Concomitant precise hemihepatectomy for the treatment of hilar cholangiocarcinoma / 中华消化外科杂志

ABSTRACT

Objective To investigate the efficacy of concomitant precise hemihepateetomy for the treatment of hilar cholangiocarcinoma.Methods The clinical data of 38 patients with hilar cholangiocarcinoma who received concomitant precise hemihepatectomy at the First Affiliated Hospital of Xi'an Jiaotong University from January 2009 to October 2012 were retrospectively analyzed.All patients were examined by B ultrasonography,computed tomography (CT),magnetic resonance cholangiopancreatography (MRCP) and CT angiography (CTA)preoperatively.The hepatic function was tested before operation.Of the 7 patients with obstructive jaundice,5 received percutaneous transhepatic cholangial drainage,and 2 received endoscopic nosalbiliary drainage.Surgical procedures were determined according to the results of imaging examination.The resection of hilar cholangiocarcinoma,postoperative histopathological examination,pre-and postoperative hepatic function and prognostic indicators were analyzed.The count data and measurement data were analyzed using the chi-square test and t test,respectively; the survival curve was drawn by Kaplan-Meier method,and the survival rate was analyzed using the Log-rank test.COX proportion hazards model was used for multivariate analysis.Results The positive rates of B ultrasonography,CT and MRCP were 65.8％ (25/38),71.1％ (27/38) and 89.5％ (34/38),respectively.The results of 5 patients who received CTA were positive.Concomitant left hemihepatectomy was performed on 28 patients,concomitant right hemihepatectomy on 10 patients; concomitant caudate lobectomy on 22 patients,concomitant resection and reconstruction of portal vein on 4 patients (including 1 patient who received left hepatic vein repair),concomitant hepatic artery resection on 12 patients (including 3 patients who received hepatic artery reconstruction).Of the 38 patients,R0 resection was performed on 32 patients,R1 resection on 4 patients,R2 resection on 2 patients.Hepatic function indicators including total bilirubin,direct bilirubin,alkaline phosphatase,gamma-glutamyl-transferase,alanine aminotransferase and aspartate aminotransferase were significantly decreased after operation (t =7.799,8.445,5.697,6.633,4.469,4.140,P ＜ 0.05).Two patients died perioperatively,with the mortality rate of 5.3％ (2/38).The main postoperative complications included bile leakage and hepatic function insufficiency,with the incidences of 28.9％ (11/38) and 21.1％ (8/38),respectively.Postoperative histopathological findings included 31 patients with invasive adenocarcinoma,5 patients with nodular adenocarcinoma,1 patient with mucinous adenocarcinoma and 1 patient with adenosquamous carcinoma.The overall 1-,2-,3-year survival rates were 66％,37％ and 21％,and the median survival time was 22.0 months.There were significant differences in the survival rates between patients who received R0 resection and those with R1/R2 resection,and between patients with N0 and N1/N2 stage (x2 =4.516,10.397,P ＜ 0.05).The results of multivariate analysis showed that positive margin and lymph node metastasis were prognostic indicators.Conclusions Concomitant precise hemihepatectomy has significantly improved the radical resection rate and the efficacy of treatment for hilar cholangiocarcinoma.Comprehensive preoperative imaging examination and hepatic function test are important for the assessment for resectability of hilar cholangiocarcinoma.Selective preoperative biliary drainage are key points to decrease postoperative morbidity and morality.