Kondo Satoshi, Takada Tadahiro, Miyazaki Masaru, Miyakawa Shuichi, Tsukada Kazuhiro, Nagino Masato, Furuse Junji, Saito Hiroya, Tsuyuguchi Toshio, Yamamoto Masakazu, Kayahara Masato, Kimura Fumio, Yoshitomi Hideyuki, Nozawa Satoshi, Yoshida Masahiro, Wada Keita, Hirano Satoshi, Amano Hodaka, Miura Fumihiko
Department of Surgical Oncology, Hokkaido University Graduate School of Medicine, Sapporo, Japan.
J Hepatobiliary Pancreat Surg. 2008;15(1):41-54. doi: 10.1007/s00534-007-1279-5. Epub 2008 Feb 16.
The only curative treatment in biliary tract cancer is surgical treatment. Therefore, the suitability of curative resection should be investigated in the first place. In the presence of metastasis to the liver, lung, peritoneum, or distant lymph nodes, curative resection is not suitable. No definite consensus has been reached on local extension factors and curability. Measures of hepatic functional reserve in the jaundiced liver include future liver remnant volume and the indocyanine green (ICG) clearance test. Preoperative portal vein embolization may be considered in patients in whom right hepatectomy or more, or hepatectomy with a resection rate exceeding 50%-60% is planned. Postoperative complications and surgery-related mortality may be reduced with the use of portal vein embolization. Although hepatectomy and/or pancreaticoduodenectomy are preferable for the curative resection of bile duct cancer, extrahepatic bile duct resection alone is also considered in patients for whom it is judged that curative resection would be achieved after a strict diagnosis of its local extension. Also, combined caudate lobe resection is recommended for hilar cholangiocarcinoma. Because the prognosis of patients treated with combined portal vein resection is significantly better than that of unresected patients, combined portal vein resection may be carried out. Prognostic factors after resection for bile duct cancer include positive surgical margins, especially in the ductal stump; lymph node metastasis; perineural invasion; and combined vascular resection due to portal vein and/or hepatic artery invasion. For patients with suspected gallbladder cancer, laparoscopic cholecystectomy is not recommended, and open cholecystectomy should be performed as a rule. When gallbladder cancer invading the subserosal layer or deeper has been detected after simple cholecystectomy, additional resection should be considered. Prognostic factors after resection for gallbladder cancer include the depth of mural invasion; lymph node metastasis; extramural extension, especially into the hepatoduodenal ligament; perineural invasion; and the degree of curability. Pancreaticoduodenectomy is indicated for ampullary carcinoma, and limited operation is also indicated for carcinoma in adenoma. The prognostic factors after resection for ampullary carcinoma include lymph node metastasis, pancreatic invasion, and perineural invasion.
胆管癌唯一的治愈性治疗方法是手术治疗。因此，首先应评估治愈性切除的适用性。存在肝、肺、腹膜或远处淋巴结转移时，不适合进行治愈性切除。关于局部扩展因素与可治愈性，尚未达成明确共识。评估黄疸肝脏肝功能储备的方法包括未来肝残余体积和吲哚菁绿（ICG）清除试验。对于计划进行右半肝及以上切除或切除率超过50%-60%的肝切除术的患者，可考虑术前门静脉栓塞。使用门静脉栓塞可降低术后并发症及手术相关死亡率。虽然肝切除术和/或胰十二指肠切除术更适合胆管癌的治愈性切除，但对于经严格评估局部扩展情况后判断可实现治愈性切除的患者，也可考虑单纯肝外胆管切除术。此外，对于肝门部胆管癌，建议联合尾状叶切除术。由于接受门静脉联合切除的患者预后明显优于未切除患者，因此可进行门静脉联合切除。胆管癌切除术后的预后因素包括手术切缘阳性，尤其是胆管残端；淋巴结转移；神经周围侵犯；以及因门静脉和/或肝动脉侵犯而进行的联合血管切除。对于疑似胆囊癌的患者，不建议行腹腔镜胆囊切除术，通常应行开腹胆囊切除术。单纯胆囊切除术后发现胆囊癌侵犯浆膜下层或更深层时，应考虑追加切除术。胆囊癌切除术后的预后因素包括壁层浸润深度；淋巴结转移；壁外扩展，尤其是侵犯肝十二指肠韧带；神经周围侵犯；以及治愈程度。壶腹癌应行胰十二指肠切除术，腺瘤内癌也可行局限性手术。壶腹癌切除术后的预后因素包括淋巴结转移、胰腺侵犯和神经周围侵犯。
