肝門部膽管癌治療進(jìn)展課件

1、Hilar Cholangiocarcinoma:Current Management 肝門膽管癌治療進(jìn)展目 錄1定 義2病 因3病理分型4診 斷5治 療 A Klatskin tumor (or hilar cholangiocarcinoma) is a cholangiocarcinoma occurring at the confluence of the right and left hepatic bile ducts 發(fā)生于肝總管或左、右肝管及其匯合處的惡性腫瘤Proliferation of malignant adenocarcinoma and fibroblast 組織學(xué)

2、特征是惡性腺癌細(xì)胞和周圍的粗纖維細(xì)胞增生specific situation and infiltrated growth 發(fā)生部位特殊、呈浸潤性生長 Low radical resection rate with high operation risk 根治性切除率低、手術(shù)風(fēng)險大 A hard-to-treat disease 難以攻克的頑癥之一Hilar Cholangiocarcinoma, Klatskin Tumor肝門膽管癌Etiology of Hilar Cholangiocarcinoma 肝門膽管癌的病因目前病因尚不清楚，與膽管慢性炎癥、膽結(jié)石及膽汁淤積可能相關(guān)可能的病因：

3、PSC 原發(fā)性硬化性膽管炎Congenital biliary malformations 先天性膽道畸形，如多囊肝、膽總管囊腫、caloris病等Chronic ulcerative colitis 慢性潰瘍性結(jié)腸炎Parasitic infections 化學(xué)致癌物，如麝貓后睪吸蟲、華支睪吸蟲等Chemical carcinogens 化學(xué)致癌物多囊肝潰瘍性結(jié)腸炎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19992009，膽管癌發(fā)生概率為14%Kristen MB等人發(fā)現(xiàn)，Mayo評分4，吸煙、酗酒、炎癥性腸病病史患者更容易發(fā)生膽管癌Best Practice & Rese

4、arch Clinical Gastroenterology 2011Roles of Clonorchis Endemicus Infection as Risk Factor for CC華支睪吸蟲是肝門膽管癌的易感因素John Z, et al. Journal of Hepato-Biliary-Pancreatic Sciences, 2014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1025mmA history of eating raw freshwater fish and a positive serologic result fo

5、r C. sinensis were significantly associated with the development of CC食用淡水魚史并且華支睪吸蟲血清學(xué)試驗陽性的患者，與肝門膽管癌的發(fā)生發(fā)展密切相關(guān)Freshwater Fish and Clonorchis Endemicus淡水魚與華支睪吸蟲淡水魚是華支睪吸蟲的第二中間宿主The Ways of Metastasis轉(zhuǎn)移途徑Roland. Z, Hepatology, 2012Hematogenous metastasis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Lymphatic metastasi

6、s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)的12.6%Contact metastasis接觸轉(zhuǎn)移一般較少發(fā)生鄰近臟器的直接浸潤，但偶爾也可直接蔓延、浸潤至鄰近組織器官，如膈、胃、結(jié)腸、網(wǎng)膜等Metastasis along nerve fibers 沿神經(jīng)蔓延Hilar CholangiocarcinomaDiagnosis肝門膽管癌診斷方法 Hilar cholangio-carcinoma Clinical manifestation ：progressive painless jaundice進(jìn)行性無痛性黃疸 Imaging： CT, MRCP, ERCP, B ultrason

7、ic, PET-CTTumor marker: CA199, CEApathology：ERCP brush cytology, biopsy 毛刷細(xì)胞學(xué)檢查，活檢Diagnosis-CTCT診斷Diagnosis-MRIMRI診斷MRCPDiagnosis-MRCPMRCP診斷The Role of Histological Diagnosis組織學(xué)診斷的作用Koea et al, world journal of surgery, 2004Buc et al, HPB, 2008ERCP brush cytology(毛刷細(xì)胞學(xué)檢查):the first choiceForceps bio

8、psy and fine-needle aspiration is not mandatoryLow sensitivityRisk of metastasisResection remains the most reliable way to rule out biliary malignancyDistribution of Hilar Cholangiocarcinoma肝門膽管癌分布Murad Aljiffry, et al. World J Gastroenterol, 2009Hilar cholangiocarcinoma5%10%的膽管癌分布于肝內(nèi)膽管60%70%的膽管癌位于膽

9、道系統(tǒng)的分叉處，即肝門膽管癌，是膽管癌的主要類型。20%30%的膽管癌位于肝外膽管Pathology of Hilar Cholangiocarcinoma病理分型Hayashi S, et al. Cancer, 1994sclerosing硬化型（70%）nodular結(jié)節(jié)型（20%）papillary乳頭狀（5%）Transmural invasion 橫向浸潤，侵犯膽管及周圍組織Longitudinal extension 縱向浸潤，粘膜和粘膜下的擴(kuò)散 腫瘤可向上膽管上下侵犯Lymph node metastasis 淋巴結(jié)轉(zhuǎn)移PathologySpreadmore favorable

10、 prognosis預(yù)后較好majority of cases主要類型名稱分型或分期依據(jù)Bismuth-Corlette classification:the most common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無肝葉萎縮MSKCC改良T分期（Memorial Sloan-Kettering Cancer Genter） 腫瘤對肝動脈和門靜脈的侵犯程度AJCC（pTNM）分期術(shù)后病理結(jié)果Claissification and Staging分型分期 Bismuth-Corlette 分型Henri Bismuth, Ann Surg,

11、 1992IIIaIIIbIV臨床最常用，有助于計劃手術(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 ITumors below the confluence of the left and right hepatic duct 腫瘤位于膽總管上端IITumors reaching the confluence 腫瘤位于左右肝管分叉部IIIaTumors occluding the common hepatic duct and either the right duct腫瘤累及肝總管、匯合部和右肝管 IIIbTumors occluding the common hepat

12、ic duct and either the left duct 腫瘤累及肝總管、匯合部和左肝管IVTumors involving the confluence and boththe right and left hepatic ducts腫瘤累及肝總管、匯合部和同時累及左右肝管IIIIIIaIIIbIVBismuth-corlette classificationBismuth5種分型Gazzaniga分期（T分期法）T分期發(fā)展于Bismuth-Corlette 分期基礎(chǔ)之上主要包括以下三個因素：1、腫瘤位置及膽管受累程度（參見Bismuth-Corlette 分期）2、有無門靜脈侵犯3

13、、有無肝葉的萎縮T3: Tumors occluding the common hepatic duct or the secondary bile duct ,and involving the hepatic portal vein offside, or with the contra lateral liver atrophy, or involving the main hepatic portal vein腫瘤侵及肝管匯合部并且雙側(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M

14、SKCC改良T分期Classification &CriteriaT1: Tumors occluding the common hepatic duct or the secondary bile duct腫瘤侵及肝管匯合部和（或）單側(cè)侵襲至二級膽管T2: Tumors occluding the common hepatic duct or the secondary bile duct ,and involving the ipsilateral hepatic portal vein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 i

15、s used for assessing the resectability of liver carcinoma.Jarnagin WR. Ann Surg，2011AJCC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

16、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 Tis N0 M0A期 T1 N0 M0B期 T2 N0 M0A期 T3 N0 M0B期 T1、T2或T3 N1 M0期 T4 任何N M0 期 任何T 任何N M1American Joint Committee on Cancer. AJCC cancer staging manual. 7th edPrognostic Factors預(yù)后因素情況很好，恢復(fù)不錯腫瘤病理類型術(shù)前膽道引流術(shù)前定位與剩余肝膽紅素水平術(shù)前CA199水平腫瘤浸潤深度手術(shù)切除類型下腔靜脈侵犯Prognostic factor: preopera

17、tive serum CA19-9 levels1、術(shù)前CA19-9水平是肝門膽管癌術(shù)后的獨立預(yù)后因素術(shù)前CA19-9低于150U/ml的膽管細(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-Ke Cai1, Int J Clin Exp Pathol, 2014術(shù)前CA199150U/ml術(shù)前CA199150U/ml Rocha FG, et al. J Hepatobiliary Pancreat Sci, 2010Preoperative serum total bilirubin 10mg/dl associated with poor prog

18、nsois術(shù)前膽紅素10mg/dl,直接影響術(shù)后生存率Prognostic factor: preoperative serum total bilirubin2、術(shù)前膽紅素與預(yù)后Prognostic factor: the volume of remnant liver3、準(zhǔn)確的術(shù)前定位與剩余肝體積影響預(yù)后Precise visualization of anatomic structures Multidirectional assessment of biliary branches and vesselsAllowing improved operative planningRyoko

19、 Sasaki, The American Journal of Surgery ,2011The volume of remnant liver and prognosis剩余肝體積與預(yù)后關(guān)系Rocha FG, J Hepatobiliary Pancreat Sci, 2010通過48例患者的臨床數(shù)據(jù)分析顯示，剩余肝體積與預(yù)后具有顯著相關(guān)性 P=0.012Liu F, et al. Dig Dis Sci, 2010YES：unrelieved biliary obstruction is associated with hepatic and renal dysfunction and

20、coagulopathyNO：Preoperative biliary drainage is associated with an increased risk of complicationPreoperative biliary drainage remains controversialRecently, Meta analysis indicated preoperative biliary drainage had no benefit Prognostic factor: preoperative Biliary Drainage4、術(shù)前膽道引流Preoperative bili

21、ary decompression in patient with cholangiocarcinoma肝門膽管癌患者術(shù)前膽道減壓Case-comparison studyMajor liver resections without PBD are safe in most patients with obstructive jaundice. Transfusion requirements and incidence of postoperative complications, especially bile leaks and subphrenic collections, are h

22、igher in jaundiced patients. Whether PBD could improve these results remains to be determined肝門膽管癌術(shù)前膽道減壓能減少并發(fā)癥發(fā)生率，但是否能提高預(yù)后結(jié)果仍需進(jìn)一步研究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)現(xiàn)：黃疸患者與無黃疸患者組病死率為（5% vs 0%），肝衰發(fā)生率（5% vs 0%），膽漏等并發(fā)癥發(fā)生率（50% vs 15%）Preoperative biliary drainage of the FLR (future liver remnant)

23、 appears to improve outcome if the predicted volume is or = 30%, preoperative biliary drainage does not appear to improve perioperative outcomeRetrospective study研究顯示，當(dāng)剩余肝體積30%時，術(shù)前膽道引流能提升肝門膽管癌患者預(yù)后，當(dāng)剩余肝體積30%時，術(shù)前膽道引流對預(yù)后影響無統(tǒng)計學(xué)差異從19972007年間的60例肝臟切除術(shù)后患者根據(jù)剩余肝體積選擇性的使用術(shù)前膽道引流，65%的患者剩余肝體積30%（39/60）對照組中，肝體積30%

24、（21/60），其中有5人出現(xiàn)了肝體積不足，有4人死亡，并且缺少術(shù)前膽道引流（P=0.009）這篇meta分析包括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Retrospective studyMeta-analyse 711 casesAdvantages and disadvantages of different methods of bile drainage不同膽管引流方法的優(yōu)劣引流方法Maguchi H et al, J Hepatobiliary Pancreat

25、 Surg, 2007Prognostic factor: histological classification5、組織學(xué)分型影響預(yù)后分化程度與生存率Saxena A, The American Journal of Surgery, 2011高分化患者組中分化患者組低分化患者組Prognostic factor: Tumor depth6、腫瘤浸潤深度及長期預(yù)后Tumor depth more accurately stratifies patients and is a better predictor of long-term outcome 腫瘤浸潤深度是評估肝門膽管癌預(yù)后的一項重要

26、指標(biāo)de Jong MC, et al. Arch Surg. 2011腫瘤浸潤深度5mm組腫瘤浸潤深度5mm組Prognostic factor: type of liver resection7、肝切除類型與預(yù)后關(guān)系 Konstadoulakis,The American Journal of Surgery, 2008Right hepatectomy had better survival19982006年間的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%Invasion of IVC indicates poor p

27、rognosis8、下腔靜脈侵犯預(yù)示不良預(yù)后Konstadoulakis, The American Journal of Surgery, 2008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的73例患者中有3例（4%）出現(xiàn)了下腔靜脈侵犯統(tǒng)計結(jié)果提示嚴(yán)重的不良預(yù)后肝門膽管癌外科治療方法Patients resected(solid line) had better overall 5-year survival (35%) than patients that were not resected. No unresected patient(dotted line) survived

28、 to 24 monthsAlan W. Hemming, Ann Surg, 2005手術(shù)切除組非手術(shù)治療組Surgical resection外科切除Surgical resection is the best treatment for hilar cholangiocarcinomaT.M. van Gulik ,European Journal of Surgical Oncology, 2011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Actuarial survival of patients underwent resectionversus those were no

29、t resected手術(shù)切除對生存率的影響Precise surgical resection for hilar cholangiocarcinoma 肝門膽管癌的外科治療IIIV根治性切除手術(shù)的范圍和術(shù)式的選擇IVIII可切除性的判斷和手術(shù)規(guī)劃的制訂精確評估肝門膽管癌的侵襲范圍精確評估預(yù)留剩余肝臟功能和必需功能性肝臟體積明確圍肝門部的脈管解剖肝門部膽管癌的診斷和治療， 2013肝門膽管癌切除的根治程度腫瘤根治術(shù)按照腫瘤切緣有無癌細(xì)胞，分為以下幾種切除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)胞癌的治療中，盡量做到R0切除R0 resect

30、ion significantly improved survival rate1、R0切除能顯著提高術(shù)后生存率Junjie Xiong et al. Journal of Surgical Research, 2014 R0 resection improved survival rate(P=0.037)Negative resection margin is the key for R0 resection: the role of intraoperative frozen sectionR0切除的關(guān)鍵是陰性切緣：術(shù)中冰凍檢測的關(guān)鍵部位Dario Ribero, et al. Ann

31、Surg, 2011術(shù)中冰凍檢測切緣若切緣陽性,未達(dá)到R0切除此時如進(jìn)一步切除并達(dá)到R0切除，可提高生存率Survival of patients resected negative margins versus those who resectedwith positive margins陰性切緣和陽性切緣患者生存率對比Patients resected with negative margins had a better 5-year survival of 45% than patients resected with positive margins, with no patient

32、resected with positive margins surviving longer than 40 monthsAlan W. Hemming, Ann Surg, 2005negative marginspositive margins2、No-touch-technique and en-bloc-resection不接觸技術(shù)和整塊切除Peter Neuhaus, et al. Ann Surg Oncol, 2012白線為切除線黑線為切除線Hilar en-bloc-resection優(yōu)點：避免腫瘤周圍肝門部血管解剖門靜脈切除提高了R0切除率歐洲外科學(xué)會主席Peter Neu

33、haus教授提出：Bismutha和Bismuth 型，只有施行擴(kuò)大右半肝和門靜脈切除，才能達(dá)到理想的廣泛切緣陰性和腫瘤不接觸原則的目標(biāo)Hilar en-bloc-resection incredibly increase the survival of CC肝門部整塊切除顯著提高肝門膽管癌生存率Peter Neuhaus, et al. Ann Surg Oncol, 2012不接觸技術(shù)、整塊切除和廣泛的切緣腫瘤陰性的三大肝門膽管癌外科手術(shù)原則整塊切除組顯著優(yōu)于普通肝切組Lymph node dissection improved prognosis 3、徹底淋巴結(jié)清掃能提高預(yù)后Young

34、LA, J Hepatobiliary Pancreat Sci, 2010范圍：清掃肝十二指腸韌帶的淋巴結(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)Lymph nodes metastasis肝門膽管癌淋巴結(jié)轉(zhuǎn)移名古屋大學(xué)附屬醫(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%）Kitagawa Y, et al. Ann Surg, 2001Group I: 無淋巴結(jié)轉(zhuǎn)移；Group II:

35、局部淋巴結(jié)轉(zhuǎn)移；Group III: 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；Group III患者術(shù)后生存與淋巴結(jié)侵犯密切相關(guān)75cases cc lymph nodes metastasis and prognosis Verona university, Italy淋巴結(jié)轉(zhuǎn)移及預(yù)后分析Alfredo Guglielmi, J Gastrointest Surg, 2013術(shù)中切除淋巴結(jié)3枚以上能提高生存期淋巴結(jié)陽性率0.25提示預(yù)后不良淋巴結(jié)陽性預(yù)后不良4、尾狀葉切除是R0切除關(guān)鍵Gazzaniga GM, J Hepatobiliary Panc

36、reat Surg, 2000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切除的關(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Resection of caudate lobe of liver greatly increase the survival肝尾狀葉切除能顯著提高生存率尾狀葉切除顯著提高患者術(shù)后總體生存與無瘤生存率，改善a 和 b期患者預(yù)后Kow AW, et al. World J Surg, 2012來自韓國Samsung Medical Center針對127例患者的回顧性分析：尾狀葉切除組尾狀葉切除組Inv

37、asion of the portal vein is not the operative contraindication5、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%）門靜脈切除能提高R0切除率（P=0.003）Young AL, J Hepatobiliary Pancreat Sci, 2010 Mechteld C. de Jong, et al. Cancer, 2012There was no significant difference in survival between portal vein resection (PVR) and No PVR門靜脈切

38、除并不增加死亡率Alan W Hemming, J Am Coll Surg, 2011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)差別238例肝門膽管細(xì)胞癌患者分別為R0、R0+PVR、R1、R2切除后，與其他三組相比，R0+PVR組生存情況不如單純R0切除（P0.001），與R1組生存情況相似（P=0.606），但優(yōu)于R2組（P=0.047）Wenlong Yu, Cell Biochem Biophys, 2014R0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的患者存在門靜脈侵犯情況，情況較單獨R0切除組差結(jié)論仍需大樣本的臨床病例驗證Common types of th

39、e vessel reconstruction after PVR肝門靜脈重建的常見類型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Hepatic artery resection and reconstruction6、肝動脈切除及重建肝動脈侵犯肝動脈重建后吻合口Male, 74ys，hepatic artery invasion, hepatic artery resection and reconstruction during operationde Santibaes E, HPB, 2012 acb離斷左、右肝動脈及右肝后動脈將左肝動脈端

40、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Bismuth b期行左半肝切除+尾狀葉切除，術(shù)中行肝動脈重建 保證膽管良好血供 無張力吻合 連續(xù)(后壁連續(xù)、前壁間斷) 5/6/7-0 prolene或可吸收線 不放置支架或T管Reconstruction of bile duct膽管重建的經(jīng)驗三支膽管重建 膽腸吻合膽腸吻合結(jié)束典型病例1男，65歲，診斷為肝門膽管癌，行半肝切除術(shù)清掃淋巴結(jié)膽管重建典型病例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Bismuth IV After HPD 胰周淋巴結(jié)轉(zhuǎn)移HPD術(shù)后 達(dá)芬奇機(jī)器人輔助外科手術(shù)系統(tǒng)醫(yī)生操作臺

41、床旁機(jī)械臂塔顯示器達(dá)芬奇機(jī)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Palliative therapy姑息性治療 大多數(shù)肝門膽管癌患者并沒有接受手術(shù)治療的機(jī)會，解除膽道梗阻成為主要治療目的，主要包括膽腸吻合旁路手術(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，適用于晚期患者，無法接受膽道支架患者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，適用于無法內(nèi)鏡膽道引流時Weber A, et al, World J Gastroenterol, 2007 Application of laparoscopy in the treatment of

42、 hilar cholangiocarcinoma field內(nèi)鏡治療在肝門膽管癌領(lǐng)域的應(yīng)用 Izbicki JR, J Gastrointest Surg, 2012術(shù)前探查：能發(fā)現(xiàn)隱匿轉(zhuǎn)移灶又減少了手術(shù)創(chuàng)傷。應(yīng)用腹腔鏡探查結(jié)合MSKCC分期，發(fā)現(xiàn)36%的T2/T3 期存在隱匿病灶。提示對T2/T3 期患者選擇性的應(yīng)用腹腔鏡探查具有一定價值手術(shù)治療：技術(shù)上的局限性限制了采用微創(chuàng)技術(shù)治療肝門膽管癌，目前報道較少有報道借助機(jī)器人腹腔鏡手術(shù)系統(tǒng)行右半肝切除聯(lián)合膽道重建Giulianotti PC. J Laparoendosc Adv Surg Tech A, 2010肝門膽管癌支架引流金屬支架長

43、期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明顯長于塑料支架者，尤其于不可切除性腫瘤患者金屬支架組塑料支架組John Z, BMC Gastroenterol. 2012通暢率對身體的腫瘤進(jìn)行手術(shù)治療和放療的前后，應(yīng)用化療，使原發(fā)腫瘤縮小，提高治愈率而進(jìn)行的化學(xué)藥物治療輔助化療Hepatobiliary Surg Nutr. 2014Kevin C等人分析了63例肝門膽管癌患者的臨床數(shù)據(jù)其中29例患者做了術(shù)前化療，和體外化療接受輔助化療患者組的五年生存率（33.9%）顯著高于未輔助化療組（13.9%）（P0.001）Liver transplantation for hilar

44、cholangiocarcinoma肝門膽管癌肝移植治療Early StgagePoor prognosis，5-year survival rate :30%，tumor recurrence rate: 50%Relative contradiction of LTMeyer et al, Transplantation, 2000Poor prognosisIndication of liver transplantation for hilar cholangiocarcinoma in Mayo Clinic梅奧醫(yī)學(xué)中心的肝門膽管癌肝移植指征Include入選指征Rea et al. Ann Surg, 20051、肝門膽管癌診斷：經(jīng)導(dǎo)管活檢或毛刷細(xì)胞學(xué)檢查陽性CA199100mg/ml和（或）斷層掃描有塊狀陰影并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)并且膽管造影有惡性腫瘤結(jié)構(gòu)2、膽囊管以上無法切除的腫瘤3、放射檢查顯示腫瘤直徑3cm4、無肝內(nèi)肝外轉(zhuǎn)移5、肝移植的候選者M(jìn)ayo Clinic Protocal外照射+5-Fu近距放射療法 口服卡培他濱（希羅達(dá)） 移植前剖腹探查評估移植Rea et al