The univariate and multivariate analysis evaluated multiple clinicopathological factors in order to assess long term survival. Major hepatic resection was carried out in 19 (82%) patients. Hepatic resection extended to the segment 4 was performed in 5 patients. Also, left hepatectomy was carried out in 14 patients, while resection of the caudate lobe in 7 (30%) patients. No hospital mortality was recorded, while the overall morbidity was 43%. The 1 year survival rate was 63.2%, and the median survival rate 19 months. Recurrencies showed up in 12 patients (52%). Among the other factors, low level of albumin (p = 0.006), positive resection margins (p = 0.003) and T (p = 0.02) mostly affected the long term survival. Surgery is the gold standard for achieving curative treatment of hilar cholangiocarcinoma. The bile duct resection, along with hepatic resection, the best option to increase long term survival of these patients. The univariate and multivariate analysis showed that low albumin levels, positive resection margins and T are the most important factors influencing long term survival.     

Forty consecutive resections of hilar cholangiocarcinoma with no postoperative mortality and no positive ductal margins: results of a prospective study

OBJECTIVE: Our objective was to perform a prospective study of surgical treatment of hilar cholangiocarcinoma according to newly established guidelines for performing safe and curative resections. SUMMARY BACKGROUND DATA: The poor survival rate after resection of hilar cholangiocarcinoma is considered to be mainly the result of in-hospital death and positive ductal margins. METHODS: Between July 1999 and December 2002, 40 of 42 surgically explored patients with hilar cholangiocarcinoma underwent resection. They were managed with preoperative biliary decompression, portal embolization, cholangiographic evaluation, and a choice of surgical procedures and techniques. RESULTS: Hospital or 30-day mortality and morbidity rates were 0% and 48%, respectively. Hepatic failure was not encountered. Histopathologic examination revealed no positive ductal margins in all 40 patients, but 2 showed positive separation margins from the right hepatic artery. The overall 3-year survival rate and median survival time were 40% and 27 months. Survival of patients with Bismuth type III or IV tumors or of patients who underwent right hepatectomy was significantly better. Survival of patients who underwent concomitant vascular resection was similar to survival of those who did not. Univariate analysis indicated the type of hepatectomy, histopathologic grade, Bismuth classification, concomitant hepatic artery resection, and International Union Against Cancer stage as significant prognostic factors. CONCLUSIONS: No postoperative mortality and no positive ductal margins were achieved according to the above guidelines in a high-volume expert center. Long-term results, however, have not been significantly improved. A survival analysis of the patient series with homogeneous conditions derived from a short study period suggests the need for additional strategies including right hepatectomy for Bismuth type I or II tumors.     

肝部分切除联合肝十二指肠韧带骨骼化治疗肝门部胆管癌

目的 总结应用肝部分切除联合肝十二指肠骨骼化治疗肝门部胆管癌的临床经验。方法回顾1999年1月～2001年12月手术治疗67例肝门胆管癌的临床资料。结果67例患者中65例手术切除,49例根治性切除(22例肝十二指肠韧带骨骼化切除,27例联合部分肝切除)。根据Bismuth分型,Ⅰ、Ⅱ型行骨骼化切除,Ⅲa型行右半肝加右尾叶切除,Ⅲb型行左半肝加左尾叶切除,Ⅳ型中行右半肝加全尾叶3例切除,左半肝加全尾叶9例切除,方叶切除者2例。2例外院曾行部分肿瘤切除加肝门胆管空肠吻合术者,我们再次行左半肝加全尾叶切除加右肝管空肠吻合术根治肿瘤。8例患者行肿瘤部分切除加肝内胆管支撑加肝门胆管空肠吻合。13例患者行门静脉部分切除,27例患者切除肝动脉。24例患者术后无并发症发生,加例发生了严重并发症。后者中14例经治疗后康复,余6例患者术后7、12、14、42、57、89d死于肝功能衰竭、心源性休克、腹内大出血、消化道大出血。术后30d病死率4、5％,根治性手术后患者中位生存期16个月(1个月～41个月),姑息治疗者为7个月(1个月～16个月)。结论 肝部分切除联合肝十二指肠韧带骨骼化可用以根治肝门部胆管癌,尾叶切除可提高根治性切除率。     

III|IV 型肝门部胆管癌的手术治疗

目的:探讨Ⅲ,Ⅳ型肝门部胆管癌的手术治疗方式和效果.方法:回顾性分析2010年4月-2013年2月期间采取手术治疗的16例Ⅲ,Ⅳ型肝门部胆管癌患者的临床资料.结果:16例中行手术切除13例,切除率为81.3％ (13/16).其中行根治性切除术(R0切除)7例,非根治性切除术6例;行左半肝+尾叶切除+右肝管成形、肝管-空肠Roux-en-Y吻合术3例,行右半肝切除+尾叶切除+左肝管成形、肝管-空肠Roux-en-Y吻合术3例,行肝方叶切除及围肝门切除+胆管开口肝门区-空肠盆式吻合术7例;其中2例因总胆红素＞400 μmm.l/L而先行经皮肝穿刺胆管引流(PTCD)后再手术.3例患者无法完成手术切除,其中2例肿瘤侵犯门静脉左右支,1例术中发现肝脏多发转移瘤,3例均行肝内扩张胆管的术中置管引流术.所有患者的术后血清总胆红素水平均明显降低或恢复至正常,术后引流有效率为100％.1例围手术期死亡.结论:对于Ⅲ,Ⅳ型肝门部胆管癌,应力争切除肿瘤,解除胆管梗阻.对肝门区胆管解剖的熟知、娴熟的手术技巧和胆大心细的操作,有望提高手术切除率.     

Major hepatic resection for hilar cholangiocarcinoma: analysis of 46 patients

HYPOTHESIS: Major hepatectomy, bile duct resection, and regional lymphadenectomy for hilar cholangiocarcinoma are associated with actual long-term (>5 years) survival. DESIGN: Retrospective outcome study. SETTING: Single tertiary referral institution. PATIENTS: Between 1979 and 1997, 46 consecutive patients had resection of hilar cholangiocarcinoma by major hepatectomy, bile duct resection, and regional lymphadenectomy. MAIN OUTCOME MEASURES: Overall survival and tumor recurrence were correlated to clinicopathological factors, operative morbidity, and mortality. RESULTS: Twenty-five patients underwent left hepatectomy, 17 underwent right hepatectomy, and 4 had extended right hepatectomy. Eighteen patients underwent resection of segment 1. Negative (R0) resection margins were achieved in 37 patients (80%). The operative mortality rate was 9%, and the surgical morbidity rate was 52%. Actual 1-year, 3-year, and 5-year survival rates were 80%, 39%, and 26%, respectively. Factors adversely associated with patient survival rates included: male sex, lymph node metastases, tumor grade 3 or 4, elevated direct serum bilirubin level at diagnosis, elevated preoperative activated partial thromboplastin time, and more than 4 U of red blood cells transfused perioperatively. Tumor size and R0 resection approached significance for survival. Factors associated with tumor recurrence included: male sex, tumor grade 3 or 4, a low hemoglobin level both at diagnosis and preoperatively, and a low preoperative prothrombin time and low alkaline phosphatase level at diagnosis and preoperatively. Median time to recurrence was 3.6 years. Tumor recurrence was predominantly local and regional. CONCLUSIONS: The actual 5-year survival rate of 26% justifies major partial hepatectomy, bile duct resection, and regional lymphadenectomy for hilar cholangiocarcinoma. The high frequency of local and regional recurrence warrants investigation of adjuvant therapy.     

A left hepatectomy and caudate lobectomy combined resection of the ventral segment of the right anterior sector for hilar cholangiocarcinoma — the efficacy of PVE (portal vein embolization) in identifying the hepatic subsegment: Report of a case

This report presents a case of a left hepatectomy and a caudate lobectomy combined resection of the ventral segment of the right anterior sector for hilar cholangiocarcinoma using percutaneous transhepatic portal vein embolization (PVE). The patient was a 44-year-old man admitted to a local hospital with obstructive jaundice. He was diagnosed to have hilar cholangiocarcinoma and was referred to the hospital for further treatment. Cholangiography revealed stenosis of the left hepatic duct and the hilar bile ducts. The dorsal branch of the right anterior sector joined the right posterior branch and the tumor did not invade to the confluence of these branches. Arteriography and portography reconstructed by multidetector-raw computed tomography revealed the ventral branches of the right anterior sector, which separately diverged from the other right anterior branches. It was therefore necessary to perform a left hepatectomy and caudate lobectomy combined resection of the ventral segment of the right anterior sector to completely remove the tumor. Portal vein embolization was thus performed on the left portal vein and the ventral branches of the right anterior sector. Intraoperatively, when the hepatic artery was temporally clamped, the demarcation between the ventral segment and the dorsal segment of the right anterior sector could be clearly visualized. The planned surgery was performed safely. This case demonstrates that the utilization of PVE is useful for a difficult and intricate hepatectomy, which requires an accurate identification of a hepatic subsegment.     

Surgical treatment of hilar bile duct carcinoma: Experience with 25 consecutive hepatectomies

To evaluate our recent surgical policy regarding hilar bile duct carcinoma, we evaluated 62 cases treated between 1976 and 1993, and 25 cases treated between 1994 and 2000. In the late period we used percutaneous transhepatic portal vein embolization (PTPE) before extended right hepatectomy; S4a + S5 + S1 hepatectomy for elderly patients and those with poor liver function; and routine total caudate lobectomy including the paracaval portion and resection of the inferior portion of the medial segment (S4a). Sixtyfive (74.7%) of the 87 patients underwent hepatectomy: 40 in the early period and 25 in the late period. Bile duct resection alone was performed in 22 patients, all in the early period. Resection was curative in 54.8% in the early period and 88.0% in the late period. The 3- and 5-year survival rates in the early period were 27.1% and 20.2%, respectively, as compared to 59.9% and 49.9% in the late period. Analysis of the 25 hepatectomies in the late period revealed improved survival times compared to patients treated by PTPE with extended right hepatectomy. No complications occurred after extended left hepatectomy or S4a + S5 + S1 hepatectomy, but four patients (16%) who underwent extended right hepatectomy plus PTPE died postoperatively. Our policy has resulted in improved outcome in patients with hilar bile duct carcinoma.     

肝门部胆管癌手术治疗：附44例报告

背景与目的：对于肝门部胆管癌（HCCA）而言,R0切除率仍然很低。目前对术前评估、术前胆道引流、门静脉栓塞、手术切除范围、手术方式、血管切除、淋巴结清扫、化疗等问题仍有很多争议。R0切除被认为是HCCA患者获取长期生存的最重要的治疗手段。笔者总结HCCA的治疗体会,并分析不同术式的有效性及近远期疗效。 方法：回顾性分析2015年1月—2020年1月行手术治疗的44例HCCA患者的临床资料。 结果：44例患者中,Bismuth-Corlette分型I型5例,II型7例,IIIa型8例,IIIb型13例,IV型11例;29例行半肝/扩大半肝+全尾叶切除（联合半肝切除）,13例行肝门部/围肝门区+全尾叶切除（围肝门切除）,术中包括门静脉部分切除修补2例,门静脉切除重建2例,肝动脉切除重建2例,另2例因肿瘤转移无法切除行T管引流。全组均完成手术,无手术死亡。术后病理结果显示,镜下切缘阴性（R0）切除37例（联合半肝切除组26例,围肝门切除组11例）,镜下切缘阳性（R1）切除5例（半肝切除2例、围肝门切除3例）。临床指标分析结果显示,联合半肝切除组的手术时间（240.4 min vs. 358.1 min）、术中出血量（705.5 mL vs. 809.9 mL）明显少于围肝门切除组,肿瘤标本切缘阳性率（6.9% vs. 23.1%）明显低于围肝门切除组（均P<0.05）;生存分析结果显示,联合半肝切除组术后与无复发生存期及1年累积生存率明显优于围肝门切除组（均P<0.05）。 结论：根治性R0切除是HCCA患者可能获得治愈的唯一方法,与围肝门切除术比较,联合半肝、尾状叶切除的大范围肝切除术,能提高R0切除率,改善无复发生存期及1年生存率。术前精确评估、合理的围手术期治疗、选择个体化的手术方案可提高HCCA的疗效。     

Aggressive surgical resection for hilar cholangiocarcinoma: is it justified? Audit of a single center's experience

BACKGROUND: The current study presents our experience with resectional surgery for patients with hilar cholangiocarcinoma (HC). METHODS: Medical records of 73 HC patients who were referred to our department between 1988 and 2006 were reviewed. Resectability rate, surgical mortality, and factors contributing to survival were investigated. RESULTS: Resectional surgery was performed in 59 patients (80.8%), 51 of whom (86.4%) underwent major hepatic resection. Negative margins were obtained in 35 of 51 patients (68.6%) and were associated with right-sided hepatectomy (80% vs 20%, P = .049). In-hospital mortality and morbidity were 6.8% and 25.4%, respectively. One-, 3- and 5-year survival rates after liver resection were 86%, 48.9%, and 34.9%, respectively. Histologic differentiation, left-sided hepatectomy, and inferior vena cava resection independently predicted survival. Patients undergoing R1 hepatectomy had significantly improved 5-year survival rates compared with patients who were unresectable (P <.01). CONCLUSIONS: Major hepatic resections with concomitant vascular resection and reconstruction, when needed, are justified for patients with Bismuth type III and IV hilar cholangiocarcinoma with negative nodes. Reluctance to incorporate segments V and/or VIII into a left lobectomy often results in tumor-positive margins and unfavorable prognosis. Resections for hilar lesions less than stage IVB, even when resulting in microscopically positive margins, confer prolonged survival compared with untreated patients. The results are further improved for patients with well-differentiated HC.     

Liver resection for bile duct cancer

Hilar cholangiocarcinoma is now diagnosed more frequently, and modern diagnostic methods allow a much more precise definition of the extent of disease, which assists in planning the therapeutic approach. Resection of tumors at the confluence of the bile ducts is possible in 20 per cent of patients. When the tumor extends along the hepatic ducts into the right or the left side of the liver, excision may be combined with partial hepatectomy. Involvement of the portal vein and hepatic artery do not necessarily preclude resection. The operative mortality rate of partial hepatectomy for hilar cholangiocarcinoma is about 10 per cent, and median survival after operation is approximately 22 months, with a few long-term cures reported. The quality of survival after the excision of tumor and biliary-enteric reconstruction is very good and indeed appears to be better than that after palliation by biliary decompression alone.     

肝叶切除术在肝门胆管癌手术中应用的价值

目的探讨联合肝叶部分切除在肝门部胆管癌根治术中的应用价值.方法对42例行手术治疗的肝门部胆管癌患者的临床资料进行回顾性分析.结果42例患者中有34例行肿瘤切除术,其中局部切除15例,右半肝切除8例,左半肝切除3例,左半肝切除联合尾叶切除4例,左肝外叶切除联合尾叶切除1例,方叶切除3例,总体手术切除率为81%.其中25例根治性切除,包括8例局部切除,及17例联合肝叶部分切除,根治性切除率为60%.根治性切除组的中位生存期28个月,姑息性手术组的中位生存期14个月,根治性切除术的1年生存率为90%,2年生存率73%,4年生存率28%,姑息性手术1年生存率为57%,2年生存率27%.结论根治性切除的生存率比姑息性手术显著提高,联合肝叶部分切除能明显提高根治性手术的切除率.     

肝胰十二指肠切除术治疗肝门部胆管癌:附11例

目的 总结肝胰十二指肠切除术(HPD)治疗肝门部胆管癌的经验.方法 回顾性分析2000年6月至2008年1月11例HPD治疗肝门部胆管癌的临床资料.结果 全组11例肝门部胆管癌按Bismush-corline分型,Ⅲ型8例,Ⅳ型3例.肝方叶切除+胰十二指肠切除术2例,肝尾叶切除+胰十二指肠切除术5例.右半肝+尾状叶+门静脉部分切除重建+胰十二指肠切除术1例,左半肝+胰十二指肠切除术3例,无死亡.胆漏3例,胰漏1例,肺部感染2例,肝功能衰竭1例,随访8例,最长者63个月.结论 对肝门部胆管癌累及胰十二指肠区域者,HPD可提高其生存质量,是安全可行的.     

Hilar cholangiocarcinoma involving the portal vein bifurcation: long-term results after resection

Abstract. Background/Purpose: Resection offers the only potential cure of hilar cholangiocarcinoma. Portal bifurcation involvement is often thought to contraindicate resection. We reviewed our experience with aggressive surgical management in 28 patients with hilar cholangiocarcinoma. Methods: All patients underwent hepatectomy and bile duct resection with hepaticojejunostomy. In 10 cases (group 1) the portal bifurcation was involved, necessitating portal resection and reconstruction; 18 (group 2) had no portal involvement. Frozen section of duct margins was routine. Survival was estimated using the Kaplan-Meier method and compared with the log-rank test. Results: Portal reconstruction in group 1 was by graft interposition (1), venoplasty using the posterior wall of the right portal vein (2), or end-end anastomosis (7). Hepatectomies included right trisegmentectomy (8), right lobectomy (4), and left lobectomy (16); 20 (71%) had concomitant caudate resection. Median survival was 18 months in group 1 and 32 months in group 2 (P, not significant [NS]). One-, 3-, and 5-year survivals were 60%, 22%, and 22%, respectively, in group 1 and 70%, 47%, and 38%, respectively, in group 2 (P = 0.319). Conclusions: Portal involvement by hilar cholangiocarcinoma does not contraindicate resection. Received: June 11, 2001 / Accepted: February 8, 2002     

联合肝叶和肝门血管切除治疗肝门胆管癌

目的　探讨治疗肝门胆管癌理想的肝叶切除术式 ,以期提高其疗效、降低并发症和病死率。方法　对 16例侵犯肝门血管的肝门胆管癌 ,采用肝I ,IV段连同肝门胆管肿瘤与受侵血管整块切除及肝十二指肠韧带骨骼化淋巴清扫。结果　 15例获手术切除 ,切除率为 93 .8% ,12例获R0 切除。无手术死亡和住院死亡。发生暂时性胆漏 1例 ,腹腔感染 1例 ,并发症发生率为 13 .3 % ,均行非手术治愈。随访病例中位生存期为 2 2个月 ,7例尚存活。结论　合并肝叶、肝门血管切除可提高肝门胆管癌的切除率和生存率 ;肝中叶和肝尾叶是肝门胆管癌手术联合切除的主要部位。肝门受侵血管的切除对提高该病切除率和根治率是有意义的 ,应酌情重建或不重建肝门血管。     

Surgical approach to bismuth Type I and II hilar cholangiocarcinomas: audit of 54 consecutive cases

OBJECTIVE: To clarify the optimal surgical strategy for Bismuth type I and II hilar cholangiocarcinomas. SUMMARY BACKGROUND DATA: Local or hilar resections is often performed for Bismuth type I and II tumors; however, reported outcomes have been unsatisfactory with a high recurrence and low survival rate. To improve survival, some authors have recommended right hepatectomy. However, the clinical value of this approach has not been validated. METHODS: Records of 54 consecutive patients who underwent resection of a Bismuth type I or II hilar cholangiocarcinoma were analyzed retrospectively. Through 1996, bile duct resection or the smallest necessary hepatic segmentectomy was performed. Beginning in 1997, choice of resection was based on the cholangiographic tumor type. For nodular or infiltrating tumor, right hepatectomy was indicated; for papillary tumor, bile duct resection with or without limited hepatectomy was chosen. RESULTS: Right hepatectomy was performed in 5 (20.8%) of 24 patients through 1996 and was done in 22 (73.3%) of 30 patients from 1997 (P = 0.0003). In patients without pM1 disease, R0 resection was achieved more frequently in the later period than in the earlier period (23 of 24 = 95.8% vs. 13 of 21 = 61.9%, P = 0.0073), which lead to better survival (5-year survival, 44.3% vs. 25.0%, P = 0.0495). In the 31 patients with nodular or infiltrating tumor, who tolerated surgery and did not have pM1 disease, survival was better in the 18 patients who underwent right hepatectomy than in those who did not (5-year survival, 62.9% vs. 23.1%, P = 0.0030). In cases of papillary tumor, bile duct resection with or without limited hepatectomy was sufficient to improve long-term survival. CONCLUSIONS: The surgical approach to Bismuth type I and II hilar cholangiocarcinomas should be determined according to cholangiographic tumor type. For nodular and infiltrating tumors, right hepatectomy is essential; for papillary tumor, bile duct resection with or without limited hepatectomy is adequate.     

Left hepatectomy accompanied by a resection of the whole caudate lobe using the dorsally fixed liver-hanging maneuver

A resection of the caudate lobe often needs to be combined with a hemi-hepatectomy for hilar cholangiocarcinoma or a liver tumor in segment 1. To achieve complete resection of the whole caudate lobe, the cut line between the right edge of the paracaval portion and the right lateral sector should be precisely controlled. The liver-hanging maneuver (LHM) is a useful anterior approach that does not require mobilization of the remnant liver. However, the precise set-up of the cut line of the right edge has not been optimized in previous reports. We herein introduce a new modification of LHM that we named the “dorsally fixed liver-hanging maneuver” (DF-LHM) based on the results in five patients who underwent left hepatectomy combined with a total resection of segment 1. This technique provided adequate cut planes along the right edge of the caudate lobe, shortening the transection time and reducing intraoperative blood loss. The DF-LHM may represent a new key technique for this type of hepatectomy, and further applications for other anatomical resections can be modeled on the strategy.     

Recurrence at surgical margin following hepatectomy for colorectal liver metastases is not associated with R1 resection and does not impact survival

BackgroundResection margin status has traditionally been associated with tumor recurrence and oncological outcome following liver resection for colorectal liver metastases. Previous studies, however, did not address the impact of resection margin on the site of tumor recurrence and did not differentiate between true local recurrence at the resection margin and recurrence elsewhere in the liver. This study aimed to determine whether positive resection margins determine local recurrence and whether recurrence at the surgical margin influences long-term survival.MethodsClinicopathological data and oncological outcomes of patients who underwent curative resection for colorectal liver metastases between 2012 and 2017 at 2 major hepatobiliary centers (Bern, Switzerland, and Berlin, Germany) were assessed. Cross-sectional imaging following hepatectomy was reviewed by radiologists in both centers to distinguish between recurrence at the resection margin, defined as hepatic local recurrence, and intrahepatic recurrence elsewhere. The association between surgical margin status and location of tumor recurrence was evaluated, and the impact on overall survival was determined.ResultsDuring the study period, 345 consecutive patients underwent hepatectomy for colorectal liver metastases. Histologic surgical margins were positive for tumor cells (R1) in 63 patients (18%). After a median follow-up time of 34 months, tumor recurrence was identified in 154 patients (45%). Hepatic local recurrence was not detected more frequently after R1 than after R0 resection (P = .555). Hepatic local recurrence was not associated with worse overall survival (P = .436), while R1 status significantly impaired overall survival (P = .025). Additionally, overall survival was equivalent between patients with hepatic local recurrence and patients with any intrahepatic and/or extrahepatic recurrence. In patients with intrahepatic recurrence only, oncological outcomes improved if local hepatic therapy was possible (resection or ablation) in comparison to patients treated only with chemotherapy or best supportive care (3-year overall survival: 85% vs 39%; P < .0001).ConclusionThe incidence of hepatic local recurrence after hepatectomy for colorectal liver metastases is independent of R1 resection margin status. Additionally, hepatic local recurrence at the resection margin is not associated with worse overall survival compared with any other intra- or extrahepatic recurrence. Therefore, R1 status at hepatectomy seems to be a surrogate factor for advanced disease without influencing location of recurrence and thereby oncological outcome. This finding may support decision-making when extending the indication for surgery in borderline resectable colorectal liver metastases.     

肝门部胆管癌的手术治疗及预后的多因素分析:附41例

目的 探讨肝门部胆管癌的手术治疗及生存预后的影响因素.方法 回顾性分析中南大学湘雅二医院1999年1月至2007年2月手术治疗的41例肝门部胆管癌的临床特点,手术方式,及随访结果.COX比例风险模型进行预后的多因素分析.结果 41例手术治疗中,切除手术21例,其中R0根治性切除11例,R1切除6例.R2切除4例,手术切除率51.2%(21/41),根治性切除率52.4%(11/21).该组病例总体1、3、5年生存率分别为41.5%,14.6%,4.9%.切除术组1、3、5年生存率分别为71.3%,28.6%,9.5%.R0,R1,R2切除术后1、3、5年生存率分别为81.8%,45.5%,18.2%;66.7%,16.7%,0;50%,0,0.结论 手术切除仍然是治疗HCC惟一有可能获得治愈和长期生存的有效手段.切缘无瘤.联合肝叶切除及肿瘤分期是影响预后的重要因素.     

Long-term survival and prognostic factors in the surgical treatment for intrahepatic cholangiocarcinoma

Background/Purpose. We retrospectively investigated the clinicopathologic features and outcome of 51 patients who underwent hepatectomy for intrahepatic cholangiocellular carcinoma (ICC) between 1991 and 2000, and we also analyzed the potential prognostic factors for long-term survival. Methods. There were 27 men and 24 women, with a mean age of 63.7 years. The surgical procedures were extended right or left hepatectomy (15 cases), right or left hepatectomy (19 cases), bisegmentectomy (3 cases), segmentectomy (7 cases), and subsegmentectomy (7 cases). The macroscopic findings of the excised tumor showed the mass-forming (MF) type (31 cases), the periductal-infiltrating (PI) type (13 cases), and the intraductal growth (IG) type (7 cases). Results. The patients with the MF type had a significantly higher incidence of lymph node metastasis (44.8%), as compared to those with the PI or IG type (15.0%). Two patients who died of hepatic failure during their hospital stay were excluded from this survival study. The cumulative 1-, 3-, and 5-year survival rates in 49 patients who underwent liver resection were 68.2%, 44.1%, and 32.4%, respectively. The patients with the IG type had the best outcome, followed by those with the PI type and MF type. The survival rates with or without lymph node metastasis were 9.0% and 60.6% at 3 years, and 9.0% and 42.9% at 5 years, respectively (P 0.05). The 1-, 2-, and 3-year survival rates in the MF-type patients with lymph node metastasis were 25.4%, 16.9%, and 0%, respectively. Eight patients (15.7%) survived for more than 5 years after operation. The gross appearance of these tumors was the PI type in 5 patients, the IG type in 2, and the IG + MF type in 1. Except for one case with the PI-type tumor, lymph node metastasis was not observed. All of the 5-year survivors underwent curative resection and none of them had any positive surgical margin. Conclusion. Analysis of the clinicopathologic factors influencing the survival after surgical treatment showed that the macroscopic type, surgical curability, lymph node metastasis, tumor size, and cancer-free margin were the most predictive.     

腹腔镜肝切除术11例临床报告

目的:探讨腹腔镜肝切除术的适应证和可行性。方法:回顾分析10例病灶位于肝脏边缘及左肝外叶(Ⅱ～Ⅵ段)及1例位于Ⅷ段的肝占位患者的临床资料。其中原发性肝细胞癌8例,肝海绵状血管瘤2例,胆管细胞癌1例,肝功能Child-Pugh评分A级9例,B级2例;AFP(+)7例;位于左肝外叶实质中的肿瘤,行规则性左肝外叶切除;位于肝脏边缘或右肝表面的肿瘤,行肝脏局部切除。结果:11例均成功完成腹腔镜肝切除术,无中转开腹。其中局部切除术7例,左肝外叶切除术4例,腹腔镜脾切除+胆囊切除术2例。平均手术时间105min,术中平均出血220ml,切除病灶最大直径10cm。全部肿瘤均完整切除,肿瘤包膜完整,无破裂。术后未发生胆漏和出血等并发症,恢复良好,术后平均住院8.5d。结论:位于肝脏边缘、右肝表面或左半肝(Ⅱ～Ⅵ段)的肝脏占位,行腹腔镜肝切除术是安全可行的。