探讨肝细胞肝癌（肝癌）侵犯胆管患者的临床病理学特点及手术疗效。

本组回顾研究对象为2001年1月至2010年1月在西安交通大学医学院第一附属医院行根治性肝切除术治疗的446例肝癌患者。患者均签署知情同意书，符合医学伦理学规定。根据有否胆道侵犯，将446例肝癌患者分成胆道侵犯组（35例）和胆道未侵犯组（411例）。胆道侵犯组男性24例，女性11例，年龄（51.3±2.0）岁，采用根治性肝切除或根治性肝切除+胆肠吻合术或癌栓切除+T管引流术。胆道未侵犯组男性329例，女性82例，年龄（50.5±0.5）岁，采用根治性肝切除术。收集两组患者的临床资料，比较两组患者的临床与病理学资料、手术情况；患者术后接受随访，记录生存情况，进行生存分析。两组患者的年龄、术前实验室检查、手术时间、术中输血量、住院时间比较采用U检验或t检验；两组患者的性别、合并肝炎及肝硬化、肝功能分级、肿瘤病理学参数、术后并发症发生率比较用χ²检验或Fisher确切概率法进行分类变量差异性检验；采用Kaplan-Meier法和Log-rank检验进行生存分析。

胆道侵犯组和胆道未侵犯组术前血清总胆红素分别为（54±19）μmol/L、（22±2）μmol/L，差异有统计学意义（t=-2.945，P=0.003）。胆道侵犯组与胆道未侵犯组患者的肿瘤直径、肿瘤数目、门静脉侵犯、小血管侵犯比较差异有统计学意义（χ²=9.715、10.232、12.543、20.423，均为P<0.05）；两组的肿瘤包膜、卫星灶、组织学分化程度比较差异无统计学意义（均为P>0.05）；胆道侵犯组患者的肿瘤切缘<1 cm者23例、≥1 cm者12例，胆道未侵犯组<1 cm者180例、≥1 cm者231例，两组比较差异有统计学意义（χ²=6.248，P=0.012）。胆道侵犯组与胆道未侵犯组的手术时间、术中输血量、住院时间分别为（5.6±1.2）h、（603±87）ml、（24.6±1.6）d和（4.2±0.5）h、（666±25）ml、（23.6±0.8）d，两组比较差异无统计学意义（t=0.275、0.779、0.688，均为P>0.05）。胆道侵犯组与胆道未侵犯组的术后并发症发生率分别为26%（9/35）和41%（168/411），两组比较差异无统计学意义（χ²=1.253，P>0.05）。胆道侵犯组1、3年生存率分别为46%、25%，胆道未侵犯组分别为75%、42%；胆道侵犯组术后中位生存期18.5个月，胆道未侵犯组为46个月，两组生存曲线比较差异有统计学意义（χ²=16.594，P<0.001）。胆道侵犯分型B1与B0、B3与B0间生存率比较差异有统计学意义（χ²=20.962、12.119，P<0.001），B3与B0间比较差异无统计学意义（χ²=0.314，P>0.05）。

黄疸为肝癌胆道侵犯患者的临床特点，当肝癌患者出现黄疸时应怀疑合并胆道侵犯。肿瘤直径>5 cm、肿瘤数目多发、门静脉侵犯、小血管侵犯的患者易发生胆道侵犯，胆道侵犯患者病理恶性程度较高，预后较差。根治性切除仍是肝癌胆道侵犯患者获得长期生存的有效治疗方法。

To investigate the clinicopathological characteristics and surgical outcome of hepatocellular carcinoma (HCC) with bile duct invasion (BDI).

Clinical data of 446 patients with HCC undergoing curative hepatectomy from January 2001 to January 2010 was studied retrospectively. Local ethical committee approval had been received and that the informed consent of all participating subjects was obtained. The patients were divided into bile duct invasion group(BDI group) and non-BDI group. There were 24 males and 11 females in BDI group with the madian age of (51.3±2.0) years. Patients in this group underwent curative hepatectomy or curative hepatectomy plus choledochojejunostomy or tumor thrombectomy plus T tube drainage. There were 329 males and 82 females in non-BDI group with the median age of (50.5±0.5) years. Patients in this group underwent curative hepatectomy. Clinicopathological parameters were collected and the operation data were compared. All the patients were followed up after the operation. The survival rate were recorded and analyzed. The age, preoperative examinations, operation time, intraoperative blood transfusion and hospital stay of all patients in two groups were compared by Mann-Whitney U test or t test. The gender ratio, cases with combined hepatitis and cirrhosis, evaluation of liver function according to Child-Pugh grading, pathological parameters of tumors, the incidence of postoperative complications in the two groups were compared by χ² or Fisher’s exact test; The survival curves were plotted using Kaplan-Meier methods and compared by Log-rank test.

The average preoperative total bilirubin level was (54±19) μmol/L and (22±2) μmol/L in BDI group and non-BDI group. There were significant differences in tumor size, tumor numbers, portal vein and microvascular invasion between the two groups were significant (χ²=9.715, 10.232, 12.543, 20.423; all in P<0.05) , but no significant differences in the tumor capsule, satellite nodules or tumor differentiation (all in P>0.05) ; There were 23 cases with surgical margin less than 1 cm in BDI group and 12 cases lager or equal to 1 cm. There were 180 cases with surgical margin smaller than 1 cm in non-BDI group and 231 cases lager or equal to 1 cm. There were significant differences between two groups (χ²=6.248, P=0.012) . The operation time, intraoperative blood transfusion and hospital stay time for BDI and non-BDI group were (5.6±1.2) h, (603±87) ml, (24.6±1.6) d and (4.2±0.5) h, (666±25) ml, (23.6±0.8) d respectively, in which there were no significant differences (t=0.275, 0.779, 0.688; all in P>0.05). The incidence of postoperative complications were 26% (9/35) in BDI group and 41% (168/411) in non-BDI group, in which there were no significant differences (χ²=1.253, P>0.05) . The 1- and 3-year survival rate were 46%, 25% in BDI group, and 75%, 42% in non-BDI group respectively. The median survival time was 18.5 months in BDI group and 46 months in non-BDI group (χ²=16.594, P<0.001) . For the subclassification of BDI, there was significant difference in the survival rate between B1 and B0, B1 and B3 (χ²=20.962, 12.119; all in P<0.001) , but was not between B3 and B0 (χ²=0.314, P<0.05) .

Preoperative jaundice is a clinical characteristic of HCC with bile duct invasion. BDI should be suspected when HCC patients complained with jaundice. Tumor size larger than 5 cm, multiple tumor numbers, portal vein and microvascular invasion are highly correlated with BDI. HCC with BDI indicates high degree of pathological malignancy and poor outcome. Curative resection remains the optimal therapy for patients with long term survival.