Department of Surgery, Center for Hepatobiliary Disease and Abdominal Transplantation, University of California San Diego, San Diego, CA 92013-8401, USA.
J Am Coll Surg. 2011 Apr;212(4):604-13; discussion 613-6. doi: 10.1016/j.jamcollsurg.2010.12.028.
Vascular reconstruction along with major liver resection in the setting of liver dysfunction caused by biliary obstruction can be associated with increased risk. The purpose of this report is to assess the role of portal vein resection and reconstruction in the surgical management of hilar cholangiocarcinoma.
Ninety-five patients with hilar cholangiocarcinoma who underwent resection between 1999 and 2010 were reviewed. Liver resections performed along with biliary resection included 84 trisegmentectomies (63 right, 21 left) and 11 lobectomies (8 left, 3 right). Thirteen patients also had simultaneous pancreaticoduodenectomy performed. Forty-two patients underwent portal vein resection and reconstruction. Five patients required reconstruction of the hepatic artery. Preoperative portal vein embolization was used in 38 patients.
Patients undergoing resection had a 5% mortality rate, with an overall morbidity rate of 36%. Patients who underwent portal vein resection had perioperative mortality and morbidity similar to those who did not have portal vein resection. Median survival was 38 months (95% CI, 29-51 months), with a 5-year survival rate of 43%. There was no difference in long-term survival between those patients who had portal vein resection and those that did not. Negative margins were achieved in 84% of cases and were associated with improved survival (p < 0.01). Five-year survival rate in patients undergoing R0 resection was 50%. Patients with positive lymph nodes appeared to have a worse 5-year survival rate than patients with node-negative status (23% versus 49%); however, only negative margin status was associated with improved survival by multivariate analysis.
Surgical resection of hilar cholangiocarcinoma that requires resection of the portal vein can be performed safely and should not be a contraindication to resection.
在由胆道梗阻引起的肝功能障碍的情况下，进行血管重建以及主要的肝切除术可能会增加风险。本报告的目的是评估门静脉切除和重建在肝门部胆管癌外科治疗中的作用。
回顾了 1999 年至 2010 年间接受切除术的 95 例肝门部胆管癌患者。与胆管切除同时进行的肝切除术包括 84 例三段切除术（63 例右，21 例左）和 11 例叶切除术（8 例左，3 例右）。13 例患者还同时进行了胰十二指肠切除术。42 例患者进行了门静脉切除和重建。5 例患者需要重建肝动脉。38 例患者术前进行了门静脉栓塞。
接受切除术的患者死亡率为 5%，总发病率为 36%。进行门静脉切除的患者与未进行门静脉切除的患者在围手术期死亡率和发病率方面相似。中位生存时间为 38 个月（95%CI，29-51 个月），5 年生存率为 43%。进行门静脉切除和未进行门静脉切除的患者之间的长期生存没有差异。84%的病例获得了阴性切缘，且与生存改善相关（p<0.01）。R0 切除的患者 5 年生存率为 50%。淋巴结阳性的患者 5 年生存率似乎比淋巴结阴性的患者差（23%比 49%）；然而，只有阴性切缘状态与多因素分析中改善的生存相关。
需要切除门静脉的肝门部胆管癌的手术切除可以安全进行，不应成为切除的禁忌症。
