肝门部胆管癌的诊治体会
摘要
目的：肝门部胆管癌(Hilar bile duct carcinoma HBDC)约占肝外胆管癌的58%～75%，近年来其发病率有上升趋势。但由于特殊解剖关系及生物学特征，HBDC早期诊断较困难，误诊率高，手术切除率低，预后极差。本文旨在探讨诊断及治疗肝门部胆管癌的最佳方法，以期降低误诊率，以期达到更加满意的治疗效果。
方法：回顾性分析我院1996-2004年间手术治疗52例肝门部胆管癌的临床病例资料。
结果：本组52例肝门部胆管癌中，男37例，女15例，男：女＝1：0.405；年龄31-71岁，平均54.8岁；病史5天-3年，平均2.5个月。其中23例入院前有就诊史，入院前误诊为黄疸性肝炎11例，误诊为胃病3例，误诊为胆道结石并发胆管炎1例。影像学检查结果如下：超声检查49例，均可见肝内胆管扩张；胆总管不扩张；胆囊空虚。其中46例有明确胆道梗阻平面；45例见肝门部肿块影；1例为肝管内条索状影，疑诊为蛔虫。CT平扫及增强扫描检查35例，均可见肝内胆管扩张，肝总管或胆总管消失；肝门部结构紊乱。其中20例可见肝门部软组织肿块，1例可见肝脏左叶增大，右叶萎缩。1例近肝门处低密度影像。1例增强扫描表现为肝门部占位早期强化。MRI检查21例，其中18例可见肝门部软组织块影, 在T1加权像为低信号,在T2加权像为高信号或混合高信号；2例胆管壁增厚、管腔不规则狭窄；1例肝转移；2例门静脉边缘欠光滑。MRCP检查15例，均可见肝门胆管内充盈缺损；肝内胆管呈树枝状或腾状扩张。ERCP检查19例，肝总管上端及肝内胆管未显影。PTC检查13例，可见肝内胆管扩张，
肝门部胆管狭窄或充盈缺损。肝动脉血管造影检查5例，见肝门区肿瘤染色，未见肝动脉侵犯。术前明确诊断48例；术中快速病理诊断3例；术后病理诊断1例。介入支架术治疗9例，其中经PTCD行支架术7例，经ERCP行支架术2例。单纯PTCD引流1例。外科手术治疗42例。外科手术治疗42例，其中根治术14例，其中根治性切除联合肝尾状叶、胰头十二指肠切除术1例，联合肝部分切除、二级肝管空肠Roux-en-Y吻合术1例，联合门静脉部分切除修补1例；姑息性切除4例；右侧肝内胆管-胆囊-空肠吻合术1例，高位胆管插管与空肠搭桥引流术4例，T型管外引流2例， U型管外引流6例。外科手术组癌肿切除共18例,切除率34.6%。术后病理诊断:高分化腺癌22例,中分化腺癌9例,低分化腺癌10例。术后肝肾功能衰竭2例；术后胆瘘2例，1例腹腔引流，1例经二次手术引流均治愈；消化道出血2例，经抑制胃酸、止血治疗治愈；膈下感染1例，胆道感染1例，经抗炎治疗治愈。围手术期死亡2例，均死于肝肾功能衰竭，围手术死亡率为4.9%。
本组围手术期死亡2例，均死于肝肾功能衰竭，余40例中31例术后获得随访，失访9例，随访率为77.5%。随访时间１个月～４0个月不等。
癌肿切除组14例，存活时间为19.08±10.10个月，其中6例生存时间>12个月，4例生存>18个月，其中1例高分化腺癌已超过3年。死亡原因均为癌肿局部复发，转移。手术引流组9例，存活时间为6.6±2.54个月，最长16个月。支架探查组7例，存活时间为4.3±2.22个月，最长9个月。探查组7例，存活时间1.2±0.5个月，最长3个月，最短仅20天。
结论：HBDC起病隐匿，病变初期多缺乏特异性的临床表现，不能引起患者及医生的足够注意和重视，入院前误诊率高。因此临床上如发现进行
性加重的无痛或隐痛性阻塞性黄疸者、急性梗阻性胆管炎者或长期上腹部疼痛者，需进一步做有关检查，以期早期诊治。现代影像技术的发展可明确诊断、判断肿瘤分型（Bismuth分型）、了解肿瘤浸润范围、初步评估手术切除可能性与手术范围，对肝门部胆管癌的手术和预后有重要意义。其中，CT和超声作为互补的检查方法,其确诊率高，可作为肝门区胆管癌诊断首选方法。加上MRI、MRCP检查基本上能明确诊断及了解手术切除可能性，若仍不能明确诊断，再选择ERCP、PTC、血管造影检查。外科切除是HBDC获长期生存的唯一治疗选择，故疑似或诊断胆门部胆管癌应早期积极手术探查。Bismuth分型可为手术方式选择提供依据。结合生存期比较，手术切除远期疗效优于其它疗法，但手术切除术后并发症明显高于其它疗法。因此，HBDC治疗，根治性切除治疗的前景仍然是很严峻的。
Objective:TO improve the levels of diagnosing hilar bile duct carcinoma,and evaluate the focus on surgical treatment of hilar bile duct carcinoma.
Methods:Retrospective analysis of surgical management was performed on patients with hilar bile duct carcinoma in China-Japan Union Hospital between January 1996 and January 2004 years.
Results: There were 37 males and 15 females in 52 cases,aged 31 to 71 years(mean 54.8 years). History is between 5 days and 3 years,mean equals 2.5 months.The tumor of 18 cases was resected.The other 13 cases,which were no resected were done with internal or external drainage.Other 9 cases,which were proformed biliary endo prostheses.
Conclusion:It is still difficult to make early diagnosis in hilar bile duct carcinoma.Imaging examination played an important role in detecting hilar bile duct carcinoma,and preoperational assessing the respectability,of which ultrasonography B and CT should be the first choice,and MR including MRI and MRCP was a kind of new,safe and sensitive method.Laparotomy must be performed in all patients while there were no contraindications. The surgical resection surpasses the other therapy in the long-term curative effect,If the tumor could not be resected ,select drainage and support treatment should be chosed in order to prolong survival times and improve life quality.Radical resection
should be accomplished if it is feasible. but complications after the surgical operative resection were obvious higher than other therapy.Therefore, the foreground of radical resection is still very rigorous.
方法：回顾性分析我院1996-2004年间手术治疗52例肝门部胆管癌的临床病例资料。
结果：本组52例肝门部胆管癌中，男37例，女15例，男：女＝1：0.405；年龄31-71岁，平均54.8岁；病史5天-3年，平均2.5个月。其中23例入院前有就诊史，入院前误诊为黄疸性肝炎11例，误诊为胃病3例，误诊为胆道结石并发胆管炎1例。影像学检查结果如下：超声检查49例，均可见肝内胆管扩张；胆总管不扩张；胆囊空虚。其中46例有明确胆道梗阻平面；45例见肝门部肿块影；1例为肝管内条索状影，疑诊为蛔虫。CT平扫及增强扫描检查35例，均可见肝内胆管扩张，肝总管或胆总管消失；肝门部结构紊乱。其中20例可见肝门部软组织肿块，1例可见肝脏左叶增大，右叶萎缩。1例近肝门处低密度影像。1例增强扫描表现为肝门部占位早期强化。MRI检查21例，其中18例可见肝门部软组织块影, 在T1加权像为低信号,在T2加权像为高信号或混合高信号；2例胆管壁增厚、管腔不规则狭窄；1例肝转移；2例门静脉边缘欠光滑。MRCP检查15例，均可见肝门胆管内充盈缺损；肝内胆管呈树枝状或腾状扩张。ERCP检查19例，肝总管上端及肝内胆管未显影。PTC检查13例，可见肝内胆管扩张，
肝门部胆管狭窄或充盈缺损。肝动脉血管造影检查5例，见肝门区肿瘤染色，未见肝动脉侵犯。术前明确诊断48例；术中快速病理诊断3例；术后病理诊断1例。介入支架术治疗9例，其中经PTCD行支架术7例，经ERCP行支架术2例。单纯PTCD引流1例。外科手术治疗42例。外科手术治疗42例，其中根治术14例，其中根治性切除联合肝尾状叶、胰头十二指肠切除术1例，联合肝部分切除、二级肝管空肠Roux-en-Y吻合术1例，联合门静脉部分切除修补1例；姑息性切除4例；右侧肝内胆管-胆囊-空肠吻合术1例，高位胆管插管与空肠搭桥引流术4例，T型管外引流2例， U型管外引流6例。外科手术组癌肿切除共18例,切除率34.6%。术后病理诊断:高分化腺癌22例,中分化腺癌9例,低分化腺癌10例。术后肝肾功能衰竭2例；术后胆瘘2例，1例腹腔引流，1例经二次手术引流均治愈；消化道出血2例，经抑制胃酸、止血治疗治愈；膈下感染1例，胆道感染1例，经抗炎治疗治愈。围手术期死亡2例，均死于肝肾功能衰竭，围手术死亡率为4.9%。
本组围手术期死亡2例，均死于肝肾功能衰竭，余40例中31例术后获得随访，失访9例，随访率为77.5%。随访时间１个月～４0个月不等。
癌肿切除组14例，存活时间为19.08±10.10个月，其中6例生存时间>12个月，4例生存>18个月，其中1例高分化腺癌已超过3年。死亡原因均为癌肿局部复发，转移。手术引流组9例，存活时间为6.6±2.54个月，最长16个月。支架探查组7例，存活时间为4.3±2.22个月，最长9个月。探查组7例，存活时间1.2±0.5个月，最长3个月，最短仅20天。
结论：HBDC起病隐匿，病变初期多缺乏特异性的临床表现，不能引起患者及医生的足够注意和重视，入院前误诊率高。因此临床上如发现进行
性加重的无痛或隐痛性阻塞性黄疸者、急性梗阻性胆管炎者或长期上腹部疼痛者，需进一步做有关检查，以期早期诊治。现代影像技术的发展可明确诊断、判断肿瘤分型（Bismuth分型）、了解肿瘤浸润范围、初步评估手术切除可能性与手术范围，对肝门部胆管癌的手术和预后有重要意义。其中，CT和超声作为互补的检查方法,其确诊率高，可作为肝门区胆管癌诊断首选方法。加上MRI、MRCP检查基本上能明确诊断及了解手术切除可能性，若仍不能明确诊断，再选择ERCP、PTC、血管造影检查。外科切除是HBDC获长期生存的唯一治疗选择，故疑似或诊断胆门部胆管癌应早期积极手术探查。Bismuth分型可为手术方式选择提供依据。结合生存期比较，手术切除远期疗效优于其它疗法，但手术切除术后并发症明显高于其它疗法。因此，HBDC治疗，根治性切除治疗的前景仍然是很严峻的。
Objective:TO improve the levels of diagnosing hilar bile duct carcinoma,and evaluate the focus on surgical treatment of hilar bile duct carcinoma.
Methods:Retrospective analysis of surgical management was performed on patients with hilar bile duct carcinoma in China-Japan Union Hospital between January 1996 and January 2004 years.
Results: There were 37 males and 15 females in 52 cases,aged 31 to 71 years(mean 54.8 years). History is between 5 days and 3 years,mean equals 2.5 months.The tumor of 18 cases was resected.The other 13 cases,which were no resected were done with internal or external drainage.Other 9 cases,which were proformed biliary endo prostheses.
Conclusion:It is still difficult to make early diagnosis in hilar bile duct carcinoma.Imaging examination played an important role in detecting hilar bile duct carcinoma,and preoperational assessing the respectability,of which ultrasonography B and CT should be the first choice,and MR including MRI and MRCP was a kind of new,safe and sensitive method.Laparotomy must be performed in all patients while there were no contraindications. The surgical resection surpasses the other therapy in the long-term curative effect,If the tumor could not be resected ,select drainage and support treatment should be chosed in order to prolong survival times and improve life quality.Radical resection
should be accomplished if it is feasible. but complications after the surgical operative resection were obvious higher than other therapy.Therefore, the foreground of radical resection is still very rigorous.
引文
[1] 黄志强.肝门部胆管癌的外科治疗.中华外科杂志，1990，28：522-524.
[2] 周宁新，黄志强，刘永雄等.肝外胆道癌全国调查1098例分析，中华外科杂志，1990，28：516-517.
[3] Lillemoe KD.Surgery for hilar cholangiocarcinma[J].J Hepatobi- liary Pancreat Surg, 2000, 7(2):115-121.
[4] 廖彩仙,杨家丁.胆管癌的基础与临床[M].广州:第二军医大学出版社,1999.69-88.
[5] 范正军,吴 阳,王陆林等.73例肝门部胆管癌诊疗体会.中国医刊,
2000.35(3):26-27.
[6] 解丽梅,张铭琏,刘守君等.超声对肝门部胆管癌的术前评估.中国临床医学影像杂志，1999，10(5):341-343.
[7] Okuda K,Ohto M,Tsuchiya T:The role of ultrasound perchtaneous
transhepatic cholangiograghy,computed tomographic scanning，and magnetic resonance imaging in the preoperative assessment of bile duct cancer. World.J.Surg.1988，12：18-20.
[8] 侯金文,华巍,李佳福等.胆管癌的CT表现及诊断价值.中国医学计算机成像杂志,1996,2(4):246－248.
[9] 沈世鹏，冷希圣等.肝门部胆管癌的影像学诊断价值.肝胆外科杂志，1997，5（5）：284-285.
[10] Eric K，Susan O，Gordon J.Imaging the pancreatic and biliary ducts with MR.Radiology，1994，192：19-22.
[11] Lillemoe KD.Surgery for hilar cholangiocarcinma [J].J Hepatobiliary Pancreat Surg, 2000, 7(2):115- 121.
[12] 邹声泉,童宜欣,陈汝福.肝门部胆管癌早期诊断的体会.华中医学杂志2000,24(1):6-7.
[13] Gibbons CP，Griffiths GJ，Cormack A.The Role of percutaneous transhepatic cholangiography and grey-scale ultrasoud in the invertigation and treatment of bile duct obstraction.Br J surg，1983，70：494-497.
[14] 彭淑牖.努力提高胆道系统恶性肿瘤的诊治水平[J].中国普通外科杂志,2001,10(1):2-5.
[15] Dufek V,petrty LJ,klener P,et al. Tumor markers in the diagnosis tumors in the subhepatic area.VnitrLek,1994,40(6):350～353.
[16] 刘永锋.肝门部胆管癌的治疗现状.中国实用外科杂志,2000,20(1):
28-31.
[17] Burke EC,Jarnagin WR,Hochwald SN,et al.Hilar Cholangiocarci- noma:patterns of spread,the importance of hepatic resection for curative operation,and a presurgical clinical staging system.AnnSurg,1998,228(3):385－388.
[18] Escartin A,Doyle H,Madariaga JR,et al.Hilar and peripheral cholangicar－cinomas,Rev Esp En ferm Dig,1998,90(8):580-583.
[19] 王曙光,韩本立.蔡景修.胆管癌的侵润、转移及外科治疗中的问题.中华实用外科杂志，1997，17(2): 116－118.
[20] 黄志强.提高肝门部胆管癌手术治疗效果的措施[J].中国实用外科杂
志,1998,18 (6):325.117－118.
[21] 陈钟,李厚祥,陈玉泉 影响肝门部胆管癌切除因素的探讨. 江苏医药杂志,2000, 26(1):8-9.
[22] Makuuchi M,Yamasaki S,Hasegawa H,et al.Preoperative portal embolization to increase safety of major hepatectomy for hilar bile duct carcinoma:a preliminary report [J]. Surgery, 1990, 107:521-527.
[23] Nimura Y,Hayakawa N,Kamiga J,et al.Hepatic segmen- tectomy with caudate lobe resection for bile duct carcinoma of the hepatic hilus.WolrdJSurg, 1990，14:535-535.
[24] Shinchi H,Takao S,Nishida H,et al.Length and quality of survival following external beam radio therapy combined with expandable metallic stent for unresectable hilar cholangio- carcinoma [J].J SurgOncol,2000,75(2):89-94.
[25] 刘鹏飞,杨甲梅 肝门部胆管癌与胆道介入治疗. 肝胆外科杂志，2003
11（5）325-327.
[26] 胡泽民,余元龙,周载平 肝门部胆管癌的外科治疗 中国普通外科杂志.11(10):592-294.
[27] Gerhards MF,vanGulik TM,deWitLT,et al.Evaluation of morbidity and mortality after resectionfor hilar cholangiocarcinoma a singl center experience[J]. Surger ,2000;127(4): 395-398.
[28] 王炳生,刘厚宝,焦苑等. 磁共振和磁共振胆道成像对胆道疾病的诊断价值.肝胆胰外科杂志. 1996,8(3): 127-129.
[2] 周宁新，黄志强，刘永雄等.肝外胆道癌全国调查1098例分析，中华外科杂志，1990，28：516-517.
[3] Lillemoe KD.Surgery for hilar cholangiocarcinma[J].J Hepatobi- liary Pancreat Surg, 2000, 7(2):115-121.
[4] 廖彩仙,杨家丁.胆管癌的基础与临床[M].广州:第二军医大学出版社,1999.69-88.
[5] 范正军,吴 阳,王陆林等.73例肝门部胆管癌诊疗体会.中国医刊,
2000.35(3):26-27.
[6] 解丽梅,张铭琏,刘守君等.超声对肝门部胆管癌的术前评估.中国临床医学影像杂志，1999，10(5):341-343.
[7] Okuda K,Ohto M,Tsuchiya T:The role of ultrasound perchtaneous
transhepatic cholangiograghy,computed tomographic scanning，and magnetic resonance imaging in the preoperative assessment of bile duct cancer. World.J.Surg.1988，12：18-20.
[8] 侯金文,华巍,李佳福等.胆管癌的CT表现及诊断价值.中国医学计算机成像杂志,1996,2(4):246－248.
[9] 沈世鹏，冷希圣等.肝门部胆管癌的影像学诊断价值.肝胆外科杂志，1997，5（5）：284-285.
[10] Eric K，Susan O，Gordon J.Imaging the pancreatic and biliary ducts with MR.Radiology，1994，192：19-22.
[11] Lillemoe KD.Surgery for hilar cholangiocarcinma [J].J Hepatobiliary Pancreat Surg, 2000, 7(2):115- 121.
[12] 邹声泉,童宜欣,陈汝福.肝门部胆管癌早期诊断的体会.华中医学杂志2000,24(1):6-7.
[13] Gibbons CP，Griffiths GJ，Cormack A.The Role of percutaneous transhepatic cholangiography and grey-scale ultrasoud in the invertigation and treatment of bile duct obstraction.Br J surg，1983，70：494-497.
[14] 彭淑牖.努力提高胆道系统恶性肿瘤的诊治水平[J].中国普通外科杂志,2001,10(1):2-5.
[15] Dufek V,petrty LJ,klener P,et al. Tumor markers in the diagnosis tumors in the subhepatic area.VnitrLek,1994,40(6):350～353.
[16] 刘永锋.肝门部胆管癌的治疗现状.中国实用外科杂志,2000,20(1):
28-31.
[17] Burke EC,Jarnagin WR,Hochwald SN,et al.Hilar Cholangiocarci- noma:patterns of spread,the importance of hepatic resection for curative operation,and a presurgical clinical staging system.AnnSurg,1998,228(3):385－388.
[18] Escartin A,Doyle H,Madariaga JR,et al.Hilar and peripheral cholangicar－cinomas,Rev Esp En ferm Dig,1998,90(8):580-583.
[19] 王曙光,韩本立.蔡景修.胆管癌的侵润、转移及外科治疗中的问题.中华实用外科杂志，1997，17(2): 116－118.
[20] 黄志强.提高肝门部胆管癌手术治疗效果的措施[J].中国实用外科杂
志,1998,18 (6):325.117－118.
[21] 陈钟,李厚祥,陈玉泉 影响肝门部胆管癌切除因素的探讨. 江苏医药杂志,2000, 26(1):8-9.
[22] Makuuchi M,Yamasaki S,Hasegawa H,et al.Preoperative portal embolization to increase safety of major hepatectomy for hilar bile duct carcinoma:a preliminary report [J]. Surgery, 1990, 107:521-527.
[23] Nimura Y,Hayakawa N,Kamiga J,et al.Hepatic segmen- tectomy with caudate lobe resection for bile duct carcinoma of the hepatic hilus.WolrdJSurg, 1990，14:535-535.
[24] Shinchi H,Takao S,Nishida H,et al.Length and quality of survival following external beam radio therapy combined with expandable metallic stent for unresectable hilar cholangio- carcinoma [J].J SurgOncol,2000,75(2):89-94.
[25] 刘鹏飞,杨甲梅 肝门部胆管癌与胆道介入治疗. 肝胆外科杂志，2003
11（5）325-327.
[26] 胡泽民,余元龙,周载平 肝门部胆管癌的外科治疗 中国普通外科杂志.11(10):592-294.
[27] Gerhards MF,vanGulik TM,deWitLT,et al.Evaluation of morbidity and mortality after resectionfor hilar cholangiocarcinoma a singl center experience[J]. Surger ,2000;127(4): 395-398.
[28] 王炳生,刘厚宝,焦苑等. 磁共振和磁共振胆道成像对胆道疾病的诊断价值.肝胆胰外科杂志. 1996,8(3): 127-129.