Ellis Ryan J, Soares Kevin C, Jarnagin William R
Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA.
Department of Surgery, Weill Cornell Medical College, New York, NY 10021, USA.
Cancers (Basel). 2022 Apr 24;14(9):2119. doi: 10.3390/cancers14092119.
Perihilar cholangiocarcinoma is a rare hepatobiliary malignancy that requires thoughtful, multidisciplinary evaluation in the preoperative setting to ensure optimal patient outcomes. Comprehensive preoperative imaging, including multiphase CT angiography and some form of cholangiographic assessment, is key to assessing resectability. While many staging systems exist, the Blumgart staging system provides the most useful combination of resectability assessment and prognostic information for use in the preoperative setting. Once resectability is confirmed, volumetric analysis should be performed. Upfront resection without biliary drainage or portal venous embolization may be considered in patients without cholangitis and an estimated functional liver remnant (FLR) > 40%. In patients with FLR < 40%, judicious use of biliary drainage is advised, with the goal of selective biliary drainage of the functional liver remnant. Percutaneous biliary drainage may avoid inadvertent contamination of the contralateral biliary tree and associated infectious complications, though the relative effectiveness of percutaneous and endoscopic techniques is an ongoing area of study and debate. Patients with low FLR also require intervention to induce hypertrophy, most commonly portal venous embolization, in an effort to reduce the rate of postoperative liver failure. Even with extensive preoperative workup, many patients will be found to have metastatic disease at exploration and diagnostic laparoscopy may reduce the rate of non-therapeutic laparotomy. Management of perihilar cholangiocarcinoma continues to evolve, with ongoing efforts to improve preoperative liver hypertrophy and to further define the role of transplantation in disease management.
肝门部胆管癌是一种罕见的肝胆恶性肿瘤，在术前需要进行全面、多学科评估，以确保患者获得最佳治疗效果。全面的术前影像学检查，包括多期CT血管造影和某种形式的胆管造影评估，是评估可切除性的关键。虽然存在多种分期系统，但Blumgart分期系统在术前评估中提供了最有用的可切除性评估和预后信息组合。一旦确认可切除性，就应进行容积分析。对于无胆管炎且估计功能性肝残余（FLR）>40%的患者，可考虑在不进行胆管引流或门静脉栓塞的情况下直接进行切除。对于FLR<40%的患者，建议谨慎使用胆管引流，目标是选择性地对功能性肝残余进行胆管引流。经皮胆管引流可避免对侧胆管树的意外污染及相关感染并发症，不过经皮和内镜技术的相对有效性仍是一个正在研究和争论的领域。FLR较低的患者也需要进行干预以诱导肝脏肥大，最常用的方法是门静脉栓塞，以降低术后肝衰竭的发生率。即使进行了广泛的术前检查，许多患者在手术探查时仍会被发现有转移性疾病，而诊断性腹腔镜检查可能会降低非治疗性剖腹手术的发生率。肝门部胆管癌的治疗仍在不断发展，目前正在努力改善术前肝脏肥大情况，并进一步明确移植在疾病治疗中的作用。
