中国实用外科杂志

中国实用外科杂志 ›› 2023, Vol. 43 ›› Issue (06): 692-696.DOI: 10.19538/j.cjps.issn1005-2208.2023.06.17

• 论著 • 上一篇    下一篇

胆囊管癌的临床特点、分型及其手术治疗探讨（附50例报告）

赵健楠，阮    祥，段安琪，余良河，刘    健，王    向，俞文隆，朱    斌，张永杰   

  1. 海军军医大学第三附属医院（上海东方肝胆外科医院）胆道二科，上海 200438
  • 出版日期:2023-06-01 发布日期:2023-06-17

  • Online:2023-06-01 Published:2023-06-17

摘要： 目的    探讨胆囊管癌（CDC）的临床特点、分型及其合理的手术方式。方法    回顾性分析2007年1月至2021年12月在海军军医大学第三附属医院行手术治疗的50例CDC病人的临床资料。依据有无梗阻性黄疸及肿瘤侵犯胆囊、肝外胆管的范围，提出了CDC的东方肝胆外科医院分型（EHBH分型），并分析其临床特点、手术方式、围手术期结果等。结果    50例病人中，男38例（76%），女12例（24%），平均年龄为（63.5±10.1）岁。临床症状黄疸36例（72%）、腹痛33例（66%）、黄疸合并腹痛21例（42%）。EHBH分型：Ⅰa型2例、Ⅰb型1例、Ⅰc型9例、Ⅰd型2例、Ⅱa型26例、Ⅱb型10例。50例病人中，行CDC根治性切除术，即胆囊及肝外胆管切除、区域淋巴结清扫（含No.8、12、13淋巴结）、胆肠吻合、联合或不联合部分肝脏（Ⅳb、Ⅴ段，楔形的胆囊床肝组织或右半肝）切除28例，其中12例（42.9%）联合肝脏切除，16例（57.1%）未联合肝脏切除；余22例行非根治性手术，包括胆囊切除和（或）胆道探查、T管引流或胆管-空肠吻合术等。28例根治性切除病人中15例（53.6%）获得随访，其中2例因全身感染，术后1个月内死亡，余13例中位生存时间为25个月；该13例中8例未行联合肝脏切除，5例行联合肝脏切除，两组间生存时间差异无统计学意义（P＞0.05）。结论    重视CDC的“腹痛、黄疸、胆囊肿大”三联征，结合影像学及超声内镜检查可提高诊断率。CDC的EHBH分型可以简洁、直观地帮助临床制定手术治疗策略。手术方式推荐以胆囊切除、肝外胆管切除、胆肠吻合及区域淋巴结（No.8、12、13淋巴结）清扫为基本术式，对于累及胆囊颈、体部（特别是腹侧）、尚无明确肝脏浸润的CDC，特别是在高龄、高危病人中，可不联合肝脏切除；而肿瘤累及胆囊颈、体部（肝侧）、存在明确肝脏浸润时，则需要联合局部肝脏切除。

关键词: 胆囊管癌, 胆囊管, 恶性肿瘤

Abstract: Clinical characteristics, classifications and surgical procedures of cystic duct carcinoma: An analysis of 50 cases        ZHAO Jian-nan, RUAN Xiang, DUAN An-qi, et al.Second Department of Biliary Surgery, Shanghai Eastern Hepatobiliary Surgery Hospital, Navay Medical University, Shanghai 200438,China
Corresponding authors： ZHU Bin， E-mail:bbinzhu@sina.com； ZHANG Yong-jie,E-mail:yongjie_zh@outlook.com
ZHAO Jian-nan and RUAN Xiang are the first authors who contributed equally to the article.
Abstract    Objective    To investigate the clinical characteristics， classifications, and reasonable surgical procedures of cystic duct carcinoma（CDC）. Methods    From January 2007 to December 2021， a retrospective study was conducted on the clinical data of 50 patients with CDC who received surgical treatment in the Third Affiliated Hospital of Naval Medical University. According to the presence of obstructive jaundice and the extent of tumor invasion of the gallbladder and extrahepatic bile duct， the Eastern Hepatobiliary Surgery Hospital classification（EHBH classification）of CDC was proposed. The clinical characteristics， surgical procedures, and perioperative outcomes were analyzed. Results    Among the 50 patients， there were 38 males（76%）and 12 females（24%） with the mean age of（63.5±10.1）years old. The most clinical symptoms of CDC were jaundice and abdominal pain， among which 36 cases（72%）were jaundice，33 cases（66%）were abdominal pain， and 21 cases（42%）were jaundice combined with abdominal pain. Based on the clinical data and previous classifications， the Eastern Hepatobiliary Surgery Hospital（EHBH）classification of CDC was proposed， two cases of type Ia， one caseofIb， nine casesofIc， two cases of Id，26 cases of Ⅱa and ten cases of Ⅱb. Among the 50 patients，28 patients underwent radical surgery， namely， gallbladder and extrahepatic bile duct resection， regional lymph node dissection（including group 8，12，13 lymph nodes），bilioenterostomy， combined or non-combined partial liver（section Ⅳb， Ⅴ，wedge-shaped liver tissue of gallbladder bed or rigth liver）resection， of which 12（42.9%）with liver resection， and 16（57.1%）without liver resection. The remaining 22 underwent nonradical surgeries， including cholecystectomy and/or exploration of the biliary tract， T-tube drainage， or bilioenterostomy. Among the 28 cases， the follow-up rate was 53.6%（15/28）， of the 15 cases， two died within one month after operation due to systemic infection. Excluding these two cases， the median survival time was 25 months. Among the 13 cases， eight were not combined with liver resection， and five were combined with liver resection. There was no significant difference in survival time between the two groups（P＞0.05）. Conclusion    Focusing on the triad of "abdominal pain， jaundice， gallbladder enlargement" of CDC and combining it with imaging and endoscopic examination can improve the diagnosis rate. The EHBH classification of CDC can guide the surgical strategy succinctly and intuitively preoperatively. Radical surgical procedures are emphasized and cholecystectomy， extrahepatic bile duct resection，choledoenterostomy, and regional lymph node dissection（Group 8，12，13）are recommended as the basic surgical procedures. For the CDC involving the neck and body of the gallbladder（especially the ventral side）without clear liver invasion， liver resection is not necessary， especially in elderly and high-risk patients， however， local liver resection is needed with liver invasion.

Key words: cystic duct carcinoma, cystic duct, malignant tumor