胆肠吻合术后远期并发胆管癌五例报告

摘要

目的 探讨胆道良性疾病胆肠吻合术(BEA)后远期并发胆管癌的可能发病机理、临床表现和治疗方法.方法 回顾性分析2003年1月至2018年8月广东医科大学茶山医院收治的5例良性胆道疾病行BEA后远期并发胆管癌患者的临床资料,同时复习有关国内外文献.结果 男性3例,女性2例,发病年龄(66. 0 ± 0. 7)岁,发病时间为术后(14. 0 ± 6. 1)年.患者临床主要表现为急性胆管炎. CA19-9联合影像学检查可提高期诊断率.远端胆管癌2例,肝门部胆管癌3例(Ⅲa 型2例,IV型1例). TNM分期:IIB 2例,III期1例,IV期2例,病理均为腺癌. 5例患者接受胆管癌切除+淋巴结清扫术和胰十二指肠切除术各1例,其余3例行经皮经肝穿刺引流术.2例患者于术后8、13个月复发死亡,3例姑息治疗患者生存时间分别为6、4和3个月.结论 肠道内容物返流以及细菌感染引起的慢性胆管炎症是胆肠吻合术后远期并发胆管癌的危险因素.建议摒弃胆总管十二指肠吻合术、间置空肠胆总管十二指肠吻合术等临床效果差且并发症多的术式.更为重要的是要严格掌握各种胆肠吻合术的适应证,保护Oddi氏括约肌功能.%Objective To study the association, clinical presentation, and diagnosis and treatment of bile duct cancer as a late complication of biliary-enteric anastomoses for benign diseases. Methods A retrospective study was carried out on 5 patients and the medical literature was reviewed. Results They were 3 males and 2 females. The average age was ( 66. 0 ± 0. 7 ) years. The average time period was ( 14. 0 ± 6. 1 ) years after biliary-enteric anastomosis. The clinical presentations included right upper quadrant pain, fever, chills and jaundice. CA19-9, CT and MRI were valuable in diagnosis. There were two patients with distal and three patients with perihilar cholangiocarcinomas (type IIIa, n=2, and type IV, n=1). Local resection with lymphadenectomy was carried out in one patient. Another patient underwent pancreaticoduodenectomy. The remaining three patients only underwent percutaneous transhepatic cholangial drainage ( PTCD). The 2 patients who underwent surgery died of progressive tumor disease at 8 and 13 months postoperatively. The other three patients who underwent palliative biliary drainage died within 6 months of PTCD. There was no significant difference between the two types of treatment ( P ＞0. 05). Conclusions Chronic cholangitis caused by reflux and bacterial infection was properly a predisposing factor leading to late development of bile duct cancer after biliary-enteric anastomosis for benign diseases. Patients treated with biliary-enteric anastomosis should be closely monitored for late development of cholangiocarcinoma. Some procedures such as choledochoduodenostomy and jejunum interposition choledochoduodenostomy should be abandoned because of their poor outcomes and severe complications. Proper indications of biliary-enteric anastomosis should strictly be followed and the Oddi's sphincter should be protected if possible to prevent late development of bile duct cancer.