Radtke Arnold, Königsrainer Alfred
Department of General, Visceral and Transplant Surgery, Comprehensive Cancer Center, University of Tübingen, Tübingen, Germany.
Visc Med. 2016 Dec;32(6):422-426. doi: 10.1159/000452921. Epub 2016 Nov 30.
The majority of patients with cholangiocarcinoma present with advanced disease that is often challenging to diagnose and to treat. The optimal preoperative evaluation requires a coordinated multidisciplinary approach. Surgical resection is the mainstay of therapy.
This systematic review delineates surgical treatment strategies for cholangiocarcinoma in general as well as special considerations concerning the particular tumor localization. A literature search (see keywords) was conducted using PubMed and publications between 1990 and 2016 regarding resectable and advanced cholangiocarcinoma were reviewed. Selected studies were utilized based on their significance and innovation.
The type and extent of resection performed depends on the location of the cholangiocarcinoma within the liver or biliary tree and the extent of local tumor invasion. The common surgical strategy contains: (i) for intrahepatic tumors: tailored partial hepatectomy combined with extended hilar, suprapancreatic, celiac axis lymphadenectomy, (ii) for hilar tumors: complete resection of the extrahepatic biliary tree combined with extended hepatectomy inclusive of segment I, resection of portal vein bifurcation, and systematic N1/N2 lymphadenectomy, and (iii) for distal tumors: en bloc pancreatoduodenectomy combined with complete resection of the extrahepatic bile duct below the hepatic confluence and systematic N1/N2 lymphadenectomy. Pathologic confirmation is not required prior to resection. Preoperative biliary drainage and remnant liver volume augmentation are necessary in selected patients with intrahepatic or hilar cholangiocarcinoma considered for extensive liver resection.
Cure for cholangiocarcinoma requires complete surgical resection with histologically negative margins. R0 resection provides a satisfactory long-term outcome in patients with lymph node-negative stage. Neoadjuvant treatment followed by liver transplantation provides long-term survival in highly selected cases with localized, unresectable, lymph node-negative hilar cholangiocarcinoma.
大多数胆管癌患者就诊时已处于晚期，其诊断和治疗往往具有挑战性。最佳的术前评估需要多学科协作。手术切除是主要的治疗方法。
本系统评价阐述了胆管癌的一般手术治疗策略以及针对特定肿瘤部位的特殊考虑因素。使用PubMed进行文献检索（见关键词），并回顾了1990年至2016年间关于可切除和晚期胆管癌的出版物。根据其重要性和创新性选择研究。
手术切除的类型和范围取决于胆管癌在肝脏或胆管树内的位置以及局部肿瘤侵犯的程度。常见的手术策略包括：（i）对于肝内肿瘤：量身定制的肝部分切除术联合扩大的肝门、胰上、腹腔干淋巴结清扫术；（ii）对于肝门部肿瘤：肝外胆管树的完整切除联合扩大的肝切除术，包括Ⅰ段切除、门静脉分叉切除和系统性N1/N2淋巴结清扫术；（iii）对于远端肿瘤：整块胰十二指肠切除术联合肝门以下肝外胆管的完整切除和系统性N1/N2淋巴结清扫术。切除前无需病理证实。对于考虑进行广泛肝切除的肝内或肝门部胆管癌患者，术前胆管引流和残余肝体积增大是必要的。
胆管癌的治愈需要进行切缘组织学阴性的完整手术切除。R0切除为淋巴结阴性分期的患者提供了满意的长期预后。新辅助治疗后肝移植在高度选择的局限性、不可切除、淋巴结阴性的肝门部胆管癌病例中可提供长期生存。
