肝门部胆管癌Ⅰ型和Ⅱ型的外科治疗策略：对长期预后的影响。

Surgical Strategies for Bismuth Type I and II Hilar Cholangiocarcinoma: Impact on Long-Term Outcomes.

机构信息

Department of Hepatobiliary Surgery and Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.

Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, USA.

出版信息

J Gastrointest Surg. 2021 Dec;25(12):3084-3091. doi: 10.1007/s11605-021-05049-3. Epub 2021 Jun 15.

DOI:10.1007/s11605-021-05049-3

PMID:34131864

Abstract

BACKGROUND

The surgical approach to treat Bismuth type I and II hilar cholangiocarcinoma (HCCA) has been a topic of debate. We sought to characterize whether bile duct resection (BDR) with or without concomitant hepatic resection (HR) was associated with R0 margin status, as well as define the impact of HR+BDR versus BDR alone on long-term survival.

METHODS

Patients who underwent curative-intent HR+BDR for HCCA between 2000 and 2014 were identified from a multi-institutional database. Perioperative and long-term outcomes were compared among patients who underwent BDR only, BDR+left hepatic resection (LHR), and BDR+right hepatic resection (RHR) for Bismuth type I and II HCCA.

RESULTS

Among 257 patients with HCCA, 61 (23.7%) patients had a Bismuth type I (n=25, 41.0%) or II (n=36, 59.0%) lesion. The incidence of R0 resection after BDR only was the same as among patients after LHR and RHR (BDR 70.0% vs. BDR+LHR 71.4% vs. BDR+RHR 76.5%, p=0.891). In contrast, severe complications were more likely after LHR and RHR than BDR only (BDR 21.4% vs. BDR+LHR 60.0% and BDR+RHR 50.0%, p=0.041). Overall (median: BDR 20.9 vs. BDR+LHR 23.2 and BDR+RHR 25.0 months, p=0.213) and recurrence-free (median: BDR 13.4 vs. BDR+LHR 15.3 and BDR+RHR 25.0, p= 0.109) survival were comparable. On multivariable analysis, while CA19-9>37.0U/ml (Ref. CA19-9≤37.0U/ml, HR 3.2, 95% CI 1.1-9.4, p=0.035) and AJCC T3-T4 disease (Ref. T1-T2, HR 4.6, 95% CI 1.5-13.7, p=0.007) were associated with long-term survival, surgical approach was not (BDR+LHR: HR 1.0, 95% CI 0.5-2.2, p=0.937; BDR+RHR: HR 0.6, 95% CI 0.3-1.3, p=0.197).

CONCLUSION

R0 resection, overall survival, and recurrence-free survival were comparable among well-selected patients who had BDR versus BDR+HR for Bismuth type I and II HCCA.

摘要

背景

治疗毕氏 I 型和 II 型肝门部胆管癌（HCCA）的手术方法一直是一个有争议的话题。我们旨在描述胆管切除术（BDR）联合或不联合肝切除术（HR）是否与 R0 切缘状态有关，并确定 HR+BDR 与单独 BDR 对长期生存的影响。

方法

从一个多机构数据库中确定了 2000 年至 2014 年间接受根治性 HR+BDR 治疗的 HCCA 患者。比较了仅行 BDR、BDR+左肝切除术（LHR）和 BDR+右肝切除术（RHR）治疗毕氏 I 型和 II 型 HCCA 的患者的围手术期和长期结局。

结果

在 257 例 HCCA 患者中，61 例（23.7%）患者存在毕氏 I 型（n=25，41.0%）或 II 型（n=36，59.0%）病变。仅行 BDR 后的 R0 切除率与行 LHR 和 RHR 后的 R0 切除率相同（BDR 为 70.0%，BDR+LHR 为 71.4%，BDR+RHR 为 76.5%，p=0.891）。相比之下，与仅行 BDR 相比，LHR 和 RHR 后严重并发症的发生率更高（BDR 为 21.4%，BDR+LHR 为 60.0%和 BDR+RHR 为 50.0%，p=0.041）。总体生存（中位：BDR 20.9 vs. BDR+LHR 23.2 和 BDR+RHR 25.0 个月，p=0.213）和无复发生存（中位：BDR 13.4 vs. BDR+LHR 15.3 和 BDR+RHR 25.0，p=0.109）相似。多变量分析显示，CA19-9>37.0U/ml（参考 CA19-9≤37.0U/ml，HR 3.2，95%CI 1.1-9.4，p=0.035）和 AJCC T3-T4 期疾病（参考 T1-T2，HR 4.6，95%CI 1.5-13.7，p=0.007）与长期生存相关，手术方式则不相关（BDR+LHR：HR 1.0，95%CI 0.5-2.2，p=0.937；BDR+RHR：HR 0.6，95%CI 0.3-1.3，p=0.197）。