Rea David J, Munoz-Juarez Manuel, Farnell Michael B, Donohue John H, Que Florencia G, Crownhart Brian, Larson Dirk, Nagorney David M
Department of Surgery, Division of Gastroenterologic and General Surgery, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
Arch Surg. 2004 May;139(5):514-23; discussion 523-5. doi: 10.1001/archsurg.139.5.514.
Major hepatectomy, bile duct resection, and regional lymphadenectomy for hilar cholangiocarcinoma are associated with actual long-term (>5 years) survival.
Retrospective outcome study.
Single tertiary referral institution.
Between 1979 and 1997, 46 consecutive patients had resection of hilar cholangiocarcinoma by major hepatectomy, bile duct resection, and regional lymphadenectomy.
Overall survival and tumor recurrence were correlated to clinicopathological factors, operative morbidity, and mortality.
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.
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.
肝门部胆管癌的扩大肝切除术、胆管切除术及区域淋巴结清扫术与实际长期（>5年）生存率相关。
回顾性结局研究。
单一的三级转诊机构。
1979年至1997年间，46例连续患者接受了扩大肝切除术、胆管切除术及区域淋巴结清扫术以切除肝门部胆管癌。
总生存率和肿瘤复发与临床病理因素、手术发病率及死亡率相关。
25例患者接受左肝切除术，17例接受右肝切除术，4例接受扩大右肝切除术。18例患者接受了第1肝段切除术。37例患者（80%）切缘阴性（R0）。手术死亡率为9%，手术发病率为52%。实际1年、3年和5年生存率分别为80%、39%和26%。与患者生存率呈负相关的因素包括：男性、淋巴结转移、肿瘤分级为3级或4级、诊断时血清直接胆红素水平升高、术前活化部分凝血活酶时间延长及围手术期输注红细胞超过4单位。肿瘤大小和R0切除对生存率接近有显著意义。与肿瘤复发相关的因素包括：男性、肿瘤分级为3级或4级、诊断时及术前血红蛋白水平低、术前凝血酶原时间低以及诊断时及术前碱性磷酸酶水平低。复发的中位时间为3.6年。肿瘤复发主要为局部和区域复发。
26%的实际5年生存率证明了肝门部胆管癌行扩大肝部分切除术、胆管切除术及区域淋巴结清扫术的合理性。局部和区域复发的高频率值得对辅助治疗进行研究。
