目的 分析中下段胆管癌切除术后切缘阳性的意义,研究影响中下段胆管癌切除术后的预后因素.方法 回顾性分析1990年1月至2006年12月收治的79例中下段且日管癌切除患者的临床病理资料.其中男性53例、女性26例,年龄30～79岁,平均61岁.中段胆管癌34例,下段胆管癌45例.行胰十二指肠切除术46例,行根治性胆总管癌切除术25例,行根治性胆总管癌切除联合肝部分切除术6例,行根治性胆总管癌切除联合门静脉部分切除术2例.5例于术后1个月内死亡,对其余74例患者的15项临床病理特征进行单因素及多因素分析.结果 74例患者总的5年生存率为30.7%,中位生存期为36个月.术后病理榆查为镜下切缘阳性(R1切除)16例(20.3%),其中肝脏端胍管切缘阳性6例,远端胆管切缘阳性3例,双侧胆管切缘阳性2例,环周切缘阳性5例.接受R0和Rl切除的患者的5年生存率分别为34.4%和15.5%.10例(17.2%)R0切除的胆管癌出现局部复发,10例(62.5%)R1切除出现复发,差异有统计学意义(X2=13.024,P<0.01).单因素分析显示术前血红蛋白水平、分化程度、肿瘤浸润深度、淋巴结转移、TNM分期及手术切缘为影响预后的因素.多因素分析显示淋巴结转移状况和切缘癌残留是影响预后的独立因素.结论 中下段胆管癌根治术中冰冻病理检查切缘达R0切除是提高长期生存的重要策略,辅助治疗的效果尚待进一步研究.%Objective To discuss the significance of a positive ductal margin and evaluate the prognostic factors related to surgical resection for middle and distal bile duct carcinoma. Methods A retrospective clinicopathological analysis of 79 patients who had undergone surgical resection for middle or distal bile ductal cancer between January 1990 and December 2006 was conducted. The surgical procedures consisted of pancreatoduodenectomy in 46 patients, bile duct resection in 25 patients, bile duct resection plus hepatectomy in 6 patients,and bile duct resection with partial resection of portal vein in 2 patients. In 74 patients,5 patients were excluded because they died after surgery without being discharged from the hospital, 15 clinicopathologic factors were evaluated using univariate and multivariate analysis. Results The overall 5-year survival rate and the median survival time was 30. 7% and 36 mouths, respectively. Sixteen of 74 patients (20.3% ) were determined to have positive ductal margins on the final pathological examination. As a result, hepatic-side ductal margin, duodenal-side ductal margin and both was found to be positive in 6,3 and 2 patients,respectively. Five patients had positive radial margins. The 5-year survival rate was 34.4% in 58 patients without microscopic residual disease (R0) ,and 15.5% in 16 patients with microscopic residual tumor (R1). The ductal recurrence rate of 16 patients with R1 resection was higher than 58 patients with R0 resection (62.5% vs. 17.2%, X2=13.024,P <0.01 ). The 1-,3-,and 5-year survival rates were better in the patients with R0 (92.5%, 56.7%, and 34.4%, respectively) than those in the patients with R1 resection (75.0% , 23.2%, and 15.5%, respectively) (P<0.05). Twelve patients received postoperative adjuvant therapy. The 5-year survival rate was not significantly different between patients with postoperative adjuvant therapy and those without (18.2% vs.31.8% ,P=0.221).The preoperative serum level of hemogiobin,pathological differentiation grade, the depth of neoplastic invasion, lymph node metastasis, B1 resection,and TNM stage were significant prognostic factors on the univariate analysis. Multivariate analysis revealed that lymph node metastasis and R1 resection were the independent prognestie factors. Conclusions In the treatment of middle and distal bile duct cancer, radical resection should be made to obtain a tumor-free margin, An aggressive surgical approach may improve the survival for middle bile duct cancer. Adjuvant therapy needs to be further developed.
展开▼
