Jarnagin W R, Burke E, Powers C, Fong Y, Blumgart L H
Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA.
Am J Surg. 1998 Jun;175(6):453-60. doi: 10.1016/s0002-9610(98)00084-1.
Palliating the effects of biliary obstruction is a major goal of therapy in patients with cancer at the hepatic duct confluence. This study was undertaken to evaluate the effectiveness of intrahepatic biliary-enteric bypass to either the segment III duct or the right sectoral hepatic ducts in patients with unresectable hilar cholangiocarcinoma or gallbladder carcinoma.
From December 1991 to October 1996, 55 consecutive bypass procedures were prospectively evaluated in patients with unresectable hilar cholangiocarcinoma or gallbladder cancer. Patients were divided into three groups based on the primary tumor and the type of bypass performed: group 1A, cholangiocarcinoma/segment III bypass (n = 20); group 1B, cholangiocarcinoma/right sectoral hepatic duct bypass (n = 14); group 2, gallbladder cancer/segment III bypass (n = 21).
Mean hospital stay (14+/-2 days) and mean blood loss (629+/-84 mL) were similar among the three groups. Perioperative death occurred in 6 patients (11%): 0 in group 1A, 3 each in groups 1B and 2. All survivors had relief of jaundice and pruritus after bypass. Complications occurred in 25 patients (45%). Preoperative transhepatic biliary drainage, performed in 14 patients prior to referral, was associated with a higher incidence of contaminated bile, greater operative blood loss, and postoperative biliary leak that was less likely to resolve spontaneously. Median survival in patients with cholangiocarcinoma (groups 1A and 1B) was 52 weeks and was unaffected by the type of bypass performed. By contrast, median survival in patients with gallbladder cancer (group 3) was 20 weeks; all but 3 died within 32 weeks of surgery. In patients with cholangiocarcinoma, the 1-year bypass patency was 80% in group 1A (segment III bypass) and 60% in group 1B (right sectoral hepatic duct bypass). Overall, there were 9 late bypass failures (18%) requiring reintervention.
Intrahepatic biliary-enteric bypass effectively relieves symptoms due to malignant hilar obstruction. In patients with cholangiocarcinoma, segment III bypass provides excellent palliation with relatively few late complications and can be performed with minimal morbidity and mortality. Bypass to the right sectoral hepatic ducts, on the other hand, is associated with significant procedure-related morbidity and mortality and more late complications. Patients with gallbladder cancer, because of their poor survival, are probably better palliated by percutaneous biliary stenting.
缓解胆管梗阻的影响是肝门部胆管癌患者治疗的主要目标。本研究旨在评估肝内胆管-肠道吻合术至Ⅲ段胆管或右肝叶胆管在不可切除的肝门部胆管癌或胆囊癌患者中的有效性。
1991年12月至1996年10月，对55例不可切除的肝门部胆管癌或胆囊癌患者连续进行的旁路手术进行前瞻性评估。根据原发肿瘤和所行旁路手术的类型将患者分为三组：1A组，胆管癌/Ⅲ段旁路（n = 20）；1B组，胆管癌/右肝叶胆管旁路（n = 14）；2组，胆囊癌/Ⅲ段旁路（n = 21）。
三组患者的平均住院时间（14±2天）和平均失血量（629±84 mL）相似。围手术期死亡6例（11%）：1A组0例，1B组和2组各3例。所有幸存者在旁路手术后黄疸和瘙痒均得到缓解。25例患者（45%）发生并发症。14例患者在转诊前进行了术前经皮肝穿刺胆道引流，其胆汁污染发生率较高、术中失血量较大，且术后胆漏自发缓解的可能性较小。胆管癌患者（1A组和1B组）的中位生存期为52周，不受所行旁路手术类型的影响。相比之下，胆囊癌患者（3组）的中位生存期为20周；除3例患者外，所有患者均在术后32周内死亡。在胆管癌患者中，1A组（Ⅲ段旁路）1年的旁路通畅率为80%，1B组（右肝叶胆管旁路）为60%。总体而言，有9例晚期旁路失败（18%）需要再次干预。
肝内胆管-肠道吻合术可有效缓解恶性肝门部梗阻引起的症状。在胆管癌患者中，Ⅲ段旁路可提供良好的姑息治疗，晚期并发症相对较少，且手术 morbidity 和 mortality 最低。另一方面，右肝叶胆管旁路与显著的手术相关 morbidity 和 mortality 以及更多的晚期并发症相关。胆囊癌患者由于生存期较短，经皮胆道支架置入术可能是更好的姑息治疗方法。
