徐驍HilarCholangiocarcinoma:CurrentManagement肝門膽管癌治療進(jìn)展長江學(xué)者、教授、主任醫(yī)師、博導(dǎo)浙江大學(xué)從屬第一醫(yī)院肝膽胰外科zdyyxx@163.com肝門部膽管癌治療進(jìn)展第1頁目錄1定義2病因3病理分型

4診斷5治療肝門部膽管癌治療進(jìn)展第2頁AKlatskintumor(orhilarcholangiocarcinoma)isacholangiocarcinomaoccurringattheconfluenceoftherightandlefthepaticbileducts發(fā)生于肝總管或左、右肝管及其匯合處惡性腫瘤Proliferationofmalignantadenocarcinomaandfibroblast組織學(xué)特征是惡性腺癌細(xì)胞和周圍粗纖維細(xì)胞增生specificsituationandinfiltratedgrowth發(fā)生部位特殊、呈浸潤性生長Lowradicalresectionratewithhighoperationrisk根治性切除率低、手術(shù)風(fēng)險大Ahard-to-treatdisease難以攻克頑癥之一HilarCholangiocarcinoma,KlatskinTumor肝門膽管癌肝門部膽管癌治療進(jìn)展第3頁EtiologyofHilarCholangiocarcinoma肝門膽管癌病因當(dāng)前病因尚不清楚，與膽管慢性炎癥、膽結(jié)石及膽汁淤積可能相關(guān)可能病因：PSC原發(fā)性硬化性膽管炎Congenitalbiliarymalformations先天性膽道畸形，如多囊肝、膽總管囊腫、calori’s病等Chroniculcerativecolitis慢性潰瘍性結(jié)腸炎Parasiticinfections化學(xué)致癌物，如麝貓后睪吸蟲、華支睪吸蟲等Chemicalcarcinogens化學(xué)致癌物多囊肝潰瘍性結(jié)腸炎肝門部膽管癌治療進(jìn)展第4頁PSC與膽道系統(tǒng)腫瘤263例原發(fā)性硬化性膽管炎，觀察時間從1999~，膽管癌發(fā)生概率為14%KristenMB等人發(fā)覺，Mayo評分＞4，吸煙、酗酒、炎癥性腸病病史患者更輕易發(fā)生膽管癌BestPractice&ResearchClinicalGastroenterology肝門部膽管癌治療進(jìn)展第5頁RolesofClonorchisEndemicus

InfectionasRiskFactorforCC

華支睪吸蟲是肝門膽管癌易感原因JohnZ,etal.JournalofHepato-Biliary-PancreaticSciences,成蟲卵沼螺、涵螺、豆螺（第一中間宿主）包囊終末宿主保蟲宿主淡水魚第二中間宿主尾蚴長約10~25mm肝門部膽管癌治療進(jìn)展第6頁AhistoryofeatingrawfreshwaterfishandapositiveserologicresultforC.sinensisweresignificantlyassociatedwiththedevelopmentofCC食用淡水魚史而且華支睪吸蟲血清學(xué)試驗陽性患者，與肝門膽管癌發(fā)生發(fā)展親密相關(guān)FreshwaterFishandClonorchisEndemicus

淡水魚與華支睪吸蟲淡水魚是華支睪吸蟲第二中間宿主肝門部膽管癌治療進(jìn)展第7頁TheWaysofMetastasis轉(zhuǎn)移路徑Roland.Z,Hepatology,Hematogenousmetastasis血行轉(zhuǎn)移肝內(nèi)血行轉(zhuǎn)移發(fā)生最早，也最常見，可侵犯門靜脈并形成瘤栓Lymphaticmetastasis淋巴轉(zhuǎn)移可局部轉(zhuǎn)移到肝門，淋巴轉(zhuǎn)移僅占轉(zhuǎn)移總數(shù)12.6%Contactmetastasis接觸轉(zhuǎn)移普通較少發(fā)生鄰近臟器直接浸潤，但偶然也可直接蔓延、浸潤至鄰近組織器官，如膈、胃、結(jié)腸、網(wǎng)膜等Metastasisalongnervefibers沿神經(jīng)蔓延肝門部膽管癌治療進(jìn)展第8頁HilarCholangiocarcinoma—Diagnosis肝門膽管癌診療方法

Hilarcholangio-carcinomaClinicalmanifestation：progressivepainlessjaundice進(jìn)行性無痛性黃疸Imaging：CT,MRCP,ERCP,Bultrasonic,PET-CTTumormarker:

CA199,CEApathology：ERCPbrushcytology,biopsy毛刷細(xì)胞學(xué)檢驗，活檢肝門部膽管癌治療進(jìn)展第9頁Diagnosis-CTCT診療肝門部膽管癌治療進(jìn)展第10頁Diagnosis-MRIMRI診療肝門部膽管癌治療進(jìn)展第11頁MRCPDiagnosis-MRCPMRCP診療肝門部膽管癌治療進(jìn)展第12頁TheRoleofHistologicalDiagnosis

組織學(xué)診療作用Koeaetal,worldjournalofsurgery,Bucetal,HPB,ERCPbrushcytology(毛刷細(xì)胞學(xué)檢驗):thefirstchoiceForcepsbiopsyandfine-needleaspiration

isnotmandatoryLowsensitivityRiskofmetastasisResectionremainsthemostreliableway

toruleoutbiliarymalignancy肝門部膽管癌治療進(jìn)展第13頁DistributionofHilarCholangiocarcinoma

肝門膽管癌分布MuradAljiffry,etal.WorldJGastroenterol,Hilarcholangiocarcinoma5%~10%膽管癌分布于肝內(nèi)膽管60%~70%膽管癌位于膽道系統(tǒng)分叉處，即肝門膽管癌，是膽管癌主要類型。20%~30%膽管癌位于肝外膽管肝門部膽管癌治療進(jìn)展第14頁PathologyofHilarCholangiocarcinoma

病理分型HayashiS,etal.Cancer,1994sclerosing硬化型（70%）nodular結(jié)節(jié)型（20%）papillary乳頭狀（5%）Transmuralinvasion

橫向浸潤，侵犯膽管及周圍組織Longitudinalextension

縱向浸潤，粘膜和粘膜下擴散腫瘤可向上膽管上下侵犯Lymphnodemetastasis

淋巴結(jié)轉(zhuǎn)移PathologySpreadmorefavorableprognosis預(yù)后很好majorityofcases主要類型肝門部膽管癌治療進(jìn)展第15頁名稱分型或分期依據(jù)Bismuth-Corletteclassification:themostcommon腫瘤解剖學(xué)部位Gazzaniga分期（加扎尼加分期、T分期法）腫瘤部位，門靜脈是否侵犯及有沒有肝葉萎縮MSKCC改良T分期（MemorialSloan-KetteringCancerGenter）腫瘤對肝動脈和門靜脈侵犯程度AJCC（pTNM）分期術(shù)后病理結(jié)果ClaissificationandStaging分型分期

肝門部膽管癌治療進(jìn)展第16頁Bismuth-Corlette分型HenriBismuth,AnnSurg,1992IIIaIIIbIV臨床最慣用，有利于計劃手術(shù)方式，但腫瘤分級程度與腫瘤可切除性和術(shù)后生存期長短之間無相關(guān)性ITumorsbelowtheconfluenceoftheleftandrighthepaticduct腫瘤位于膽總管上端IITumorsreachingtheconfluence腫瘤位于左右肝管分叉部IIIaTumorsoccludingthecommonhepaticductandeithertherightduct腫瘤累及肝總管、匯合部和右肝管IIIbTumorsoccludingthecommonhepaticductandeithertheleftduct腫瘤累及肝總管、匯合部和左肝管IVTumorsinvolvingtheconfluenceandboththerightandlefthepaticducts腫瘤累及肝總管、匯合部和同時累及左右肝管肝門部膽管癌治療進(jìn)展第17頁IIIIIIaIIIbIVBismuth-corletteclassification

Bismuth5種分型肝門部膽管癌治療進(jìn)展第18頁Gazzaniga分期（T分期法）T分期發(fā)展于Bismuth-Corlette分期基礎(chǔ)之上主要包含以下三個原因：1、腫瘤位置及膽管受累程度（參見Bismuth-Corlette分期）2、有沒有門靜脈侵犯3、有沒有肝葉萎縮肝門部膽管癌治療進(jìn)展第19頁T3:Tumorsoccludingthecommonhepaticductorthesecondarybileduct

,andinvolvingthehepaticportalveinoffside,orwiththecontralateralliveratrophy,orinvolvingthemainhepaticportalvein腫瘤侵及肝管匯合部而且雙側(cè)都侵襲至二級膽管或腫瘤單側(cè)侵襲至二級膽管同時合并對側(cè)門靜脈受累；或腫瘤單側(cè)侵襲至二級膽管同時合并對側(cè)肝葉萎縮；或腫瘤累及門靜脈主干或者雙側(cè)門靜脈均受累MSKCC改良T分期Classification

&CriteriaT1:

Tumorsoccludingthecommonhepaticductorthesecondarybileduct腫瘤侵及肝管匯合部和（或）單側(cè)侵襲至二級膽管T2:

Tumorsoccludingthecommonhepaticductorthesecondarybileduct

,andinvolvingtheipsilateralhepaticportalvein腫瘤侵及肝管匯合部和（或）單側(cè)侵襲至二級膽管,同時合并同側(cè)門靜脈受累和（或）同側(cè)肝葉萎縮MSKCC

isusedforassessingtheresectabilityoflivercarcinoma.JarnaginWR.AnnSurg，肝門部膽管癌治療進(jìn)展第20頁AJCC分期原發(fā)腫瘤（T）Tis：原位膽管癌；T1:浸潤肌層或纖維層；T2a:侵及膽管周圍纖維組織；T2b:侵及膽管鄰近肝實質(zhì)；T3:侵犯單側(cè)門靜脈/肝動脈；T4:侵犯門靜脈主干或雙側(cè)分支；或肝總動脈；或雙側(cè)II級膽管；或單側(cè)II級膽管加對側(cè)門靜脈或肝動脈浸潤區(qū)域淋巴結(jié)（N）N0：無淋巴結(jié)轉(zhuǎn)移；N1：局部淋巴結(jié)轉(zhuǎn)移（膽囊管、膽總管、肝動脈、門靜脈旁）N2:遠(yuǎn)處淋巴結(jié)轉(zhuǎn)移（主動脈、腸系膜上動靜脈、下腔靜脈、腹腔動脈旁淋巴結(jié)轉(zhuǎn)移；遠(yuǎn)處轉(zhuǎn)移（M）

M0無遠(yuǎn)處轉(zhuǎn)移；M1發(fā)生遠(yuǎn)處轉(zhuǎn)移

0期TisN0M0ⅠA期T1N0M0ⅠB期T2N0

M0ⅡA期T3N0M0ⅡB期T1、T2或T3

N1M0Ⅲ期T4任何NM0

Ⅳ期任何T任何NM1AmericanJointCommitteeonCancer.AJCCcancerstagingmanual.7thed肝門部膽管癌治療進(jìn)展第21頁PrognosticFactors

預(yù)后原因情況很好，恢復(fù)不錯腫瘤病理類型術(shù)前膽道引流術(shù)前定位與剩下肝膽紅素水平術(shù)前CA199水平腫瘤浸潤深度手術(shù)切除類型下腔靜脈侵犯肝門部膽管癌治療進(jìn)展第22頁Prognosticfactor:

preoperativeserumCA19-9levels

1、術(shù)前CA19-9水平是肝門膽管癌術(shù)后獨立預(yù)后原因術(shù)前CA19-9低于150U/ml膽管細(xì)胞癌患者組術(shù)后生存顯著優(yōu)于術(shù)前CA19-9高于150U/ml組（P=0.000）Wen-KeCai1,IntJClinExpPathol,術(shù)前CA199＜150U/ml術(shù)前CA199＞150U/ml肝門部膽管癌治療進(jìn)展第23頁RochaFG,etal.JHepatobiliaryPancreatSci,Preoperativeserumtotalbilirubin>10mg/dlassociatedwithpoorprognsois術(shù)前膽紅素>10mg/dl,直接影響術(shù)后生存率Prognosticfactor:

preoperativeserumtotalbilirubin

2、術(shù)前膽紅素與預(yù)后肝門部膽管癌治療進(jìn)展第24頁Prognosticfactor:

thevolumeofremnantliver3、準(zhǔn)確術(shù)前定位與剩下肝體積影響預(yù)后PrecisevisualizationofanatomicstructuresMultidirectionalassessmentofbiliarybranchesandvesselsAllowingimprovedoperativeplanningRyokoSasaki,TheAmericanJournalofSurgery,肝門部膽管癌治療進(jìn)展第25頁Thevolumeofremnantliverandprognosis

剩下肝體積與預(yù)后關(guān)系RochaFG,JHepatobiliaryPancreatSci,經(jīng)過48例患者臨床數(shù)據(jù)分析顯示，剩下肝體積與預(yù)后含有顯著相關(guān)性P=0.012肝門部膽管癌治療進(jìn)展第26頁LiuF,etal.DigDisSci,YES：unrelievedbiliaryobstructionisassociatedwithhepaticandrenaldysfunctionandcoagulopathyNO：PreoperativebiliarydrainageisassociatedwithanincreasedriskofcomplicationPreoperativebiliarydrainageremainscontroversialRecently,MetaanalysisindicatedpreoperativebiliarydrainagehadnobenefitPrognosticfactor:

preoperativeBiliaryDrainage

4、術(shù)前膽道引流肝門部膽管癌治療進(jìn)展第27頁Preoperativebiliarydecompressioninpatientwithcholangiocarcinoma

肝門膽管癌患者術(shù)前膽道減壓Case-comparisonstudyMajorliverresectionswithoutPBDaresafeinmostpatientswithobstructivejaundice.Transfusionrequirementsandincidenceofpostoperativecomplications,especiallybileleaksandsubphreniccollections,arehigherinjaundicedpatients.WhetherPBDcouldimprovetheseresultsremainstobedetermined肝門膽管癌術(shù)前膽道減壓能降低并發(fā)癥發(fā)生率，不過否能提升預(yù)后結(jié)果仍需深入研究20例黃疸患者作了肝切除但未行術(shù)前膽道引流27例對照組患者肝切除但未黃疸患者結(jié)果發(fā)覺：黃疸患者與無黃疸患者組病死率為（5%vs0%），肝衰發(fā)生率（5%vs0%），膽漏等并發(fā)癥發(fā)生率（50%vs15%）肝門部膽管癌治療進(jìn)展第28頁PreoperativebiliarydrainageoftheFLR(futureliverremnant)appearstoimproveoutcomeifthepredictedvolumeis<30%.However,inpatientswithFLR>or=30%,preoperativebiliarydrainagedoesnotappeartoimproveperioperativeoutcomeRetrospectivestudy研究顯示，當(dāng)剩下肝體積＜30%時，術(shù)前膽道引流能提升肝門膽管癌患者預(yù)后，當(dāng)剩下肝體積≥30%時，術(shù)前膽道引流對預(yù)后影響無統(tǒng)計學(xué)差異從1997~年間60例肝臟切除術(shù)后患者依據(jù)剩下肝體積選擇性使用術(shù)前膽道引流，65%患者剩下肝體積≥30%（39/60）對照組中，肝體積≤30%（21/60），其中有5人出現(xiàn)了肝體積不足，有4人死亡，而且缺乏術(shù)前膽道引流（P=0.009）肝門部膽管癌治療進(jìn)展第29頁這篇meta分析包含10個研究711位肝門膽管癌，其中442位合并黃疸患者進(jìn)行了術(shù)前膽管引流，233位黃疸患者未進(jìn)行術(shù)前引流，臨床數(shù)據(jù)分析不支持肝門膽管癌合并黃疸患者能從引流中獲益RetrospectivestudyMeta-analyse711cases肝門部膽管癌治療進(jìn)展第30頁Advantagesanddisadvantagesofdifferentmethodsofbiledrainage

不一樣膽管引流方法優(yōu)劣引流方法MaguchiHetal,JHepatobiliaryPancreatSurg,肝門部膽管癌治療進(jìn)展第31頁Prognosticfactor:histologicalclassification

5、組織學(xué)分型影響預(yù)后分化程度與生存率SaxenaA,TheAmericanJournalofSurgery,高分化患者組中分化患者組低分化患者組肝門部膽管癌治療進(jìn)展第32頁Prognosticfactor:Tumordepth6、腫瘤浸潤深度及長久預(yù)后Tumordepthmoreaccuratelystratifiespatientsandisabetterpredictoroflong-termoutcome腫瘤浸潤深度是評定肝門膽管癌預(yù)后一項主要指標(biāo)deJongMC,etal.ArchSurg.腫瘤浸潤深度＜5mm組腫瘤浸潤深度＞5mm組肝門部膽管癌治療進(jìn)展第33頁Prognosticfactor:typeofliverresection

7、肝切除類型與預(yù)后關(guān)系

Konstadoulakis,TheAmericanJournalofSurgery,

Righthepatectomyhadbettersurvival1998~年間73位肝門膽管癌患者51位患者進(jìn)行了右半肝切除術(shù)22位患者進(jìn)行了左半肝切除術(shù)5年生存率分別是48.9%和21.7%肝門部膽管癌治療進(jìn)展第34頁InvasionofIVCindicatespoorprognosis8、下腔靜脈侵犯預(yù)示不良預(yù)后Konstadoulakis,TheAmericanJournalofSurgery,下腔靜脈侵犯患者術(shù)后生存率顯著低于未侵犯者納入本研究73例患者中有3例（4%）出現(xiàn)了下腔靜脈侵犯統(tǒng)計結(jié)果提醒嚴(yán)重不良預(yù)后肝門部膽管癌治療進(jìn)展第35頁肝門膽管癌外科治療方法肝門部膽管癌治療進(jìn)展第36頁Patientsresected(solidline)hadbetteroverall5-yearsurvival(35%)thanpatientsthatwerenotresected.Nounresectedpatient(dottedline)survivedto24monthsAlanW.Hemming,AnnSurg,手術(shù)切除組非手術(shù)治療組Surgicalresection

外科切除肝門部膽管癌治療進(jìn)展第37頁SurgicalresectionisthebesttreatmentforhilarcholangiocarcinomaT.M.vanGulik,EuropeanJournalofSurgicalOncology,

手術(shù)切除組患者術(shù)后生存率顯著優(yōu)于非手術(shù)組及肝移植組Actuarialsurvivalofpatientsunderwentresection

versusthosewerenotresected

手術(shù)切除對生存率影響肝門部膽管癌治療進(jìn)展第38頁Precisesurgicalresectionforhilarcholangiocarcinoma

肝門膽管癌外科治療IIIV根治性切除手術(shù)范圍和術(shù)式選擇IVIII可切除性判斷和手術(shù)規(guī)劃制訂準(zhǔn)確評定肝門膽管癌侵襲范圍準(zhǔn)確評定預(yù)留剩下肝臟功效和必需功效性肝臟體積明確圍肝門部脈管解剖肝門部膽管癌診療和治療，

肝門部膽管癌治療進(jìn)展第39頁肝門膽管癌切除根治程度腫瘤根治術(shù)按照腫瘤切緣有沒有癌細(xì)胞，分為以下幾個切除R0指切緣無癌細(xì)胞，完整切除R1切除指鏡下見切緣有癌細(xì)胞R2指肉眼可見切緣癌細(xì)胞在肝門部膽管細(xì)胞癌治療中，盡可能做到R0切除肝門部膽管癌治療進(jìn)展第40頁R0resectionsignificantlyimprovedsurvivalrate

1、R0切除能顯著提升術(shù)后生存率JunjieXiongetal.JournalofSurgicalResearch,

R0resectionimprovedsurvivalrate(P=0.037)肝門部膽管癌治療進(jìn)展第41頁NegativeresectionmarginisthekeyforR0resection:

theroleofintraoperativefrozensection

R0切除關(guān)鍵是陰性切緣：術(shù)中冰凍檢測關(guān)鍵部位

DarioRibero,etal.AnnSurg,術(shù)中冰凍檢測切緣若切緣陽性,未到達(dá)R0切除此時如深入切除并到達(dá)R0切除，可提升生存率肝門部膽管癌治療進(jìn)展第42頁Survivalofpatientsresectednegativemarginsversus

thosewhoresectedwithpositivemargins

陰性切緣和陽性切緣患者生存率對比Patientsresectedwithnegativemarginshadabetter5-yearsurvivalof45%thanpatientsresectedwithpositivemargins,withnopatientresectedwithpositivemarginssurvivinglongerthan40monthsAlanW.Hemming,AnnSurg,negativemarginspositivemargins肝門部膽管癌治療進(jìn)展第43頁2、No-touch-techniqueanden-bloc-resection不接觸技術(shù)和整塊切除PeterNeuhaus,etal.AnnSurgOncol,白線為切除線黑線為切除線Hilaren-bloc-resection優(yōu)點：防止腫瘤周圍肝門部血管解剖門靜脈切除提升了R0切除率歐洲外科學(xué)會主席PeterNeuhaus教授提出：BismuthⅢa和BismuthⅣ型，只有施行擴大右半肝和門靜脈切除，才能到達(dá)理想廣泛切緣陰性和腫瘤不接觸標(biāo)準(zhǔn)目標(biāo)肝門部膽管癌治療進(jìn)展第44頁Hilaren-bloc-resectionincrediblyincreasethesurvivalofCC肝門部整塊切除顯著提升肝門膽管癌生存率PeterNeuhaus,etal.AnnSurgOncol,不接觸技術(shù)、整塊切除和廣泛切緣腫瘤陰性三大肝門膽管癌外科手術(shù)標(biāo)準(zhǔn)整塊切除組顯著優(yōu)于普通肝切組肝門部膽管癌治療進(jìn)展第45頁Lymphnodedissectionimprovedprognosis

3、徹底淋巴結(jié)清掃能提升預(yù)后YoungLA,JHepatobiliaryPancreatSci,范圍：清掃肝十二指腸韌帶淋巴結(jié)和結(jié)締組織（12,12p,12b組）,胰頭上、后淋巴結(jié)（胰腺上、后13a組），及肝總動脈周圍淋巴結(jié)

（8組）徹底清掃淋巴結(jié)與預(yù)后顯著相關(guān)肝門部膽管癌治療進(jìn)展第46頁Lymphnodesmetastasis肝門膽管癌淋巴結(jié)轉(zhuǎn)移名古屋大學(xué)從屬醫(yī)院110例肝門膽管癌手術(shù)切除患者30%~50%伴淋巴轉(zhuǎn)移膽總管旁淋巴結(jié)（42.7%）門靜脈旁（30.9%）肝總動脈旁（27.3%）胰頭十二指腸后（14.5%）KitagawaY,etal.AnnSurg,GroupI:無淋巴結(jié)轉(zhuǎn)移；GroupII:局部淋巴結(jié)轉(zhuǎn)移；GroupIII:腹主動脈旁淋巴結(jié)轉(zhuǎn)移；A:鏡檢陽性；B:肉眼陽性+鏡檢陽性；C:無法切除；GroupIII患者術(shù)后生存與淋巴結(jié)侵犯親密相關(guān)肝門部膽管癌治療進(jìn)展第47頁75casescclymphnodesmetastasisandprognosisVeronauniversity,Italy淋巴結(jié)轉(zhuǎn)移及預(yù)后分析AlfredoGuglielmi,JGastrointestSurg,術(shù)中切除淋巴結(jié)>3枚以上能提升生存期淋巴結(jié)陽性率>0.25提醒預(yù)后不良淋巴結(jié)陽性預(yù)后不良肝門部膽管癌治療進(jìn)展第48頁4、尾狀葉切除是R0切除關(guān)鍵GazzanigaGM,JHepatobiliaryPancreatSurg,行尾狀葉切除未行尾狀葉切除肝門膽管癌尾狀葉累及高達(dá)40%-98%，故尾狀葉切除是R0切除關(guān)鍵尾狀葉膽管：可匯入左、右肝管及左、右肝管匯合處肝門膽管癌常累及肝尾狀葉肝門部膽管癌治療進(jìn)展第49頁Resectionofcaudatelobeoflivergreatlyincreasethesurvival肝尾狀葉切除能顯著提升生存率尾狀葉切除顯著提升患者術(shù)后總體生存與無瘤生存率，改進(jìn)Ⅲa和Ⅲb期患者預(yù)后KowAW,etal.WorldJSurg,來自韓國SamsungMedicalCenter針對127例患者回顧性分析：尾狀葉切除組尾狀葉切除組肝門部膽管癌治療進(jìn)展第50頁Invasionoftheportalvein

isnottheoperativecontraindication

5、門靜脈侵犯不是手術(shù)禁忌征肝門膽管癌門靜脈侵犯較多見（36%）門靜脈切除能提升R0切除率（P=0.003）YoungAL,JHepatobiliaryPancreatSci,

MechteldC.deJong,etal.Cancer,肝門部膽管癌治療進(jìn)展第51頁Therewasnosignificantdifferenceinsurvival

betweenportalveinresection(PVR)andNoPVR

門靜脈切除并不增加死亡率AlanWHemming,JAmCollSurg,門靜脈切除組與非門靜脈切除組術(shù)后生存無統(tǒng)計學(xué)差異肝門部膽管癌治療進(jìn)展第52頁238例肝門膽管細(xì)胞癌患者分別為R0、R0+PVR、R1、R2切除后，與其它三組相比，R0+PVR組生存情況不如單純R0切除（P＜0.001），與R1組生存情況相同（P=0.606），但優(yōu)于R2組（P=0.047）WenlongYu,CellBiochemBiophys,R0切除合并門靜脈切除相比單純R0切除降低了生存率合并門靜脈切除患者存在門靜脈侵犯情況，情況較單獨R0切除組差結(jié)論仍需大樣本臨床病例驗證肝門部膽管癌治療進(jìn)展第53頁CommontypesofthevesselreconstructionafterPVR肝門靜脈重建常見類型PV-SMVPV重建方法例舉利用Y形髂動脈行門靜脈-脾靜脈、門靜脈-腸系膜上靜脈吻合肝門部膽管癌治療進(jìn)展第54頁Hepaticarteryresectionandreconstruction

6、肝動脈切除及重建肝動脈侵犯肝動脈重建后吻合口Male,74ys，hepaticarteryinvasion,hepaticarteryresectionandreconstructionduringoperation肝門部膽管癌治療進(jìn)展第55頁deSantiba?esE,HPB,acb離斷左、右肝動脈及右肝后動脈將左肝動脈端與右肝后動脈吻合重建完成后行左半肝切除兩例肝門膽管癌BismuthⅢb期行左半肝切除+尾狀葉切除，術(shù)中行肝動脈重建肝門部膽管癌治療進(jìn)展第56頁

確保膽管良好血供無張力吻合連續(xù)(后壁連續(xù)、前壁間斷)

5/6/7-0prolene或可吸收線不放置支架或T管Reconstructionofbileduct膽管重建經(jīng)驗肝門部膽管癌治療進(jìn)展第57頁三支膽管重建肝門部膽管癌治療進(jìn)展第58頁膽腸吻合肝門部膽管癌治療進(jìn)展第59頁膽腸吻合結(jié)束肝門部膽管癌治療進(jìn)展第60頁經(jīng)典病例1男，65歲，診療為肝門膽管癌，行半肝切除術(shù)清掃淋巴結(jié)膽管重建肝門部膽管癌治療進(jìn)展第61頁經(jīng)典病例2侵犯肝臟男性,46歲，肝門膽管癌伴胰腺周圍淋巴結(jié)轉(zhuǎn)移，行胰十二指腸聯(lián)合肝臟切除BismuthIVAfterHPD胰周淋巴結(jié)轉(zhuǎn)移HPD術(shù)后

肝門部膽管癌治療進(jìn)展第62頁達(dá)芬奇機器人輔助外科手術(shù)系統(tǒng)醫(yī)生操作臺床旁機械臂塔顯示器肝門部膽管癌治療進(jìn)展第63頁達(dá)芬奇機器人與肝膽外科手術(shù)車器械護(hù)士術(shù)者巡回護(hù)士麻醉師助手顯示器肝門部膽管癌治療進(jìn)展第64頁Palliativetherapy姑息性治療大多數(shù)肝門膽管癌患者并沒有接收手術(shù)治療機會，解除膽道梗阻成為主要治療目標(biāo)，主要包含膽腸吻合旁路手術(shù)、內(nèi)鏡膽道引流和經(jīng)皮肝穿刺膽道引流。有效，并發(fā)癥相對較多，適合用于晚期患者，無法接收膽道支架患者ERCPPTCD膽腸吻合旁路手術(shù)安全，有效廉價，應(yīng)用廣泛有效，相對安全，適合用于無法內(nèi)鏡膽道引流時WeberA,etal,WorldJGastroenterol,

肝門部膽管癌治療進(jìn)展第65頁Applicationoflaparoscopyinthetreatmentofhilarcholangiocarcinomafield內(nèi)鏡治療在肝門膽管癌領(lǐng)域應(yīng)用

IzbickiJR,JGastrointestSurg,

術(shù)前探查：能發(fā)覺隱匿轉(zhuǎn)移灶又降低了手術(shù)創(chuàng)傷。應(yīng)用腹腔鏡探查結(jié)合MSKCC分期，發(fā)覺36%T2/T3期存在隱匿病灶。提醒對T2/T3期患者選擇性應(yīng)用腹腔鏡探查含有一定價值手術(shù)治療：技術(shù)上不足限制了采取微創(chuàng)技術(shù)治療肝門膽管癌，當(dāng)前報道較少有報道借助機器人腹腔鏡手術(shù)系統(tǒng)行右半肝切除聯(lián)合膽道重建GiulianottiPC.JLaparoendoscAdvSurgTechA,肝門部膽管癌治療進(jìn)展第66頁肝門膽管癌支架引流金屬支架長久通暢率和相對成本效益比塑料支架高，金屬支架能保持通暢時間顯著長于塑料支架者，尤其于不可切除性腫瘤患者金屬支架組塑料支架組JohnZ,BMCGastroenterol.通暢率肝門部膽管癌治療進(jìn)展第67頁對身體腫瘤進(jìn)行手術(shù)治療和放療前后，應(yīng)用化療，使原發(fā)腫瘤縮小，提升治愈率而進(jìn)行化學(xué)藥品治療輔助化療HepatobiliarySurgNutr.KevinC等人分析了63例肝門膽管癌患者臨床數(shù)據(jù)其中29例患者做了術(shù)前化療，和體外化療接收輔助化療患者組五年生存率（33.9%）顯著高于未輔助化療組（13.9%）（P＜0.001）肝門部膽管癌治療進(jìn)展第68頁Livertransplantationforhilarcholangiocarcinoma

肝門膽管癌肝移植治療EarlyStgagePoorprognosis，5-yearsurvivalrate:30%，tumorrecurrencerate:50%RelativecontradictionofLTMeyeretal,Transplantation,Poor

prognosis肝門部膽管癌治療進(jìn)展第69頁IndicationoflivertransplantationforhilarcholangiocarcinomainMayoClinic

梅奧醫(yī)學(xué)中心肝門膽管癌肝移植指征Include入選指征Reaetal.

AnnSurg,

1、肝門膽管癌診療：經(jīng)導(dǎo)管活檢或毛刷細(xì)胞學(xué)檢驗陽性CA199＞100mg/ml和（或）斷層掃描有塊狀陰影而且膽管造影有惡性腫瘤結(jié)構(gòu)FISH檢測膽管染色體倍數(shù)而且膽管造影有惡性腫瘤結(jié)構(gòu)2、膽囊管以上無法切除腫瘤3、放射檢驗顯示腫瘤直徑≤3cm4、無肝內(nèi)肝外轉(zhuǎn)移5、肝移植候選者