本文選題：肝門部膽管癌 + 肝切除　； 參考：《華中科技大學》2016年博士論文

【摘要】：第一部分肝門部膽管癌根治術中血管切除重建的系統(tǒng)評價及meta分析目的：探討聯(lián)合血管切除重建在肝門部膽管癌根治性手術中的安全性和有效性。方法：檢索PubMed數(shù)據(jù)庫和Cochrane圖書館數(shù)據(jù)庫,篩選相關文獻,對聯(lián)合受累血管切除和未行血管切除組比較,觀察術后并發(fā)癥,圍手術期死亡率,R0切除率,5年存活率.Meta分析采用RevMan 5.3.5軟件進行數(shù)據(jù)分析。結果：共計納入14篇文獻,比較血管切除組與未切除組在術后總體并發(fā)癥發(fā)生率上兩組之間無統(tǒng)計學意義(OR=1.54; 95% CI 0.77-3.07；P=0.22);同樣對術后死亡率分析比較顯示聯(lián)合血管切除組與未切除組術后死亡率上并無明顯差異(OR=1.24; 95% CI 0.52.2.93；P=0.63),但聯(lián)合動脈切除重建時,患者術后死亡率較未切除組顯著增加(OR=3.84; 95%CI 1.27-11.63; P=0.02),在R0切除上血管切除組比例更高(OR=3.84; 95% CI 1.27-11.63;P=0.03),聯(lián)合血管切除組5年生存率低于未切除組(OR=1.9; 95% CI 1.23-2.93; P=0.004).結論：聯(lián)合血管切除重建治療肝門部膽管癌是相對安全可行的,有利于提高RO切除率,改善預后。由于納入文獻有限,尚需大樣本的臨床隨機對照試驗來進一步驗證聯(lián)合血管切除重建在肝門部膽管癌根治性手術中的作用。第二部分肝切除聯(lián)合肝動脈切除對動物肝功能影響的實驗研究目的：研究肝切除聯(lián)合動脈切除對大鼠肝臟功能的影響。方法：S-D雄性大鼠40只,隨機分為三組。A組：對照組行開腹；B組：動脈切除重建組行左肝切除;C組：動脈切除,行左肝切除肝動脈切除；模型構建成功后,觀察術后大鼠恢復情況及術后死亡率,術后24小時,72小時及術后7天采集大鼠血液檢測血清AST、ALT、TB、ALP肝功能。免疫組化檢測PCNA肝臟組織增殖情況。結果：左肝切除及肝動脈切除,術后大鼠麻醉蘇醒慢,部分大鼠出現(xiàn)死亡。與對照組相比,當同時結扎肝動脈及切除左肝時,大鼠術后肝功能水平變化最大,術后大鼠血清ALT、AST水平顯著升高,而隨后肝功能漸恢復,至術后7d時仍在正常值以上,其變化水平與對照組及單獨行肝切除組相比具有統(tǒng)計學意義(P0.05)。聯(lián)合肝切除及肝動脈切除組大鼠術后7d肝組織PCNA表達較對照組及肝切除組表達強度下降,并且部分細胞出現(xiàn)形態(tài)學變化,肝動脈切除后,大鼠肝組織增殖能力受到抑制。結論：肝切除合并肝動脈切除后大鼠肝臟功能受影響較大,術后肝功能恢復較慢。肝切除合并肝動脈切除后大鼠肝臟肝再生受到抑制。第三部分聯(lián)合血管切除t建在肝門部膽管癌根治術中的應用(本中心經(jīng)驗)目的：探討肝門部膽管癌的外科術前管理及治療策略,研究肝門部膽管癌聯(lián)合肝葉切除及血管切除重建在根治性手術中的價值。方法：對2009.7-2014.1在我們單治療組就治的142例HC患者的臨床資料進行回顧性分析,入院后完善術前B超,MDCT,MRCP相關檢查,術前合并黃疸患者在B超引導下行PTCD減黃,并動態(tài)監(jiān)測患者肝功能,待膽紅素水平下降至正常后行ICG檢測。術前3D評估,確定患者Bismuth分型,及腫瘤侵犯肝實質(zhì)及周圍血管情況,在此基礎上預定手術規(guī)劃,評價患者術后保留肝體積,肝儲備功能,并與術中情況進行比較。結果：142例患者經(jīng)充分術前準備及評估后共96例行肝門部膽管癌根治術,其中16例聯(lián)合血管切除重建,16例患者中,行左半肝加尾狀葉切除11例,2例行左三葉切除,3例行右半肝切除。聯(lián)合門靜脈切除重建11例,其中門靜脈主干楔形切除修補4例,門靜脈端端吻合6例,門靜脈右前支切除重建1例。4例患者因腫瘤侵犯肝右動脈行聯(lián)合肝右動脈切除+大隱靜脈架橋重建術,1例患者肝右動脈切除后行端端吻合。3D評估Bismuth分型準確率為87.5%。對肝動脈變異情況進行評估,肝動脈總體變異率為23%。3D提示門靜脈評估準確率為93.7%,評估動脈侵犯的準確率為87.5%。16例血管切除重建患者術后并發(fā)癥為：1例膽漏,無腹腔出血及腹腔感染,無血管內(nèi)血栓形成相關并發(fā)癥,并發(fā)癥率為6.25%;無圍手術期死亡。16例患者隨訪結果如下：1例患者術后3月內(nèi)死亡,1例術后半年內(nèi)發(fā)生肝臟轉(zhuǎn)移于術后9月死亡。2例患者術后失訪,其余患者均繼續(xù)隨訪中。結論：在大型醫(yī)療中心開展聯(lián)合血管切除重建的肝門部膽管癌根治術有利于提高腫瘤可切除率,改善患者預后。完善的術前管理及3D精準評估及合理的手術策略可減少肝門部膽管癌術后并發(fā)癥,保證手術安全性。
[Abstract]:Part 1 systematic evaluation of vascular resection and reconstruction in hilar cholangiocarcinoma and meta analysis objective: To explore the safety and effectiveness of combined resection and reconstruction in the radical operation of hilar cholangiocarcinoma. Methods: retrieval of PubMed database and Cochrane library database, screening related literature, and excision of associated vessels. Compared with the untreated group, the postoperative complications, peri operative mortality, R0 resection rate, and the 5 year survival rate.Meta analysis were analyzed by RevMan 5.3.5 software. Results: a total of 14 articles were included, and there was no statistical significance between the two groups in the vascular resection group and the unresected group (OR=1.54; 95% CI 0.77-3.07; P=0.22); compared with the postoperative mortality analysis, there was no significant difference between the combined resection group and the unresected group (OR=1.24; 95% CI 0.52.2.93; P=0.63), but the postoperative mortality of the patients was significantly increased (OR=3.84; 95%CI 1.27-11.63; P=0.02). The proportion of excised upper vessel resection group was higher (OR=3.84; 95% CI 1.27-11.63; P=0.03). The 5 year survival rate of the combined resection group was lower than that of the unresected group (OR=1.9; 95% CI 1.23-2.93; P=0.004). Conclusion: combined vascular resection and reconstruction for the treatment of hilar cholangiocarcinoma is relatively safe and beneficial to improve the rate of RO excision and improve the prognosis. Due to the inclusion Limited and large sample clinical randomized controlled trials to further verify the role of combined resection and reconstruction in the radical operation of hilar cholangiocarcinoma. Second experimental study on the effect of hepatectomy combined with hepatic arterectomy on animal liver function: To study the effect of hepatectomy combined with arterectomy on liver function in rats. Methods: 40 S-D male rats were randomly divided into three groups of.A groups: the control group was open to the abdomen; group B: left liver resection in the arterial resection and reconstruction group; group C: artery excision and left liver resection of the hepatic artery; after the model construction was successful, the recovery and postoperative mortality of the rats were observed, 24 hours, 72 hours after operation and 7 days after the operation. Test the liver function of serum AST, ALT, TB and ALP. Immunohistochemical staining was used to detect the proliferation of PCNA liver tissue. Results: left hepatectomy and hepatic artery excision, the rats were awakened slowly after the operation, and some rats died. Compared with the control group, the liver function level was the largest after ligating the hepatic artery and the left liver, the rat serum was ALT after operation. The level of AST increased significantly, and then the liver function was gradually restored to the normal value at 7d after operation, and the level of the change was statistically significant compared with the control group and the hepatectomy group (P0.05). The expression of PCNA in the liver tissue of the combined hepatectomy and hepatic artery excision group was lower than that of the control group and the hepatectomy group. The proliferation ability of liver tissue in rats was inhibited after hepatic artery excision. Conclusion: hepatectomy combined with hepatic artery excision in rat liver function was greatly affected, liver function recovery was slow after operation. Hepatectomy combined with hepatic artery excision in rats liver regeneration was inhibited. Third part combined vascular resection t was built. Objective: To explore the preoperative management and treatment strategies of hilar cholangiocarcinoma, and to study the value of hepatic hilar cholangiocarcinoma combined with hepatic lobectomy and vascular resection in radical operation. Methods: the clinical effect of 2009.7-2014.1 in 142 patients with HC in our single treatment group. The data were analyzed retrospectively, and the preoperative B-ultrasound, MDCT, and MRCP related examination were perfected. Before operation, the patients with jaundice were treated with PTCD reduction under B-ultrasound guidance, and the liver function was monitored dynamically, and the level of bilirubin decreased to the normal ICG test. Preoperative 3D assessment, Bismuth classification, and tumor invasion of the liver parenchyma and peripheral blood vessels were determined. On this basis, the operation plan was scheduled to evaluate the retention of liver volume and liver reserve function after operation and compare with the intraoperative conditions. Results: 96 cases of 142 patients underwent radical resection of hepatic hilar cholangiocarcinoma after full preoperative preparation and evaluation, of which 16 cases were combined with vascular resection and reconstruction, 16 cases were left with left hemi liver plus caudate lobectomy and 2 cases. Left trifolectomy, 3 cases of right hemicresectomy and 11 cases of combined portal vein resection, including 4 cases of portal vein wedging repair, 6 cases of portal end anastomosis, 1 cases of right anterior branch resection and reconstruction of the right artery of the hepatic artery combined with right hepatic artery resection plus great saphenous vein bridge reconstruction, and 1 cases of right hepatic artery cut in the patients with the right anterior vein of the portal vein in the 3 cases. The accuracy of Bismuth typing was evaluated by 87.5%. in the posterior end anastomosis (.3D). The total variation rate of the hepatic artery was 23%.3D, the accuracy of portal vein evaluation was 93.7%, and the accuracy of the evaluation of the artery invasion was the postoperative complication of the patients undergoing vascular resection and reconstruction in 87.5%.16 cases: 1 cases of bile leakage, no abdominal bleeding and abdominal sensation. Complications were associated with no intravascular thrombus formation, the complication rate was 6.25%, and no perioperative death in.16 patients was followed up as follows: 1 patients died within March, 1 patients died within half a year after the operation and.2 died in September after the operation, and the rest of the patients were followed up. Conclusion: in a large medical center, the patients were followed up. The resection and reconstruction of the hilar cholangiocarcinoma can improve the resectability of the tumor and improve the prognosis of the patients. Perfect preoperative management, accurate 3D evaluation and reasonable surgical strategy can reduce the postoperative complications of hilar cholangiocarcinoma and ensure the safety of the operation.
【學位授予單位】：華中科技大學
【學位級別】：博士
【學位授予年份】：2016
【分類號】：R735.8

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