联合血管切除重建在肝门部胆管癌根治术中的应用

发布时间：2018-05-24 06:19

本文选题：肝门部胆管癌 + 肝切除　；参考：《华中科技大学》2016年博士论文

【摘要】：第一部分肝门部胆管癌根治术中血管切除重建的系统评价及meta分析目的：探讨联合血管切除重建在肝门部胆管癌根治性手术中的安全性和有效性。方法：检索PubMed数据库和Cochrane图书馆数据库,筛选相关文献,对联合受累血管切除和未行血管切除组比较,观察术后并发症,围手术期死亡率,R0切除率,5年存活率.Meta分析采用RevMan 5.3.5软件进行数据分析。结果：共计纳入14篇文献,比较血管切除组与未切除组在术后总体并发症发生率上两组之间无统计学意义(OR=1.54; 95% CI 0.77-3.07；P=0.22);同样对术后死亡率分析比较显示联合血管切除组与未切除组术后死亡率上并无明显差异(OR=1.24; 95% CI 0.52.2.93；P=0.63),但联合动脉切除重建时,患者术后死亡率较未切除组显著增加(OR=3.84; 95%CI 1.27-11.63; P=0.02),在R0切除上血管切除组比例更高(OR=3.84; 95% CI 1.27-11.63;P=0.03),联合血管切除组5年生存率低于未切除组(OR=1.9; 95% CI 1.23-2.93; P=0.004).结论：联合血管切除重建治疗肝门部胆管癌是相对安全可行的,有利于提高RO切除率,改善预后。由于纳入文献有限,尚需大样本的临床随机对照试验来进一步验证联合血管切除重建在肝门部胆管癌根治性手术中的作用。第二部分肝切除联合肝动脉切除对动物肝功能影响的实验研究目的：研究肝切除联合动脉切除对大鼠肝脏功能的影响。方法：S-D雄性大鼠40只,随机分为三组。A组：对照组行开腹；B组：动脉切除重建组行左肝切除;C组：动脉切除,行左肝切除肝动脉切除；模型构建成功后,观察术后大鼠恢复情况及术后死亡率,术后24小时,72小时及术后7天采集大鼠血液检测血清AST、ALT、TB、ALP肝功能。免疫组化检测PCNA肝脏组织增殖情况。结果：左肝切除及肝动脉切除,术后大鼠麻醉苏醒慢,部分大鼠出现死亡。与对照组相比,当同时结扎肝动脉及切除左肝时,大鼠术后肝功能水平变化最大,术后大鼠血清ALT、AST水平显著升高,而随后肝功能渐恢复,至术后7d时仍在正常值以上,其变化水平与对照组及单独行肝切除组相比具有统计学意义(P0.05)。联合肝切除及肝动脉切除组大鼠术后7d肝组织PCNA表达较对照组及肝切除组表达强度下降,并且部分细胞出现形态学变化,肝动脉切除后,大鼠肝组织增殖能力受到抑制。结论：肝切除合并肝动脉切除后大鼠肝脏功能受影响较大,术后肝功能恢复较慢。肝切除合并肝动脉切除后大鼠肝脏肝再生受到抑制。第三部分联合血管切除t建在肝门部胆管癌根治术中的应用(本中心经验)目的：探讨肝门部胆管癌的外科术前管理及治疗策略,研究肝门部胆管癌联合肝叶切除及血管切除重建在根治性手术中的价值。方法：对2009.7-2014.1在我们单治疗组就治的142例HC患者的临床资料进行回顾性分析,入院后完善术前B超,MDCT,MRCP相关检查,术前合并黄疸患者在B超引导下行PTCD减黄,并动态监测患者肝功能,待胆红素水平下降至正常后行ICG检测。术前3D评估,确定患者Bismuth分型,及肿瘤侵犯肝实质及周围血管情况,在此基础上预定手术规划,评价患者术后保留肝体积,肝储备功能,并与术中情况进行比较。结果：142例患者经充分术前准备及评估后共96例行肝门部胆管癌根治术,其中16例联合血管切除重建,16例患者中,行左半肝加尾状叶切除11例,2例行左三叶切除,3例行右半肝切除。联合门静脉切除重建11例,其中门静脉主干楔形切除修补4例,门静脉端端吻合6例,门静脉右前支切除重建1例。4例患者因肿瘤侵犯肝右动脉行联合肝右动脉切除+大隐静脉架桥重建术,1例患者肝右动脉切除后行端端吻合。3D评估Bismuth分型准确率为87.5%。对肝动脉变异情况进行评估,肝动脉总体变异率为23%。3D提示门静脉评估准确率为93.7%,评估动脉侵犯的准确率为87.5%。16例血管切除重建患者术后并发症为：1例胆漏,无腹腔出血及腹腔感染,无血管内血栓形成相关并发症,并发症率为6.25%;无围手术期死亡。16例患者随访结果如下：1例患者术后3月内死亡,1例术后半年内发生肝脏转移于术后9月死亡。2例患者术后失访,其余患者均继续随访中。结论：在大型医疗中心开展联合血管切除重建的肝门部胆管癌根治术有利于提高肿瘤可切除率,改善患者预后。完善的术前管理及3D精准评估及合理的手术策略可减少肝门部胆管癌术后并发症,保证手术安全性。
[Abstract]:Part 1 systematic evaluation of vascular resection and reconstruction in hilar cholangiocarcinoma and meta analysis objective: To explore the safety and effectiveness of combined resection and reconstruction in the radical operation of hilar cholangiocarcinoma. Methods: retrieval of PubMed database and Cochrane library database, screening related literature, and excision of associated vessels. Compared with the untreated group, the postoperative complications, peri operative mortality, R0 resection rate, and the 5 year survival rate.Meta analysis were analyzed by RevMan 5.3.5 software. Results: a total of 14 articles were included, and there was no statistical significance between the two groups in the vascular resection group and the unresected group (OR=1.54; 95% CI 0.77-3.07; P=0.22); compared with the postoperative mortality analysis, there was no significant difference between the combined resection group and the unresected group (OR=1.24; 95% CI 0.52.2.93; P=0.63), but the postoperative mortality of the patients was significantly increased (OR=3.84; 95%CI 1.27-11.63; P=0.02). The proportion of excised upper vessel resection group was higher (OR=3.84; 95% CI 1.27-11.63; P=0.03). The 5 year survival rate of the combined resection group was lower than that of the unresected group (OR=1.9; 95% CI 1.23-2.93; P=0.004). Conclusion: combined vascular resection and reconstruction for the treatment of hilar cholangiocarcinoma is relatively safe and beneficial to improve the rate of RO excision and improve the prognosis. Due to the inclusion Limited and large sample clinical randomized controlled trials to further verify the role of combined resection and reconstruction in the radical operation of hilar cholangiocarcinoma. Second experimental study on the effect of hepatectomy combined with hepatic arterectomy on animal liver function: To study the effect of hepatectomy combined with arterectomy on liver function in rats. Methods: 40 S-D male rats were randomly divided into three groups of.A groups: the control group was open to the abdomen; group B: left liver resection in the arterial resection and reconstruction group; group C: artery excision and left liver resection of the hepatic artery; after the model construction was successful, the recovery and postoperative mortality of the rats were observed, 24 hours, 72 hours after operation and 7 days after the operation. Test the liver function of serum AST, ALT, TB and ALP. Immunohistochemical staining was used to detect the proliferation of PCNA liver tissue. Results: left hepatectomy and hepatic artery excision, the rats were awakened slowly after the operation, and some rats died. Compared with the control group, the liver function level was the largest after ligating the hepatic artery and the left liver, the rat serum was ALT after operation. The level of AST increased significantly, and then the liver function was gradually restored to the normal value at 7d after operation, and the level of the change was statistically significant compared with the control group and the hepatectomy group (P0.05). The expression of PCNA in the liver tissue of the combined hepatectomy and hepatic artery excision group was lower than that of the control group and the hepatectomy group. The proliferation ability of liver tissue in rats was inhibited after hepatic artery excision. Conclusion: hepatectomy combined with hepatic artery excision in rat liver function was greatly affected, liver function recovery was slow after operation. Hepatectomy combined with hepatic artery excision in rats liver regeneration was inhibited. Third part combined vascular resection t was built. Objective: To explore the preoperative management and treatment strategies of hilar cholangiocarcinoma, and to study the value of hepatic hilar cholangiocarcinoma combined with hepatic lobectomy and vascular resection in radical operation. Methods: the clinical effect of 2009.7-2014.1 in 142 patients with HC in our single treatment group. The data were analyzed retrospectively, and the preoperative B-ultrasound, MDCT, and MRCP related examination were perfected. Before operation, the patients with jaundice were treated with PTCD reduction under B-ultrasound guidance, and the liver function was monitored dynamically, and the level of bilirubin decreased to the normal ICG test. Preoperative 3D assessment, Bismuth classification, and tumor invasion of the liver parenchyma and peripheral blood vessels were determined. On this basis, the operation plan was scheduled to evaluate the retention of liver volume and liver reserve function after operation and compare with the intraoperative conditions. Results: 96 cases of 142 patients underwent radical resection of hepatic hilar cholangiocarcinoma after full preoperative preparation and evaluation, of which 16 cases were combined with vascular resection and reconstruction, 16 cases were left with left hemi liver plus caudate lobectomy and 2 cases. Left trifolectomy, 3 cases of right hemicresectomy and 11 cases of combined portal vein resection, including 4 cases of portal vein wedging repair, 6 cases of portal end anastomosis, 1 cases of right anterior branch resection and reconstruction of the right artery of the hepatic artery combined with right hepatic artery resection plus great saphenous vein bridge reconstruction, and 1 cases of right hepatic artery cut in the patients with the right anterior vein of the portal vein in the 3 cases. The accuracy of Bismuth typing was evaluated by 87.5%. in the posterior end anastomosis (.3D). The total variation rate of the hepatic artery was 23%.3D, the accuracy of portal vein evaluation was 93.7%, and the accuracy of the evaluation of the artery invasion was the postoperative complication of the patients undergoing vascular resection and reconstruction in 87.5%.16 cases: 1 cases of bile leakage, no abdominal bleeding and abdominal sensation. Complications were associated with no intravascular thrombus formation, the complication rate was 6.25%, and no perioperative death in.16 patients was followed up as follows: 1 patients died within March, 1 patients died within half a year after the operation and.2 died in September after the operation, and the rest of the patients were followed up. Conclusion: in a large medical center, the patients were followed up. The resection and reconstruction of the hilar cholangiocarcinoma can improve the resectability of the tumor and improve the prognosis of the patients. Perfect preoperative management, accurate 3D evaluation and reasonable surgical strategy can reduce the postoperative complications of hilar cholangiocarcinoma and ensure the safety of the operation.
【学位授予单位】：华中科技大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R735.8

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