Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
Ann Surg. 2012 Apr;255(4):754-62. doi: 10.1097/SLA.0b013e31824a8d82.
To review our experiences with left-sided hepatectomy for perihilar cholangiocarcinoma, to compare left hepatectomy with left trisectionectomy, and to evaluate the clinical significance of left trisectionectomy from the viewpoint of surgical oncology.
Only 4 large case series have been reported on left trisectionectomy, with only a few patients diagnosed with perihilar cholangiocarcinoma. Therefore, the oncologic advantage of left trisectionectomy compared with left hepatectomy for perihilar cholangiocarcinoma is still unclear.
This study involved 201 patients who underwent left-sided hepatectomy for perihilar cholangiocarcinoma (86 trisectionectomies and 115 hepatectomies). Surgical outcome and survival were compared between the 2 types of hepatectomy. The length of the resected right posterior bile duct was also measured.
Patients who underwent trisectionectomy had more advanced tumors, thus requiring combined vascular and/or other organ resection. Operative time and blood loss were significantly greater in trisectionectomy than in hepatectomy; therefore, overall morbidity was significantly higher in the former (59.3% vs 33.0%, P < 0.001). Mortality was similar (1.2% vs 0.9%) in both techniques. The length of the resected supraportal right posterior bile duct was significantly longer in trisectionectomy than in hepatectomy (20.7 ± 6.4 vs 13.6 ± 5.2 mm, P < 0.001). However, there was no difference in length of the infraportal type right posterior bile duct. The percentage of negative radial and distal common bile duct margins was similar, but the percentage of negative right posterior bile duct margins was significantly higher in trisectionectomy than in hepatectomy (97.7% vs 89.6%, P = 0.027). Overall, R0 resection was achieved in 84.9% of patients with trisectionectomy and in 70.4% of patients with hepatectomy (P = 0.019). Survival rates were similar between patients with trisectionectomy and those with hepatectomy (36.8% vs 34.0% at 5-year), despite the fact that the former had more advanced disease.
Left trisectionectomy for perihilar cholangiocarcinoma, although technically demanding, can be performed with similar mortality rates as left hepatectomy. From an oncologic viewpoint, this operation can increase the number of negative proximal ductal margins, leading to a high proportion of R0 resection, and, in turn, to improved survival rates of patients with advanced left-sided perihilar cholangiocarcinoma.
回顾我们在肝门部胆管癌行左半肝切除的经验，比较左半肝切除与左三叶切除，从外科肿瘤学的角度评价左三叶切除的临床意义。
仅有 4 项大型病例系列报告了左三叶切除，且仅有少数患者被诊断为肝门部胆管癌。因此，肝门部胆管癌行左三叶切除与左半肝切除相比，其在肿瘤学方面的优势仍不清楚。
本研究纳入了 201 例行左半肝切除治疗肝门部胆管癌的患者（86 例行左三叶切除，115 例行左半肝切除）。比较了两种肝切除术的手术结果和生存情况。还测量了切除的右后肝管的长度。
行三叶切除术的患者肿瘤进展更严重，因此需要联合血管和（或）其他器官切除。三叶切除术的手术时间和出血量明显多于左半肝切除术；因此，前者的总并发症发生率显著更高（59.3%比 33.0%，P<0.001）。两种技术的死亡率相似（1.2%比 0.9%）。三叶切除术切除的门静脉上方右后肝管长度明显长于左半肝切除术（20.7±6.4比 13.6±5.2mm，P<0.001）。然而，门静脉下方类型的右后肝管长度无差异。切缘阴性的肝内胆管和胆总管的比例相似，但右后肝管切缘阴性的比例在三叶切除术中明显高于左半肝切除术（97.7%比 89.6%，P=0.027）。整体上，三叶切除术组的 R0 切除率为 84.9%，左半肝切除术组为 70.4%（P=0.019）。尽管三叶切除术组的疾病更严重，但两组患者的生存率相似（5 年时为 36.8%比 34.0%）。
虽然肝门部胆管癌行左三叶切除技术要求较高，但死亡率与左半肝切除术相似。从肿瘤学的角度来看，这种手术可以增加近端胆管切缘阴性的数量，从而提高 R0 切除率，并最终提高左肝门胆管癌晚期患者的生存率。
