Su C H, Tsay S H, Wu C C, Shyr Y M, King K L, Lee C H, Lui W Y, Liu T J, P'eng F K
Division of General Surgery, Department of Surgery, Veterans General Hospital-Taipei, Taiwan, Republic of China.
Ann Surg. 1996 Apr;223(4):384-94. doi: 10.1097/00000658-199604000-00007.
OBJECTIVE; Morbidity and mortality involved in the resection of hilar cholangiocarcinoma were reviewed retrospectively. The clinicopathologic and laboratory parameters that might influence the patient's survival also were re-evaluated.
Although much progress has been made in the diagnosis and management of hilar cholangiocarcinoma, long-term outlook for most patients remains poor. Surgical resection is usually prohibited because of its local invasiveness, and most patients can only be managed by palliative drainage. Recently, many surgeons have adopted a more aggressive resection with varying degrees of success. Several prognostic factors in bile duct carcinoma have been proposed; however, no reports have specifically focused on resected hilar cholangiocarcinoma and its prognostic survival factors using multivariate analysis.
The clinical records and pathologic slides of 49 cases with resected hilar cholangiocarcinoma were reviewed retrospectively. Twenty clinical and laboratory parameters were evaluated for their correlation with postoperative morbidity and mortality, whereas 31 variables were evaluated for their significance with postoperative survival. Variables showing statistical significance in the first univariate analysis were included in the following multivariate analysis using stepwise logistic regression test for factors affecting morbidity and mortality and Cox stepwise proportional hazard model for factors influencing survival.
There were 5 in-hospital deaths, and the cumulative 5-year survival rate in 44 patients who survived was 14.9%, with a median survival of 14.0 months. Multivariate analysis disclosed that co-existent hepatolithiasis and lower serum asparate aminotransferase levels (<90 U/L) had a significant low incidence of postoperative morbidity, whereas a serum albumin of less than 3 g/dL was the only significant factor affecting mortality. Regarding survival, univariate analysis identified eight significant factors: 1) total bilirubin > or = 10 mg/dL, 2) curative resection, 3) histologic type, 4) perineural invasion, 5) liver invasion, 6) depth of cancer invasion, 7) positive proximal resected margin, and 8) positive surgical margin. However, multivariate analysis disclosed total bilirubin > or = 10 mg/dL, curative resection, and histologic type as the three most significant independent variables.
Surgical resection provides the best survival for hilar cholangiocarcinoma. An adequate nutritional support to increase serum albumin over 3 g/dL is the most important factor to decrease postoperative mortality. Moreover, preoperative biliary drainage to decrease jaundice and a curative resection with adequate surgical margin are recommended if longer survival is anticipated. Patients with well-differentiated adenocarcinoma seem to survive longer compared to those with moderately or poorly differentiated tumors.
目的；回顾性分析肝门部胆管癌切除术中的发病率和死亡率。对可能影响患者生存的临床病理和实验室参数也进行了重新评估。
尽管在肝门部胆管癌的诊断和治疗方面取得了很大进展，但大多数患者的长期预后仍然很差。由于其局部侵袭性，通常禁止手术切除，大多数患者只能进行姑息性引流。最近，许多外科医生采用了更积极的切除术，取得了不同程度的成功。已经提出了胆管癌的几个预后因素；然而，尚无报告专门针对切除的肝门部胆管癌及其预后生存因素进行多变量分析。
回顾性分析49例肝门部胆管癌切除患者的临床记录和病理切片。评估20项临床和实验室参数与术后发病率和死亡率的相关性，同时评估31项变量与术后生存的意义。在第一次单变量分析中显示有统计学意义的变量被纳入以下多变量分析，使用逐步逻辑回归检验影响发病率和死亡率的因素，以及Cox逐步比例风险模型影响生存的因素。
有5例住院死亡，44例存活患者的累积5年生存率为14.9%，中位生存期为14.0个月。多变量分析显示，并存肝内胆管结石和较低的血清天冬氨酸转氨酶水平（<90 U/L）术后发病率显著较低，而血清白蛋白低于3 g/dL是影响死亡率的唯一显著因素。关于生存，单变量分析确定了八个显著因素：1）总胆红素≥10 mg/dL，2）根治性切除，3）组织学类型，4）神经周围侵犯，5）肝脏侵犯，6）癌症侵犯深度，7）近端切缘阳性，8）手术切缘阳性。然而，多变量分析显示总胆红素≥10 mg/dL、根治性切除和组织学类型是三个最显著的独立变量。
手术切除为肝门部胆管癌提供了最佳生存机会。充分的营养支持以将血清白蛋白提高到3 g/dL以上是降低术后死亡率的最重要因素。此外，如果预期生存期更长，建议术前进行胆管引流以减轻黄疸，并进行有足够手术切缘的根治性切除。与中分化或低分化肿瘤患者相比，高分化腺癌患者似乎存活时间更长。
