• 中山大學(xué)附屬第一醫(yī)院肝膽外科（廣州 510080）;

肝門部膽管癌（hilar cholangiocarcinoma），又稱Klaskin癌，是指起源于左右肝管、分叉部和肝總管上段膽管上皮的惡性腫瘤，約占膽管癌的60%~70%［1］。由于其臨床表現(xiàn)隱匿，早期難以被發(fā)現(xiàn)。目前根治性手術(shù)是最有效的提高其生存率的治療方式，隨著肝門部膽管癌R0切除率的不斷升高，5年生存率不斷提高［2，3］，但仍有不少問(wèn)題有待于解決……

引用本文： 何強(qiáng),梁力建. 肝門部膽管癌外科治療的若干問(wèn)題. 中國(guó)普外基礎(chǔ)與臨床雜志, 2009, 16(11): 869-872. doi: 復(fù)制

1. Khan SA, Thomas HC, Davidson BR, et al. Cholangiocarcinoma [Ｊ]. Lancet， 2005; 366(9493): 1303-1314.
2. DeOliveira ML, Cunningham SC, Cameron JL, et al. Cho-langiocarcinoma: thirty-one-year experience with 564 patients at a single institution [Ｊ]. Ann Surg, 2007; 245(5): 755-762.
3. Hidalgo E, Asthana S, Nishio H, et al. Surgery for hilar cholangiocarcinoma: the Leeds experience [Ｊ]. Eur J Surg Oncol, 2008; 34(7): 787-794.
4. Nagino M, Takada T, Miyazaki M, et al. Preoperative biliary drainage for biliary tract and ampullary carcinomas [Ｊ]. J Hepatobiliary Pancreat Surg, 2008; 15(1): 25-30.
5. Nimura Y. Preoperative biliary drainage before resection for cholangiocarcinoma (Pro) [Ｊ]. HPB (Oxford), 2008; 10(2): 130-133.
6. 陳東, 彭寶崗, 李紹強(qiáng), 等. 肝門部膽管癌術(shù)前減黃臨床價(jià)值 [Ｊ]. 中國(guó)實(shí)用外科雜志, 2007; 27(10): 805-808.
7. Yokoyama Y, Nagino M, Nishio H, et al. Recent advances in the treatment of hilar cholangiocarcinoma: portal vein embolization [Ｊ]. J Hepatobiliary Pancreat Surg, 2007; 14(5): 447-454.
8. Komori K, Nagino M, Nimura Y. Hepatocyte morphology and kinetics after portal vein embolization [Ｊ]. Br J Surg, 2006; 93(6): 745-751.
9. Nagino M, Kamiya J, Nishio H, et al. Two hundred forty consecutive portal vein embolizations before extended hepatectomy for biliary cancer: surgical outcome and long-term follow-up [Ｊ]. Ann Surg, 2006; 243(3): 364-372.
10. de Baère T, Roche A, Amenabar JM, et al. Liver abscess formation after local treatment of liver tumors [Ｊ]. Hepatology, 1996; 23(6): 1436-1440.
11. Doppman JL, Girton M, Vermess M. The risk of hepatic artery embolization in the presence of obstructive jaundice [Ｊ]. Radiology, 1982; 143(1): 37-43.
12. Di Stefano DR, de Baere T, Denys A, et al. Preoperative percutaneous portal vein embolization: evaluation of adverse events in 188 patients [Ｊ]. Radiology, 2005; 234(2): 625-630.
13. Greene FL, Page DL, Fleming ID, et al. AJCC cancer staging manual [S]. 6th eds. Berlin Heidelberg-New York: Springer, 2002.
14. Nishio H, Nagino M, Oda K, et al. TNM classification for perihilar cholangiocarcinoma: comparison between 5th and 6th editions of the AJCC/UICC staging sys [Ｊ]. Langenbecks Arch Surg, 2005; 390(4): 319-327.
15. Burke EC, Jarnagin WR, Hochwald SN, et al. Hilar Cholangiocarcinoma: patterns of spread, the importance of hepatic resection for curative operation, and a presurgical clinical staging system [Ｊ]. Ann Surg, 1998; 228(3): 385-394.
16. Jarnagin WR, Fong Y, DeMatteo RP, et al. Staging, resectability, and outcome in 225 patients with hilar cholangiocarcinoma [Ｊ]. Ann Surg, 2001; 234(4): 507-517.
17. Chen RF, Li ZH, Zhou JJ, et al. Preoperative evaluation with T-staging system for hilar cholangiocarcinoma [Ｊ]. World J Gastroenterol, 2007; 13(43): 5754-5759.
18. 彭承宏, 趙之明, 彭淑牖, 等. 用 T-分期系統(tǒng)回顧性分析 47例肝門部膽管癌 [Ｊ]. 中華外科雜志, 2005; 43 (1): 56-59.
19. Ito F, Agni R, Rettammel RJ, et al. Resection of hilar cholangiocarcinoma: concomitant liver resection decreases hepatic recurrence [Ｊ]. Ann Surg, 2008; 248(2): 273-279.
20. 賴佳明， 梁力建， 李紹強(qiáng)， 等. 手術(shù)切除治療肝門部膽管癌 [Ｊ]. 中華肝膽外科雜志， 2006; 12(8): 509-511.
21. Yubin L, Chihua F, Zhixiang J, et al. Surgical management and prognostic factors of hilar cholangiocarcinoma: experience with 115 cases in China [Ｊ]. Ann Surg Oncol, 2008; 15(8): 2113-2119.
22. Tsalis K, Vasiliadis K, Kalpakidis V, et al. A single-center experience in the management of Altemeier-Klatskin tumors [Ｊ]. J Gastrointestin Liver Dis, 2007; 16(4): 383-389.
23. 周寧新, 黃志強(qiáng), 張文智, 等. 402例肝門部膽管癌臨床分型、手術(shù)方式與遠(yuǎn)期療效的綜合分析 [Ｊ]. 中華外科雜志, 2006; 44(23): 1599-1603.
24. Ikeyama T, Nagino M, Oda K, et al. Surgical approach to bismuth Type Ⅰ and Ⅱ hilar cholangiocarcinomas: audit of 54 consecutive cases [Ｊ]. Ann Surg, 2007; 246(6): 1052-1057.
25. Paik KY, Choi DW, Chung JC, et al. Improved survival following right trisectionectomy with caudate lobectomy without operative mortality: surgical treatment for hilar cholangiocarcinoma [Ｊ]. J Gastrointest Surg, 2008; 12(7): 1268-1274.
26. van Gulik TM, Gouma DJ. Changing perspectives in the assessment of resectability of hilar cholangiocarcinoma [Ｊ]. Ann Surg Oncol, 2007; 14(7): 1969-1971.
27. Hemming AW, Kim RD, Mekeel KL, et al. Portal vein resection for hilar cholangiocarcinoma [Ｊ]. Am Surg, 2006; 72(7): 599-604.
28. Miyazaki M, Kato A, Ito H, et al. Combined vascular resection in operative resection for hilar cholangiocarcinoma: does it work or not? [Ｊ]. Surgery, 2007; 141(5): 581-588.
29. 韓風(fēng), 周進(jìn)學(xué), 張玲, 等. 肝葉切除聯(lián)合門靜脈切除和重建在肝門部膽管癌根治術(shù)中的應(yīng)用 [Ｊ]. 中華外科雜志， 2007； 45（11）： 763-765.
30. Sakamoto Y, Sano T, Shimada K, et al. Clinical significance of reconstruction of the right hepatic artery for biliary malignancy [Ｊ]. Langenbecks Arch Surg, 2006; 391(3): 203-208.
31. Miyazaki M, Kimura F, Shimizu H, et al. Recent advance in the treatment of hilar cholangiocarcinoma: hepatectomy with vascular resection [Ｊ]. J Hepatobiliary Pancreat Surg, 2007; 14(5): 463-468.
32. 黃志強(qiáng). 肝門部膽管癌外科治療觀念能否有所轉(zhuǎn)變 [Ｊ]. 臨床外科雜志, 2008; 16(1): 3-4.
33. Han SS, Jang JY, Lee KU, et al. Actual long-term outcome of Klatskin’s tumor after surgical resection [Ｊ]. Hepatogastroenterology, 2008; 55(88): 1986-1992.
34. 孫學(xué)軍， 石景森， 何平, 等. 影響膽管癌切除術(shù)后的預(yù)后因素分析 [Ｊ]. 中國(guó)普外基礎(chǔ)與臨床雜志, 2006; 13(1): 85-88.
35. Nagino M, Kamiya J, Arai T, et al. “Anatomic” right hepatic trisectionectomy (extended right hepatectomy) with caudate lobectomy for hilar cholangiocarcinoma [Ｊ]. Ann Surg, 2006; 243(1): 28-32.
36. Pinson CW, Rossi RL. Extended right hepatic lobectomy, left hepatic lobectomy, and skeletonization resection for proximal bile duct cancer [Ｊ]. World J Surg, 1988; 12(1):52-59.
37. Bismuth H, Nakache R, Diamond T. Management strategies in resection for hilar cholangiocarcinoma [Ｊ]. Ann Surg, 1992; 215(1): 31-38.
38. Kitagawa Y, Nagino M, Kamiya J, et al. Lymph node metastasis from hilar cholangiocarcinoma: audit of 110 patients who underwent regional and paraaortic node dissection [Ｊ]. Ann Surg, 2001; 233(3): 385-392.
39. 蔡秀軍， 沈波. 肝門部膽管癌術(shù)中淋巴結(jié)清掃 [Ｊ]. 中國(guó)實(shí)用外科雜志， 2007; 27(5): 366-367.
40. Baton O, Azoulay D, Adam DV, et al. Major hepatectomy for hilar cholangiocarcinoma type 3 and 4: prognostic factors and longterm outcomes [Ｊ]. J Am Coll Surg, 2007; 204(2): 250-260.
41. Tojima Y, Nagino M, Ebata T, et al. Immunohistochemically demonstrated lymph node micrometastasis and prognosis in patients with otherwise node-negative hilar cholangiocarcinoma [Ｊ]. Ann Surg, 2003; 237(2): 201-207.
42. Jonas S, Benckert C, Thelen A, et al. Radical surgery for hilar cholangiocarcinoma [Ｊ]. Eur J Surg Oncol, 2008; 34(3): 263-271.
43. Rea DJ, Heimbach JK, Rosen CB, et al. Liver transplantation with neoadjuvant chemoradiation is more effective than resection for hilar cholangiocarcinoma [Ｊ]. Ann Surg, 2005; 242(3): 451-458.
44. Thelen A, Neuhaus P. Liver transplantation for hilar cholangiocarcinoma [Ｊ]. J Hepatobiliary Pancreat Surg, 2007; 14(5): 469-475.
  1. 1. Khan SA, Thomas HC, Davidson BR, et al. Cholangiocarcinoma [Ｊ]. Lancet， 2005; 366(9493): 1303-1314.
  2. 2. DeOliveira ML, Cunningham SC, Cameron JL, et al. Cho-langiocarcinoma: thirty-one-year experience with 564 patients at a single institution [Ｊ]. Ann Surg, 2007; 245(5): 755-762.
  3. 3. Hidalgo E, Asthana S, Nishio H, et al. Surgery for hilar cholangiocarcinoma: the Leeds experience [Ｊ]. Eur J Surg Oncol, 2008; 34(7): 787-794.
  4. 4. Nagino M, Takada T, Miyazaki M, et al. Preoperative biliary drainage for biliary tract and ampullary carcinomas [Ｊ]. J Hepatobiliary Pancreat Surg, 2008; 15(1): 25-30.
  5. 5. Nimura Y. Preoperative biliary drainage before resection for cholangiocarcinoma (Pro) [Ｊ]. HPB (Oxford), 2008; 10(2): 130-133.
  6. 6. 陳東, 彭寶崗, 李紹強(qiáng), 等. 肝門部膽管癌術(shù)前減黃臨床價(jià)值 [Ｊ]. 中國(guó)實(shí)用外科雜志, 2007; 27(10): 805-808.
  7. 7. Yokoyama Y, Nagino M, Nishio H, et al. Recent advances in the treatment of hilar cholangiocarcinoma: portal vein embolization [Ｊ]. J Hepatobiliary Pancreat Surg, 2007; 14(5): 447-454.
  8. 8. Komori K, Nagino M, Nimura Y. Hepatocyte morphology and kinetics after portal vein embolization [Ｊ]. Br J Surg, 2006; 93(6): 745-751.
  9. 9. Nagino M, Kamiya J, Nishio H, et al. Two hundred forty consecutive portal vein embolizations before extended hepatectomy for biliary cancer: surgical outcome and long-term follow-up [Ｊ]. Ann Surg, 2006; 243(3): 364-372.
  10. 10. de Baère T, Roche A, Amenabar JM, et al. Liver abscess formation after local treatment of liver tumors [Ｊ]. Hepatology, 1996; 23(6): 1436-1440.
  11. 11. Doppman JL, Girton M, Vermess M. The risk of hepatic artery embolization in the presence of obstructive jaundice [Ｊ]. Radiology, 1982; 143(1): 37-43.
  12. 12. Di Stefano DR, de Baere T, Denys A, et al. Preoperative percutaneous portal vein embolization: evaluation of adverse events in 188 patients [Ｊ]. Radiology, 2005; 234(2): 625-630.
  13. 13. Greene FL, Page DL, Fleming ID, et al. AJCC cancer staging manual [S]. 6th eds. Berlin Heidelberg-New York: Springer, 2002.
  14. 14. Nishio H, Nagino M, Oda K, et al. TNM classification for perihilar cholangiocarcinoma: comparison between 5th and 6th editions of the AJCC/UICC staging sys [Ｊ]. Langenbecks Arch Surg, 2005; 390(4): 319-327.
  15. 15. Burke EC, Jarnagin WR, Hochwald SN, et al. Hilar Cholangiocarcinoma: patterns of spread, the importance of hepatic resection for curative operation, and a presurgical clinical staging system [Ｊ]. Ann Surg, 1998; 228(3): 385-394.
  16. 16. Jarnagin WR, Fong Y, DeMatteo RP, et al. Staging, resectability, and outcome in 225 patients with hilar cholangiocarcinoma [Ｊ]. Ann Surg, 2001; 234(4): 507-517.
  17. 17. Chen RF, Li ZH, Zhou JJ, et al. Preoperative evaluation with T-staging system for hilar cholangiocarcinoma [Ｊ]. World J Gastroenterol, 2007; 13(43): 5754-5759.
  18. 18. 彭承宏, 趙之明, 彭淑牖, 等. 用 T-分期系統(tǒng)回顧性分析 47例肝門部膽管癌 [Ｊ]. 中華外科雜志, 2005; 43 (1): 56-59.
  19. 19. Ito F, Agni R, Rettammel RJ, et al. Resection of hilar cholangiocarcinoma: concomitant liver resection decreases hepatic recurrence [Ｊ]. Ann Surg, 2008; 248(2): 273-279.
  20. 20. 賴佳明， 梁力建， 李紹強(qiáng)， 等. 手術(shù)切除治療肝門部膽管癌 [Ｊ]. 中華肝膽外科雜志， 2006; 12(8): 509-511.
  21. 21. Yubin L, Chihua F, Zhixiang J, et al. Surgical management and prognostic factors of hilar cholangiocarcinoma: experience with 115 cases in China [Ｊ]. Ann Surg Oncol, 2008; 15(8): 2113-2119.
  22. 22. Tsalis K, Vasiliadis K, Kalpakidis V, et al. A single-center experience in the management of Altemeier-Klatskin tumors [Ｊ]. J Gastrointestin Liver Dis, 2007; 16(4): 383-389.
  23. 23. 周寧新, 黃志強(qiáng), 張文智, 等. 402例肝門部膽管癌臨床分型、手術(shù)方式與遠(yuǎn)期療效的綜合分析 [Ｊ]. 中華外科雜志, 2006; 44(23): 1599-1603.
  24. 24. Ikeyama T, Nagino M, Oda K, et al. Surgical approach to bismuth Type Ⅰ and Ⅱ hilar cholangiocarcinomas: audit of 54 consecutive cases [Ｊ]. Ann Surg, 2007; 246(6): 1052-1057.
  25. 25. Paik KY, Choi DW, Chung JC, et al. Improved survival following right trisectionectomy with caudate lobectomy without operative mortality: surgical treatment for hilar cholangiocarcinoma [Ｊ]. J Gastrointest Surg, 2008; 12(7): 1268-1274.
  26. 26. van Gulik TM, Gouma DJ. Changing perspectives in the assessment of resectability of hilar cholangiocarcinoma [Ｊ]. Ann Surg Oncol, 2007; 14(7): 1969-1971.
  27. 27. Hemming AW, Kim RD, Mekeel KL, et al. Portal vein resection for hilar cholangiocarcinoma [Ｊ]. Am Surg, 2006; 72(7): 599-604.
  28. 28. Miyazaki M, Kato A, Ito H, et al. Combined vascular resection in operative resection for hilar cholangiocarcinoma: does it work or not? [Ｊ]. Surgery, 2007; 141(5): 581-588.
  29. 29. 韓風(fēng), 周進(jìn)學(xué), 張玲, 等. 肝葉切除聯(lián)合門靜脈切除和重建在肝門部膽管癌根治術(shù)中的應(yīng)用 [Ｊ]. 中華外科雜志， 2007； 45（11）： 763-765.
  30. 30. Sakamoto Y, Sano T, Shimada K, et al. Clinical significance of reconstruction of the right hepatic artery for biliary malignancy [Ｊ]. Langenbecks Arch Surg, 2006; 391(3): 203-208.
  31. 31. Miyazaki M, Kimura F, Shimizu H, et al. Recent advance in the treatment of hilar cholangiocarcinoma: hepatectomy with vascular resection [Ｊ]. J Hepatobiliary Pancreat Surg, 2007; 14(5): 463-468.
  32. 32. 黃志強(qiáng). 肝門部膽管癌外科治療觀念能否有所轉(zhuǎn)變 [Ｊ]. 臨床外科雜志, 2008; 16(1): 3-4.
  33. 33. Han SS, Jang JY, Lee KU, et al. Actual long-term outcome of Klatskin’s tumor after surgical resection [Ｊ]. Hepatogastroenterology, 2008; 55(88): 1986-1992.
  34. 34. 孫學(xué)軍， 石景森， 何平, 等. 影響膽管癌切除術(shù)后的預(yù)后因素分析 [Ｊ]. 中國(guó)普外基礎(chǔ)與臨床雜志, 2006; 13(1): 85-88.
  35. 35. Nagino M, Kamiya J, Arai T, et al. “Anatomic” right hepatic trisectionectomy (extended right hepatectomy) with caudate lobectomy for hilar cholangiocarcinoma [Ｊ]. Ann Surg, 2006; 243(1): 28-32.
  36. 36. Pinson CW, Rossi RL. Extended right hepatic lobectomy, left hepatic lobectomy, and skeletonization resection for proximal bile duct cancer [Ｊ]. World J Surg, 1988; 12(1):52-59.
  37. 37. Bismuth H, Nakache R, Diamond T. Management strategies in resection for hilar cholangiocarcinoma [Ｊ]. Ann Surg, 1992; 215(1): 31-38.
  38. 38. Kitagawa Y, Nagino M, Kamiya J, et al. Lymph node metastasis from hilar cholangiocarcinoma: audit of 110 patients who underwent regional and paraaortic node dissection [Ｊ]. Ann Surg, 2001; 233(3): 385-392.
  39. 39. 蔡秀軍， 沈波. 肝門部膽管癌術(shù)中淋巴結(jié)清掃 [Ｊ]. 中國(guó)實(shí)用外科雜志， 2007; 27(5): 366-367.
  40. 40. Baton O, Azoulay D, Adam DV, et al. Major hepatectomy for hilar cholangiocarcinoma type 3 and 4: prognostic factors and longterm outcomes [Ｊ]. J Am Coll Surg, 2007; 204(2): 250-260.
  41. 41. Tojima Y, Nagino M, Ebata T, et al. Immunohistochemically demonstrated lymph node micrometastasis and prognosis in patients with otherwise node-negative hilar cholangiocarcinoma [Ｊ]. Ann Surg, 2003; 237(2): 201-207.
  42. 42. Jonas S, Benckert C, Thelen A, et al. Radical surgery for hilar cholangiocarcinoma [Ｊ]. Eur J Surg Oncol, 2008; 34(3): 263-271.
  43. 43. Rea DJ, Heimbach JK, Rosen CB, et al. Liver transplantation with neoadjuvant chemoradiation is more effective than resection for hilar cholangiocarcinoma [Ｊ]. Ann Surg, 2005; 242(3): 451-458.
  44. 44. Thelen A, Neuhaus P. Liver transplantation for hilar cholangiocarcinoma [Ｊ]. J Hepatobiliary Pancreat Surg, 2007; 14(5): 469-475.