切换至 "中华医学电子期刊资源库"
高级检索
中华肝脏外科手术学电子杂志

中华肝脏外科手术学电子杂志 ›› 2024, Vol. 13 ›› Issue (03) : 350 -356. doi: 10.3877/cma.j.issn.2095-3232.2024.03.016

临床研究

显微外科肝动脉重建在累及第一肝门胆管癌外科治疗的应用
韦德令1, 蒋佳君1, 徐邦浩1, 王继龙1, 朱海1, 卢婷婷2, 张灵3, 曾晶晶4, 郭雅5, 文张5,†()   
  1. 1. 530021　南宁，广西医科大学；530021　南宁，广西医科大学第一附属医院肝胆外科；530021　南宁，广西消化道肿瘤加速康复外科基础研究重点实验室
    2. 530021　南宁，广西医科大学第一附属医院超声科
    3. 530021　南宁，广西医科大学第一附属医院放射科
    4. 530021　南宁，广西医科大学第一附属医院病理科
    5. 530021　南宁，广西医科大学第一附属医院肝胆外科；530021　南宁，广西消化道肿瘤加速康复外科基础研究重点实验室
  • 收稿日期:2024-02-20 出版日期:2024-06-10
  • 通信作者: 文张
  • 基金资助:
    广西壮族自治区卫生健康委员会项目(20210962)

Application of microsurgical hepatic artery reconstruction in surgical treatment of cholangiocarcinoma involving the first porta hepatis

Deling Wei1, Jiajun Jiang1, Banghao Xu1, Jilong Wang1, Hai Zhu1, Tingting Lu2, Ling Zhang3, Jingjing Zeng4, Ya Guo5, Zhang Wen5,†()   

  1. 1. Guangxi Medical University, Nanning 530021, China; Department of Hepatobiliary Surgery, the First Affiliated Hospital of Guangxi Medical University, Nanning 530021, China; Key Laboratory of Basic Research of Accelerated Rehabilitation Surgery for Digestive Tract Tumors in Guangxi Zhuang Autonomous Region, Nanning 530021, China
    2. Department of Ultrasound, the First Affiliated Hospital of Guangxi Medical University, Nanning 530021, China
    3. Department of Radiology, the First Affiliated Hospital of Guangxi Medical University, Nanning 530021, China
    4. Department of Pathology, the First Affiliated Hospital of Guangxi Medical University, Nanning 530021, China
    5. Department of Hepatobiliary Surgery, the First Affiliated Hospital of Guangxi Medical University, Nanning 530021, China; Key Laboratory of Basic Research of Accelerated Rehabilitation Surgery for Digestive Tract Tumors in Guangxi Zhuang Autonomous Region, Nanning 530021, China
  • Received:2024-02-20 Published:2024-06-10
  • Corresponding author: Zhang Wen
全文 ( ) 下载PDF ( ) 导出引用
引用本文：

韦德令, 蒋佳君, 徐邦浩, 王继龙, 朱海, 卢婷婷, 张灵, 曾晶晶, 郭雅, 文张. 显微外科肝动脉重建在累及第一肝门胆管癌外科治疗的应用[J]. 中华肝脏外科手术学电子杂志, 2024, 13(03): 350-356.

Deling Wei, Jiajun Jiang, Banghao Xu, Jilong Wang, Hai Zhu, Tingting Lu, Ling Zhang, Jingjing Zeng, Ya Guo, Zhang Wen. Application of microsurgical hepatic artery reconstruction in surgical treatment of cholangiocarcinoma involving the first porta hepatis[J]. Chinese Journal of Hepatic Surgery(Electronic Edition), 2024, 13(03): 350-356.

目的

探讨显微外科肝动脉重建在累及第一肝门的肝内胆管癌（ICC-IFPH）和肝门部胆管癌（HCCA）的手术安全性和疗效。

方法

回顾性分析2017年6月至2023年10月在广西医科大学第一附属医院确诊为ICC-IFPH或HCCA的11例患者临床资料。患者均签署知情同意书，符合医学伦理学规定。其中男6例，女5例；年龄44～73岁，中位年龄55岁。患者均接受肿瘤切除联合肝动脉切除和重建，观察患者围手术期资料和随访数据。

结果

患者平均手术时间（541±154）min，出血量中位数696（200，1 900）ml；肝动脉重建时间（23±6） min，动脉内径（2.0±0.5）mm，切除长度（3.3±1.0）cm。术后肝动脉通畅率100%（11/11）。R0切除10例，R1切除1例。术后Clavien-Dindo并发症分级为Ⅲa级2例，其中1例术后发生胆漏、肝脓肿，另1例术后胰瘘。无发生术后肝衰竭、围手术期死亡。随访期间3例分别于术后3、10、48个月死亡。患者中位随访时间10个月，随访超过12个月以上有7例。

结论

显微外科肝动脉重建在ICC-IFPH和HCCA的外科治疗中具有较好的安全性和可行性，为剩余肝脏提供了富氧动脉血，降低术后肝衰竭的发生，提高胆管癌手术切除率，有助于提高患者生活质量，改善患者的预后。

关键词: 显微外科, 胆管癌, 血管侵犯, 肝动脉重建, 外科治疗
Objective

To evaluate the safety and efficacy of microsurgical hepatic artery reconstruction in the treatment of intrahepatic cholangiocarcinoma involving the first porta hepatis (ICC-IFPH) and hilar cholangiocarcinoma (HCCA).

Methods

Clinical data of 11 patients diagnosed with ICC-IFPH or HCCA in the First Affiliated Hospital of Guangxi Medical University from June 2017 to October 2023 were retrospectively analyzed. The informed consents of all patients were obtained and the local ethical committee approval was received. Among them, 6 patients were male and 5 female, aged 44-73 years, with a median age of 55 years. All patients underwent tumor resection combined with hepatic artery resection and reconstruction. Perioperative data and follow-up data were observed.

Results

The average operation time was (541±154) min. The median blood loss was 696 (200, 1 900) ml. The reconstruction time of hepatic artery was (23±6) min. The inner diameter of artery was (2.0±0.5) mm, and the length of resected artery was (3.3±1.0) cm. Postoperative patency rate of hepatic artery was 100% (11/11). R0 resection was performed in 10 cases and R1 resection in 1 case. According to the Clavien-Dindo classification, 2 patients developed grade Ⅲa complications, including postoperative bile leakage and liver abscess in 1 case and pancreatic fistula in the other case. No postoperative liver failure or perioperative death occurred. During postoperative follow-up, 3 patients died at postoperative 3, 10 and 48 months, respectively. The median follow-up duration was 10 months, and 7 patients were followed up for over 12 months.

Conclusions

Microsurgical hepatic artery reconstruction is a safe and feasible procedure for ICC-IFPH and HCCA, which can provide oxygen-enriched arterial blood for the remaining liver, lower the incidence of postoperative liver failure, enhance surgical resection rate of cholangiocarcinoma, and improve the quality of life and clinical prognosis of patients.

Key words: Microsurgery, Cholangiocarcinoma, Vascular invasion, Hepatic artery reconstruction, Surgical treatment
图1 一例ICC-IFPH患者术前CT及三维重建注：a为CT图，b为三维重建图，示肝左叶明显萎缩伴肝内胆管扩张明显，肝右动脉受侵犯（箭头）；ICC-IFPH为累及第一肝门的肝内胆管癌
图2 一例ICC-IFPH患者术中肝动脉重建注：a示肿瘤累及RHA（箭头），切除受累的动脉；b示HA修剪、测量后行MHAR；c示动静脉均重建结束后，术中超声确认血流通畅；MHAR为显微外科肝动脉重建，RHA为肝右动脉，PHA为肝固有动脉，CHA为肝总动脉，GDA为胃十二指肠动脉，ICC-IFPH为肝内胆管癌累及第一肝门部
表1 11例累及第一肝门的胆管癌患者手术方式及肝动脉吻合方式
例序 手术方式 吻合动脉 吻合方式
1 左半肝切除+ PVR+ MHAR RHA RHA-RHA
2 左半肝联合尾状叶切除+ PVR + MHAR + BD RHA RHA-RHA
3 扩大左半肝+尾状叶+ PVR + MHAR + BD RHA RHA-RHA
4 左半肝切除+左尾叶切除+ MHAR + BD RHA RHA-GDA
5 左半肝联合左尾叶切除+ MHAR + BD RHA RHA-LHA
6 左半肝联合左尾状叶切除+ MPV侧壁切除修补+ MHAR RHA RHA-LHA
7 左半肝联合尾状叶切除+ MPV切除、人工血管移植重建+ IVC楔形切除修补+ MHAR + BD PVA LHA-MPV端侧吻合
8 左半肝联合尾状叶切除+ MPV侧壁切除、自体肝圆韧带补片+ MHAR + BD A67 A67-GDA
9 左半肝切除联合全尾状叶切除+ PVR + V5人工血管移植至IVC重建+ MHAR + BD RHA RHA-RHA
10 左半肝联合全尾状叶切除+胰头部分切+ PVR + MHAR + BD RHA RHA-GDA
11 BD +胰头部分切除+ MHAR RHA RHA-RHA
表2 行MHAR的累及第一肝门胆管癌术后病理特征及随访资料
例序 术后病理 分化程度 周围神经受累 淋巴结阳性 R0切除 TNM分期 Bismuth分型 AJCC分期 随访时间（月） 生存状态
1 肝内胆管癌 低分化 是 是 是 T4N1M0 N ⅢB 48 死亡
2 肝门部胆管癌 中分化 是 是 是 T4N1M0 Ⅳ ⅢC 10 死亡
3 肝门部胆管癌 中分化 是 是 无 T4N1M0 Ⅳ ⅢC 3 死亡
4 肝内胆管癌 中分化 是 无 是 T4N0M0 N ⅢB 16 存活
5 肝门部胆管癌 低分化 是 无 是 T4N0M0 Ⅱ ⅢB 15 存活
6 肝内胆管癌 中分化 是 是 是 T4N1M0 N ⅢB 14 存活
7 肝门部胆管癌 中分化 是 是 是 T4N1M0 Ⅳ ⅢC 12 存活
8 肝门部胆管癌 中分化 是 是 是 T4N1M0 Ⅳ ⅢC 7 存活
9 肝内胆管癌 低分化 是 是 是 T4N1M0 N ⅢB 4 存活
10 肝门部胆管癌 低分化 是 无 是 T3N0M0 Ⅳ ⅢA 3 存活
11 肝门部胆管癌 中分化 是 是 是 T1N1M0 Ⅰ ⅢC 2 存活
[1]
Banales JM, Marin JJG, Lamarca A, et al. Cholangiocarcinoma 2020: the next horizon in mechanisms and management[J]. Nat Rev Gastroenterol Hepatol, 2020, 17(9):557-588.
[2]
Capobianco I, Rolinger J, Nadalin S. Resection for Klatskin tumors: technical complexities and results[J]. Transl Gastroenterol Hepatol, 2018, 3: 69.
[3]
Nagino M, Nimura Y, Nishio H, et al. Hepatectomy with simultaneous resection of the portal vein and hepatic artery for advanced perihilar cholangiocarcinoma: an audit of 50 consecutive cases[J]. Ann Surg, 2010, 252(1):115-123.
[4]
Mizuno T, Ebata T, Yokoyama Y, et al. Combined vascular resection for locally advanced perihilar cholangiocarcinoma[J]. Ann Surg, 2022, 275(2):382-390.
[5]
Matsuyama R, Mori R, Ota Y, et al. Significance of vascular resection and reconstruction in surgery for hilar cholangiocarcinoma: with special reference to hepatic arterial resection and reconstruction[J]. Ann Surg Oncol, 2016, 23(Suppl 4):475-484.
[6]
Balci D, Ahn CS. Hepatic artery reconstruction in living donor liver transplantation[J]. Curr Opin Organ Transplant, 2019, 24(5):631-636.
[7]
Lin CM, Lin SL, Hung YJ, et al. Using 3D microscope for hepatic artery reconstruction in living donor liver transplant[J]. J Clin Med, 2022, 11(20):6195.
[8]
Zhang JZ, Yang CX, Gao S, et al. Three-dimensional visualization and evaluation of hilar cholangiocarcinoma resectability and proposal of a new classification[J]. World J Surg Oncol, 2023, 21(1):239.
[9]
Kondo S, Hirano S, Ambo Y, et al. Arterioportal shunting as an alternative to microvascular reconstruction after hepatic artery resection[J]. Br J Surg, 2004, 91(2):248-251.
[10]
Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of6 336 patients and results of a survey[J]. Ann Surg, 2004, 240(2):205-213.
[11]
Amin MB, Greene FL, Edge SB, et al. The Eighth Edition AJCC Cancer Staging Manual: continuing to build a bridge from a population-based to a more "personalized" approach to cancer staging[J]. CA Cancer J Clin, 2017, 67(2):93-99.
[12]
Song Y, Zhang Y, Zhen Z, et al. Effects of portal vein resection and hepatic artery resection on long-term survival in Klatskin tumor: a meta-analysis[J]. World J Surg Oncol, 2022, 20(1):230.
[13]
Kuriyama N, Komatsubara H, Nakagawa Y, et al. Impact of combined vascular resection and reconstruction in patients with advanced perihilar cholangiocarcinoma[J]. J Gastrointest Surg, 2021, 25(12):3108-3118.
[14]
Sugiura T, Uesaka K, Okamura Y, et al. Major hepatectomy with combined vascular resection for perihilar cholangiocarcinoma[J]. BJS Open, 2021, 5(4):zrab064.
[15]
Huang S, Fahradyan A, Ahearn A, et al. Arterial anastomosis using microsurgical techniques in adult live donor liver transplant: a focus on technique and outcomes at a single institution[J]. J Reconstr Microsurg, 2023, 39(1):70-80.
[16]
Li Z, Zhang W, Shen Y, et al. Microsurgical replacement of the right hepatic artery with the donor superior mesenteric artery in cadaveric donor pediatric liver transplantation[J]. Pediatr Surg Int, 2022, 39(1):13.
[17]
Nickel KJ, Staples J, Meeberg G, et al. The transition to microsurgical technique for hepatic artery reconstruction in pediatric liver transplantation[J]. Plast Reconstr Surg, 2021, 148(2):248e-257e.
[18]
Sitta R, Roberts J, Gardner J, et al. A novel microsurgical reconstruction technique in a living-related liver donor hepatic artery dissection using the native hepatic artery[J]. Am J Transplant, 2022, 22(10):2467-2469.
[19]
Tan BK, Fong HC, Tan EK, et al. Strategies for a successful hepatic artery anastomosis in liver transplantation: a review of 51 cases[J]. Ann Acad Med Singap, 2021, 50(9):679-685.
[20]
Feng MX, Zhang JX, Wan P, et al. Hepatic artery reconstruction in pediatric liver transplantation: experience from a single group[J]. Hepatobiliary Pancreat Dis Int, 2020, 19(4):307-310.
[21]
Zhang Q, Wu J, Tian Y, et al. Arterial resection and reconstruction in pancreatectomy: surgical technique and outcomes[J]. BMC Surg, 2019, 19(1):141.
[22]
Broelsch CE, Whitington PF, Emond JC, et al. Liver transplantation in children from living related donors. surgical techniques and results[J]. Ann Surg, 1991, 214(4):428-437.
[23]
Mori K, Nagata I, Yamagata S, et al. The introduction of microvascular surgery to hepatic artery reconstruction in living-donor liver transplantation-its surgical advantages compared with conventional procedures[J]. Transplantation, 1992, 54(2):263-268.
[24]
Lee CF, Lu JC, Zidan A, et al. Microscope-assisted hepatic artery reconstruction in adult living donor liver transplantation-a review of 325 consecutive cases in a single center[J]. Clin Transplant, 2017, 31(2).
[25]
Qiu J, Wu H, Prasoon P, et al. Portal vein arterialization in hilar cholangiocarcinoma: one case report and literature review[J]. Eur J Gastroenterol Hepatol, 2012, 24(3):229-232.
[26]
Serrablo A, Serrablo L, Alikhanov R, et al. Vascular resection in perihilar cholangiocarcinoma[J]. Cancers, 2021, 13(21):5278.
[27]
Hernandez JA, Mullens CL, Aoyama JT, et al. Analysis of outcomes in living donor liver transplants involving reconstructive microsurgeons[J]. J Reconstr Microsurg, 2020, 36(3):223-227.
[28]
Li PC, Thorat A, Jeng LB, et al. Hepatic artery reconstruction in living donor liver transplantation using surgical loupes: achieving low rate of hepatic arterial thrombosis in 741 consecutive recipients-tips and tricks to overcome the poor hepatic arterial flow[J]. Liver Transpl, 2017, 23(7):887-898.
[29]
Marubashi S, Kobayashi S, Wada H, et al. Hepatic artery reconstruction in living donor liver transplantation: risk factor analysis of complication and a role of MDCT scan for detecting anastomotic stricture[J]. World J Surg, 2013, 37(11):2671-2677.
[30]
Yang Y, Yan LN, Zhao JC, et al. Microsurgical reconstruction of hepatic artery in A-a LDLT: 124 consecutive cases without HAT[J]. World J Gastroenterol, 2010, 16(21):2682-2688.
[31]
Ohdan H, Tashiro H, Ishiyama K, et al. Microsurgical hepatic artery reconstruction during living-donor liver transplantation by using head-mounted surgical binocular system[J]. Transpl Int, 2007, 20(11):970-973.
[1] 李淼, 朱连华, 韩鹏, 姜波, 费翔. 高帧频超声造影评价肝细胞癌血管形态与风险因素的研究[J]. 中华医学超声杂志（电子版）, 2023, 20(09): 911-915.
[2] 刘林峰, 王增涛, 王云鹏, 钟硕, 郝丽文, 仇申强, 陈超. 足底内侧皮瓣联合甲骨皮瓣在手指V度缺损再造中的临床应用[J]. 中华损伤与修复杂志(电子版), 2023, 18(06): 480-484.
[3] 高彬, 阿曼塔依·努尔塔依, 宁江红, 邵英梅. 胆管癌的光动力治疗[J]. 中华普通外科学文献(电子版), 2024, 18(01): 76-80.
[4] 李佳隆, 韩青雷, 宋铭杰, 古丽米拉·亚森江, 钟锴, 蒋铁民, 郭强, 吐尔干艾力·阿吉, 邵英梅. Bismuth-Corlette Ⅱ型肝门部胆管癌行扩大肝切除与围肝门切除的临床疗效分析[J]. 中华普通外科学文献(电子版), 2023, 17(06): 438-443.
[5] 尚培中, 张润萍, 张伟, 贾国洪, 李晓武, 苗建军, 刘冰. 梗阻性黄疸临床防治新技术单中心应用研究[J]. 中华普外科手术学杂志(电子版), 2024, 18(01): 104-107.
[6] 彭旭, 邵永孚, 李铎, 邹瑞, 邢贞明. 结肠肝曲癌的诊断和外科治疗[J]. 中华普外科手术学杂志(电子版), 2024, 18(01): 108-110.
[7] 唐浩, 梁平, 徐小江, 曾凯, 文拨辉. 三维重建指导下腹腔镜右半肝加尾状叶切除治疗Bismuth Ⅲa型肝门部胆管癌的临床研究[J]. 中华普外科手术学杂志(电子版), 2023, 17(06): 688-692.
[8] 王礼光, 严庆, 廖珊, 符荣党, 陈焕伟. 微血管侵犯及手术切缘对肝细胞癌患者术后生存预后的影响[J]. 中华肝脏外科手术学电子杂志, 2024, 13(02): 151-157.
[9] 孙振, 谭天华, 郑洋洋, 李喆, 宋京海. 基于术前纤维蛋白原与白蛋白比值构建肝癌微血管侵犯的预测模型[J]. 中华肝脏外科手术学电子杂志, 2024, 13(01): 27-32.
[10] 陈明政, 栗玉龙, 唐流康, 谢峰. IDH1突变应用于肝内胆管癌治疗的研究进展[J]. 中华肝脏外科手术学电子杂志, 2024, 13(01): 103-108.
[11] 严庆, 刘颖, 邓斐文, 陈焕伟. 微血管侵犯对肝癌肝移植患者生存预后的影响[J]. 中华肝脏外科手术学电子杂志, 2023, 12(06): 624-629.
[12] 李晓东, 魏云. 冠状切口额下入路治疗前颅窝巨大脑膜瘤[J]. 中华神经创伤外科电子杂志, 2023, 09(05): 318-319.
[13] 周章明, 余水, 梁张. 老年破裂前循环动脉瘤患者的急诊显微手术治疗研究[J]. 中华脑科疾病与康复杂志(电子版), 2024, 14(02): 106-111.
[14] 陈立华. 中小型前庭神经鞘瘤治疗方式选择的原则和依据[J]. 中华脑科疾病与康复杂志(电子版), 2024, 14(01): 1-7.
[15] 中国抗癌协会食管癌专业委员会. 机器人辅助食管切除术中国临床专家共识（2023版）[J]. 中华胸部外科电子杂志, 2024, 11(01): 1-15.
阅读次数
全文


摘要

版权所有 中华医学会 中华医学电子音像出版社有限责任公司  京ICP备14006079号-1  网络出版服务许可证：(署)网出证(京)字第075号