Nuzzo Gennaro, Giuliante Felice, Ardito Francesco, Giovannini Ivo, Aldrighetti Luca, Belli Giulio, Bresadola Fabrizio, Calise Fulvio, Dalla Valle Raffaele, D'Amico Davide F, Gennari Leandro, Giulini Stefano M, Guglielmi Alfredo, Jovine Elio, Pellicci Riccardo, Pernthaler Heinrich, Pinna Antonio D, Puleo Stefano, Torzilli Guido, Capussotti Lorenzo, Cillo Umberto, Ercolani Giorgio, Ferrucci Massimo, Mastrangelo Laura, Portolani Nazario, Pulitanò Carlo, Ribero Dario, Ruzzenente Andrea, Scuderi Vincenzo, Federico Bruno
Hepatobiliary Surgery Unit, A. Gemelli Hospital, Catholic University of the Sacred Heart, Rome, Italy.
Arch Surg. 2012 Jan;147(1):26-34. doi: 10.1001/archsurg.2011.771.
To evaluate improvements in operative and long-term results following surgery for hilar cholangiocarcinoma.
Retrospective multicenter study including 17 Italian hepatobiliary surgery units.
A total of 440 patients who underwent resection for hilar cholangiocarcinoma from January 1, 1992, through December 31, 2007.
Postoperative mortality, morbidity, overall survival, and disease-free survival.
Postoperative mortality and morbidity after liver resection were 10.1% and 47.6%, respectively. At multivariate logistic regression, extent of resection (right or right extended hepatectomy) and intraoperative blood transfusion were independent predictors of postoperative mortality (P = .03 and P = .006, respectively); in patients with jaundice, mortality was also higher without preoperative biliary drainage than with biliary drainage (14.3% vs 10.7%). During the study period, there was an increasingly aggressive approach, with more frequent caudate lobectomies, vascular resections, and resections for advanced tumors (T stage of 3 or greater and tumors with poor differentiation). Despite the aggressive approach, the blood transfusion rate decreased from 81.0% to 53.2%, and mortality slightly decreased from 13.6% to 10.8%. Median overall survival significantly increased from 16 to 30 months (P = .05). At multivariate analysis, R1 resection, lymph node metastases, and T stage of 3 or greater independently predicted overall and disease-free survival.
Surgery for hilar cholangiocarcinoma has improved with decreased operative risk despite a more aggressive surgical policy. Long-term survival after liver resection has also increased, despite the inclusion of cases with more advanced hilar cholangiocarcinoma. Preoperative biliary drainage was a safe strategy before right or right extended hepatectomy in patients with jaundice. Pathologic factors independently predicted overall and disease-free survival at multivariate analysis.
评估肝门部胆管癌手术后手术效果及长期预后的改善情况。
一项回顾性多中心研究，纳入17个意大利肝胆外科单位。
共有440例患者在1992年1月1日至2007年12月31日期间接受了肝门部胆管癌切除术。
术后死亡率、发病率、总生存率和无病生存率。
肝切除术后的死亡率和发病率分别为10.1%和47.6%。多因素逻辑回归分析显示，切除范围（右半肝或右扩大肝切除术）和术中输血是术后死亡的独立预测因素（P分别为0.03和0.006）；在黄疸患者中，术前未进行胆管引流者的死亡率也高于进行胆管引流者（14.3%对10.7%）。在研究期间，手术方式越来越激进，尾状叶切除术、血管切除术以及晚期肿瘤（T分期为3期或更高且分化差的肿瘤）切除术更为频繁。尽管手术方式激进，但输血率从81.0%降至53.2%，死亡率也从13.6%略有降至10.8%。中位总生存期从16个月显著增加至30个月（P = 0.05）。多因素分析显示，R1切除、淋巴结转移和T分期为3期或更高是总生存和无病生存的独立预测因素。
尽管手术策略更为激进，但肝门部胆管癌手术的手术风险降低，效果有所改善。尽管纳入了更多晚期肝门部胆管癌病例，但肝切除术后的长期生存率也有所提高。对于黄疸患者，术前胆管引流是右半肝或右扩大肝切除术之前的安全策略。多因素分析时，病理因素是总生存和无病生存的独立预测因素。
