Kamachi Hirofumi, Kamiyama Toshiya, Tsuruga Yousuke, Orimo Tatsuya, Wakayama Kenji, Shimada Shingo, Kakisaka Tatsuhiko, Yokoo Hideki, Yamashita Kenichiro, Taketomi Akinobu
Department of Gastroenterological Surgery I, Graduated School of Medicine, Hokkaido University, N-15, W-7, Kita-ku, Sapporo, Hokkaido, 060-0838, Japan.
Department of Transplant Surgery, Graduated School of Medicine, Hokkaido University, N-15, W-7, Kita-ku, Sapporo, Hokkaido, 060-0838, Japan.
Langenbecks Arch Surg. 2018 May;403(3):387-394. doi: 10.1007/s00423-017-1633-2. Epub 2017 Oct 23.
To increase the surgical opportunities for locally advanced perihilar bile duct cancers that require left-sided hepatectomies, we developed the transparenchymal glissonean approach (TGA); it comprises intra-hepatic exposure and dissection of the Glisson's sheath to gain access to the hepatic artery and portal vein for reconstruction.
Following skeletonization of the hepatoduodenal ligament, the proximal portions of invaded vessels are exposed. If extra-hepatic attempts to access the distal portions of the invaded vessels fail, TGA can be used. The distal portion of the invaded right or right posterior Glisson's sheath is exposed following liver transection. The anterior portion of the wall of bile duct is cut and transected circumferentially including the fibrous plate tissue. The non-invaded portal vein and hepatic artery are isolated and dissected towards the hepatic hilum until the invaded distal portion of the vessels, and vascular reconstructions are performed.
TGA was performed in 9 patients; 5 patients underwent left hemihepatectomy and 4 underwent left tri-sectionectomy. Eight patients needed vascular reconstruction. Clavien-Dindo classification (CDC) grades IIIa and IIIb were recorded in 6 and 1 patients, respectively. No patients had CDC grades IV and V disease. Pathologically, all cases were pT4; 3 cases were R0, 5 were R1 with microscopic positive margin, and 2 were R1 with microscopic metastasis. The overall median survival time was 25.0 months.
TGA is feasible with acceptable prognosis and expands the surgical opportunities.
为增加需要行左半肝切除术的局部晚期肝门部胆管癌的手术机会，我们开发了经实质肝蒂入路（TGA）；该入路包括肝内暴露和肝蒂鞘膜的解剖，以显露肝动脉和门静脉进行重建。
在肝十二指肠韧带骨骼化后，暴露受侵血管的近端部分。如果肝外途径无法显露受侵血管的远端部分，则可采用TGA。肝实质离断后，暴露受侵的右侧或右后肝蒂鞘膜的远端部分。切开胆管壁的前部，并环形横断包括纤维板组织。分离并向肝门方向解剖未受侵的门静脉和肝动脉，直至受侵血管的远端部分，然后进行血管重建。
9例患者接受了TGA手术；5例行左半肝切除术，4例行左三叶切除术。8例患者需要进行血管重建。Clavien-Dindo分级（CDC）IIIa级和IIIb级分别有6例和1例。无患者为CDC IV级和V级病变。病理检查显示，所有病例均为pT4；3例R0切除，5例R1切除，切缘镜下阳性，2例R1切除，有镜下转移。总中位生存时间为25.0个月。
TGA是可行的，预后可接受，且扩大了手术机会。
