Kondo Satoshi, Hirano Satoshi, Ambo Yoshiyasu, Tanaka Eiichi, Okushiba Shunichi, Morikawa Toshiaki, Katoh Hiroyuki
Department of Surgical Oncology, Hokkaido University Graduate School of Medicine, Kita-ku, Sapporo, Japan.
Ann Surg. 2004 Jul;240(1):95-101. doi: 10.1097/01.sla.0000129491.43855.6b.
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.
The poor survival rate after resection of hilar cholangiocarcinoma is considered to be mainly the result of in-hospital death and positive ductal margins.
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.
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.
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.
我们的目的是根据新制定的安全根治性切除指南，对肝门部胆管癌的手术治疗进行前瞻性研究。
肝门部胆管癌切除术后生存率低被认为主要是院内死亡和胆管切缘阳性的结果。
1999年7月至2002年12月期间，42例接受手术探查的肝门部胆管癌患者中有40例行切除术。他们接受了术前胆道减压、门静脉栓塞、胆管造影评估，并选择了手术方式和技术。
医院或30天死亡率和发病率分别为0%和48%。未发生肝衰竭。组织病理学检查显示，40例患者胆管切缘均为阴性，但2例患者右肝动脉切缘阳性。3年总生存率和中位生存时间分别为40%和27个月。Bismuth III型或IV型肿瘤患者或接受右肝切除术患者的生存率明显更高。接受同期血管切除患者的生存率与未接受血管切除患者相似。单因素分析表明，肝切除类型、组织病理学分级、Bismuth分类、同期肝动脉切除以及国际抗癌联盟分期是重要的预后因素。
在一个大型专家中心，按照上述指南未出现术后死亡病例，胆管切缘也均为阴性。然而，长期结果并未得到显著改善。对短期内得出的条件均一的患者系列进行生存分析表明，需要采取额外的策略，包括对Bismuth I型或II型肿瘤行右肝切除术。
