Akamatsu Nobuhisa, Sugawara Yasuhiko, Hashimoto Daijo
Nobuhisa Akamatsu, Daijo Hashimoto, Department of Hepato-Biliary-Pancreatic Surgery, Saitama Medical Center, Saitama Medical University, 1981 Tsujido-cho, Kamoda, Kawagoe, Saitama 350-8550, Japan.
World J Clin Oncol. 2011 Feb 10;2(2):94-107. doi: 10.5306/wjco.v2.i2.94.
The aim of this review is to describe recent advances and topics in the surgical management of bile duct cancer. Radical resection with a microscopically negative margin (R0) is the only way to cure cholangiocarcinoma and is associated with marked survival advantages compared to margin-positive resections. Complete resection of the tumor is the surgeon's ultimate aim, and several advances in the surgical treatment for bile duct cancer have been made within the last two decades. Multidetector row computed tomography has emerged as an indispensable diagnostic modality for the precise preoperative evaluation of bile duct cancer, in terms of both longitudinal and vertical tumor invasion. Many meticulous operative procedures have been established, especially extended hepatectomy for hilar cholangiocarcinoma, to achieve a negative resection margin, which is the only prognostic factor under the control of the surgeon. A complete caudate lobectomy and resection of the inferior part of Couinaud's segment IV coupled with right or left hemihepatectomy has become the standard surgical procedure for hilar cholangiocarcinoma, and pylorus-preserving pancreaticoduodenectomy is the first choice for distal bile duct cancer. Limited resection for middle bile duct cancer is indicated for only strictly selected cases. Preoperative treatments including biliary drainage and portal vein embolization are also indicated for only selected patients, especially jaundiced patients anticipating major hepatectomy. Liver transplantation seems ideal for complete resection of bile duct cancer, but the high recurrence rate and decreased patient survival after liver transplant preclude it from being considered standard treatment. Adjuvant chemotherapy and radiotherapy have a potentially crucial role in prolonging survival and controlling local recurrence, but no definite regimen has been established to date. Further evidence is needed to fully define the role of liver transplantation and adjuvant chemo-radiotherapy.
本综述的目的是描述胆管癌外科治疗的最新进展和相关主题。切缘显微镜下阴性（R0）的根治性切除是治愈胆管癌的唯一方法，与切缘阳性的切除相比，具有显著的生存优势。肿瘤的完整切除是外科医生的最终目标，在过去二十年中，胆管癌的外科治疗取得了多项进展。多排螺旋计算机断层扫描已成为术前精确评估胆管癌不可或缺的诊断方式，可用于评估肿瘤的纵向和垂直侵犯情况。为实现阴性切缘，已确立了许多精细的手术操作，尤其是针对肝门部胆管癌的扩大肝切除术，阴性切缘是外科医生能够控制的唯一预后因素。完整的尾状叶切除术以及联合右半肝或左半肝切除术切除Couinaud肝段IV的下部，已成为肝门部胆管癌的标准手术方式，保留幽门的胰十二指肠切除术是远端胆管癌的首选。仅在严格筛选的病例中才考虑对中段胆管癌进行有限切除。术前治疗，包括胆道引流和门静脉栓塞，也仅适用于部分患者，尤其是预期进行扩大肝切除术的黄疸患者。肝移植似乎是胆管癌完整切除的理想方法，但肝移植后的高复发率和患者生存率降低使其无法成为标准治疗方法。辅助化疗和放疗在延长生存期和控制局部复发方面可能具有关键作用，但迄今为止尚未确立明确的治疗方案。需要进一步的证据来全面明确肝移植和辅助放化疗的作用。
