Radical resection for high cholangiocarcinoma

Radical resection of high cholangiocarcinoma for surgical treatment of upper biliary duct cancer. Proximal bile duct carcinoma or hilar bile duct carcinoma is the most common site of extrahepatic biliary tract cancer. Due to the development of modern imaging diagnostic techniques, there is an increasing trend. Improving the understanding of the hilar cholangiocarcinoma, early diagnosis, and thorough surgical resection are important advances in current biliary surgery. Treating diseases: cholangiocarcinoma Indication Radical resection of high cholangiocarcinoma is applicable to: 1. The clinical diagnosis is that the upper end of the bile duct involves the bifurcation of the hepatic duct. If there is no surgical contraindication and the general health condition of the patient can tolerate surgery and appropriate medical technical conditions, radical resection should be selected. 2. There may be a surgical resection of one of the intrahepatic metastases or the lymph node metastasis of the hepatic duodenal ligament. 3. Patients with hepatic lobe enlargement-atrophy syndrome need to have hepatectomy at the same time. 4. Diagnosis of bile duct papillary adenoma, papillary adenocarcinoma, highly differentiated hepatic duct bifurcation cancer, if no radical surgery for the first time, no surgical contraindications, it is feasible to re-surgical resection. Contraindications 1. Local metastasis of tumors, such as intraperitoneal tumor implantation, tumor nodules on the omentum, and transfer to the umbilicus along the round ligament of the liver. 2. Lymph node metastasis other than the hepatoduodenal ligament cannot be included in the scope of radical resection. 3. Bilateral intrahepatic metastasis. 4. Invasion of the secondary branch of the bilateral hepatic duct. 5. Angiography shows involvement of the bilateral hepatic artery or portal vein or its trunk. 6. Severe obstructive jaundice, the general condition is very poor, can not tolerate major surgery. 7. With viral hepatitis, diffuse damage to the liver parenchyma, extensive hepatectomy should be very careful in radical resection. 8. Patients with acute cholangitis should first drain the bile duct to control infection. The mortality rate of radical resection and hepatectomy in patients with acute cholangitis is high. Preoperative preparation 1. The location and extent of biliary obstruction should be accurately estimated. It can be determined by non-invasive methods such as B-mode ultrasound, CT, MRCP, etc. If necessary, PTC and ERCP can be performed before surgery. However, care must be taken to prevent complications such as biliary infections and bile leakage. 2. If PTC and PTCD have been performed before surgery, surgery should be performed at an early stage. After 2 to 3 weeks, there may be a fatal biliary infection due to delayed surgery, and liver function cannot be achieved even after 2 to 3 weeks of drainage. restore. 3. Preoperative PTCD is generally only used in patients with severe obstructive jaundice and the general condition is too poor to perform surgery in time. Under drainage, care should be taken to avoid infection and loss of water and electrolytes. If it can be drained through the endoscope, the effect is better than PTCD. 4. Patients with obvious weight loss and malnutrition began to strengthen intravenous nutrition supplement 1 week before surgery to correct hypokalemia, hyponatremia, anemia, hypoproteinemia, and vitamin K11 supplementation. 5. Oral bile salt preparation. 6. Antibiotic bowel preparation. 7. Oral administration of ranitidine 150mg before surgery. 8. Stomach tube and indwelling catheter. 9. Prophylactic use of antibiotics, in view of patients with obstructive jaundice, acute renal failure may occur after surgery, should avoid the use of antibiotics such as Qingda toxins with nephrotoxicity. Surgical procedure 1. Generally, a long oblique incision under the right costal margin is used. From the front end of the right 11th rib to the left upper abdomen, the rectus abdominis, the sacral ligament, the round ligament of the liver are cut, and the right rib arch is pulled upward with a large rib retractor. The left and right sides of the hepatic hilum and the liver can be satisfactorily revealed; sometimes, if the left and right lobe of the liver are obviously swollen, a "ridge" shaped double-ribbed incision can be used to enhance the exposure. 2. Intraperitoneal exploration to check whether there is ascites, peritoneal surface, presence or absence of implants on the omentum, metastatic cancer nodules, peritoneal metastasis usually occurs first in the peritoneal surface of the hilar, sometimes extending along the falciform ligament and the round ligament Umbilical, peritoneal metastasis indicates that radical resection has not been performed. Extensive lymph node metastasis of the hilar cholangiocarcinoma is rare. It is more common that the cancer tissue infiltrates into the surrounding tissue and forms a hard mass at the hepatic hilum. The frozen pathological biopsy often shows the infiltration of cancer cells into the connective tissue. Common, is also the main form of local metastasis of cholangiocarcinoma. Therefore, surgical exploration often finds that the border around the hepatic mass is unclear, relatively fixed, and difficult to move, but this is not a sign that cannot be surgically removed. One of the important markers for determining whether a bile duct bifurcation cancer can be removed is the relationship between the tumor and the important blood vessels in the hilum. General exploration has a fashion that cannot be concluded. The method of examination is to use the left hand index finger and the middle finger to extend to the back of the hepatic hilum, touch the path of the hepatic artery and the right hepatic artery, whether the pulsation is normal, whether it is surrounded by the tumor; then check the portal vein and its left and right branches, if the portal vein Still soft and full, the possibility of surgical resection is great; if the hard cancer tissue can be touched behind the portal vein, the portal vein has been surrounded by cancer and cannot be radically removed. Checking the upper limit of cancer needs to determine whether there is a violation of the secondary branch of the liver tube, whether there is intrahepatic metastasis, and whether hepatectomy is needed. If there is a sign of enlargement-atrophy of the liver lobe, it is usually atrophy of the left lobe of the liver, indicating that there is a blockage of the secondary branch of the hepatic duct and often accompanied by obstruction of the portal vein. For example, the bifurcation cancer originating from the left hepatic duct often has Invasion of the left branch of the portal vein and vascular obstruction, so the left hepatic lobe resection (often with the caudate lobe) is required. If the cholangiocarcinoma originates from the bifurcation, the left and right sides of the liver are symmetrically enlarged. When there is a lack of PTC photos before surgery, in order to determine the upper limit of tumor invasion, fine needles can be placed on the left side of the liver and the inside of the gallbladder neck. Puncture and aspiration, if a clear liquid (or bile) is obtained, it means that the obstruction is below it, and it is possible to perform the bifurcation of the hilar hepatic duct. If the metastatic induration on the liver is still limited to one side of the tumor, it does not prevent radical resection including hepatectomy. 3. The important blood vessels of the hilar are "skeletal". When it is determined that radical resection is performed, the peritoneum in front of the duodenal ligament is first cut at the upper edge of the duodenum. According to the position of the hepatic artery pulsation, the hepatic artery was isolated, and the hepatic artery was pulled up with a fine silicone rubber tube (silicone rubber tube for deep intravenous infusion), and separated downward to the junction with the gastroduodenal artery. The lymphatic, nerve, and adipose tissue on the inner side of the hepatic artery was cut off, and separated from the hepatic artery, and gradually separated upward. The hepatic artery was distracted, the lymph, fat and connective tissue around the portal vein were cut off, and the portal vein trunk was shown. The portal vein was separated in the sheath by a right angle vascular clamp and the portal vein was lifted through a silicone rubber tube. Finally, the lower end of the common bile duct is separated at the upper edge of the pancreas, and it is lifted with a silicone rubber tube to "skeletalize" the important structure in the hepatoduodenal ligament. In addition to the portal vein and hepatic artery, the duodenum Lymphatic, fat, nerve, and fibrous connective tissue on the ligament should be removed from the biliary tumor. If the tumor is located deep in the hilar, when there is no suitable large frame-type costal retractor, the liver can be removed before the hepatic hilum is treated to increase the exposure of the surgical field. 4. Anatomical variations of the hepatic artery are more common. A common variation is the ectopic origin of the right hepatic artery, usually derived from the superior mesenteric artery. At this time, the blood vessel is deep in the portal vein, from the right rear of the common bile duct to the gallbladder triangle to the right end of the liver lateral groove. Branch to the gallbladder. During surgery, you should touch the right rear of the common bile duct with or without arterial pulsation. If there is such a variation, the right hepatic artery should be separated from the surrounding lymphoid adipose tissue and pulled up with a thin silicone rubber tube, because the lymphatic and fat on the right side of the bile duct The tissue needs to be removed from the bile duct. 5. Cut off the common bile duct. At the upper edge of the pancreas, the lower end of the common common bile duct is cut off between the two vascular clamps, and the distal suture is closed. If the lower edge of the bifurcation cancer has involved the opening of the cystic duct, the bile duct margin tissue should be taken for cryosection to prevent sometimes cancer cells. It is infiltrated under the mucous membrane and is difficult to find by the naked eye. The upper end of the common bile duct is pulled upward, and the bile duct is separated from the anterior wall of the portal vein in the portal vein sheath, together with lymphatic adipose tissue around the portal vein, up to the upper end of the bile duct. There is a right hepatic artery that traverses the back of the bile duct and is wrapped in the same soft tissue sheath for further separation. 6. Free gallbladder. Starting from the bottom of the gallbladder, the gallbladder was retrogradely freed, and the adhesion and hemorrhage of the gallbladder bed were ligated one by one. Traction of the bottom of the gallbladder, separation of the gallbladder neck and liver adhesion, if the cancer is located in the bifurcation of the hepatic duct, you can find the dilated right anterior segment of the bile duct in the posterior upper part of the gallbladder neck; if the cancer has invaded the right side of the second When the liver tube is graded, it is found that the hard block of the part is deeply spread in the liver along the direction of the hepatic duct, and there is no clear boundary with the surrounding tissue. The relationship between the duct system at the right end of the hepatic hilum is often mutated. It is common to have the lowest position of the right portal vein, and the right hepatic artery between the right trunk of the portal vein and the right hepatic duct can be determined by touching its pulsation. Common variations include: 1 right portal branch of the portal vein is too early, position is low, right portal vein is very short; 2 right anterior and posterior branches of the right hepatic artery are too early; 3 ectopic right hepatic artery is from the back of the gallbladder neck Enter the right hepatic hilum; 4 if it is a split right hepatic duct, there is no right hepatic duct trunk, and the right posterior hepatic duct often comes out from the bifurcation part, so it is difficult to find at this step. The anatomical relationship of the tubal system in the hilum is complicated, the variation is many, it is difficult to predict, and when there is tumor obstruction, the local anatomical relationship is changed, so the separation here must be carefully performed, and the fine needle is used occasionally. Puncture aspiration to determine whether the structure encountered is a blood vessel or a bile duct to avoid major bleeding from vascular injury. 7. Pull the free gallbladder and bile duct downward, hook the lower edge of the liver lobe, cut the hepatic capsule at the leading edge of the hepatic hilar groove, bluntly separate under the capsule, push open the liver parenchyma, and the liver The door panel is lowered. When separating the hilar plate, it must be placed under the hepatic capsule to avoid deepening into the liver parenchyma and causing massive bleeding in the left anterior branch of the injured hepatic vein. Then the free end of the gallbladder and the common bile duct are turned up and traction is applied, and the upper end of the bile duct is gradually separated from the left and right branches of the right hepatic artery and the portal vein. In an earlier case, the tumor can be branched from the portal vein. open. The hepatic bile duct is wrapped around the fibrous tissue of the Glisson sheath at the hepatic hilum, which is not easy to separate, and in the cholangiocarcinoma, the cancer cells infiltrate the connective tissue around the bile duct, so the bile duct cannot be isolated separately, but must be connected to the surrounding bile duct. Tissue and hepatic hilum were removed. 8. The bile duct and gallbladder are pulled to the right side, and the liver tissue bridge between the left outer lobe and the inner lobe of the liver is cut, so that the left hepatic fissure can be fully revealed. The hepatic duct above the obstruction of the bile duct bifurcation is dilated, so the left hepatic duct can be puncture in the left hepatic vein with a fine needle. Generally, the colorless and transparent bile in the dilated hepatic duct can be easily extracted to achieve the purpose of positioning, and further Separate and separate the left branch of the portal vein from the bile duct. After puncture positioning, a traction line was sutured about 1 cm above the boundary of the tumor to cut the anterior wall of the left hepatic duct. The upper end of the bile duct is mostly of the type of well-differentiated adenocarcinoma, so the boundary between the tumor and the normal bile duct wall is more clear and easy to identify; sometimes when the boundary is not clear enough, it should be cut on the thin, dilated bile duct. After the left hepatic duct is incision, the circumference is gradually cut transversely until it is transversely broken. The proximal end fracture is marked by two traction lines, and the distal end is used as traction to facilitate the removal of the bifurcation of the bile duct. When cutting the left hepatic duct, care should be taken to avoid damage to the left branch of the portal vein that is in close contact with the posterior wall. Bleeding at the end of the bile duct should be sutured with thin lines to stop bleeding. The common bile duct end and the left hepatic duct stump are used as traction, and the portal vein bifurcation is separated from the bile duct tumor along the anterior wall of the portal vein. When only the bifurcation of the bile duct is performed, the left and right branches of the portal vein can be preserved intact; If the portal vein is compromised, some of the portal vein walls can be removed and repaired under the control of a non-invasive vascular clamp. When the left hepatic duct is severed, if the cutting plane is closer to the bifurcation of the bile duct, the left end of the hepatic portal may have only a larger opening of the left hepatic duct. If the plane of the left hepatic duct is closer to the left hepatic fissure, there is more than one left hepatic bile duct opening at the left end of the hepatic hilum, usually 3 or 4, including the left inner lobe, the left outer lobe, and the caudate lobe. Openings, sometimes there are separate openings in the upper left segment (II segment) and the lower segment (III segment) bile duct. 9. The length of the trunk of the right hepatic duct is short, with an average of about 0.84 cm, so the bifurcation of the hepatic duct may involve the opening of the right anterior and posterior hepatic ducts; in addition, about half of the right hepatic duct is schizophrenic, right front The right posterior hepatic duct does not merge into the trunk of the right hepatic duct. The right posterior hepatic duct opening is the most common in the top of the bifurcation. Therefore, the right anterior and right posterior hepatic ducts are blocked by the bifurcation. When separating to the right, a fine needle should be used to puncture the suction from time to time to determine which is the dilated hepatic bile duct and which is the branch of the portal vein. For those who have been determined to be dilated hepatic bile ducts, they can be cut off, and the end-segment is marked with a traction line; thus, it is gradually separated to the right side until the right hepatic duct is cut. Gallbladder, extrahepatic bile duct, hepatic portal fat lymphoid tissue, bile duct bifurcation and tumor resection, the right end of the hilar can have 3 or 4 dilated hepatic bile duct openings, all of which are sutured to facilitate identification. When the bifurcation of the bile duct and the tumor are removed to the right side, due to the structure of the caudate lobe hepatic duct and the right posterior lobe hepatic duct, it is necessary to pull the gallbladder, the common bile duct, and the left hepatic duct end to the right side to reveal the bile duct. The deep side of the fork is to be puncture and suction. When it is found to be a bile duct, it is cut, cut, and gradually separated to the right side. Keep the gallbladder and bile ducts to the right and gradually cut off the dilated right hepatic bile duct. Finally, the whole piece of the extrahepatic bile duct and its bifurcation tumor, gallbladder, hepatic duodenal ligament lymph, fat, nerve tissue, sometimes together with part of the liver. Left and right hepatic duct openings were left at the hilum and were to be reconstructed. However, it is more common to have multiple intrahepatic bile duct openings of different sizes in the hepatic hilar groove above the portal vein bifurcation, which can be as many as 5-8, which is closely related to the portal vein branch, and should be treated during surgery. Take care to avoid injury to the portal vein. 10. The adjacent hepatic duct openings at the left and right ends of the hepatic hilum are sutured together by a thin thread to form a larger bile duct. Sometimes, if the left and right hepatic duct ends are relatively close, the posterior side wall portion may also be Close together, become the back wall of the liver orifice. The author advocates that after the removal of hilar cholangiocarcinoma, a silicone rubber U-shaped tube should be placed for a long time. Therefore, the left and right thick intrahepatic bile ducts are generally selected, and the left outer lower bile duct and the right lower front or lower lower bile duct are placed with a silicone rubber U-shaped tube, which is drawn through the left and right liver surfaces. 11. Sewing the thin wire (preferably a 4-0 absorbable synthetic suture with a needle) on the anterior wall of the bile duct anastomosis, the suture is long and the needle is retained, and the vascular clamp is fixed in order. Above the incision, as a traction during biliary-intestinal anastomosis and facilitating suturing of the anterior wall of the anastomosis. At this point, the surgical treatment of the hilar is temporarily closed. It is advisable to clean the surgical field, remove the blood clot, and carefully stop the bleeding. The liver door is filled with a wet pad for further processing. 12. Lift the transverse colon, find the upper end of the jejunum in the left upper abdomen, make a Roux-en-Y jejunum fistula, and close the suture with a broken end. The length of the ankle is usually about 50cm. We are used to doing a biliary anastomosis before the colon to simplify the operation. After the surgical treatment under the transverse colon, such as cutting, anastomosing the jejunum, closing the mesenteric space, etc., the intestinal fistula is pulled up to the hepatic hilum for anastomosis. 13. The jejunal hilar bile duct anastomosis, first suture the posterior wall of the anastomosis. The suture is long when suturing. After all the sutures are completed, the jejunum is sent to the hepatic hilum and the suture is ligated. Because the hilar bile duct wall and the portal vein bifurcation are very close, and after radical resection, there is no residual soft tissue left in the area, so when the suture is inserted into the posterior wall, a clear visual field must be provided to prevent the suture from penetrating the portal vein wall. As a result, bleeding occurred at the time or after surgery. After the removal of the upper cholangiocarcinoma, there are often multiple intrahepatic bile duct openings of different sizes at the hilum. Currently, we do not make the anastomosis of each hepatic bile duct opening and jejunum, which is very time consuming and does not prevent bile leakage after surgery; Therefore, the commonly used method is to match these hepatic duct openings as a whole with a Roux-en-Y jejunum fistula. 14. Finally, the sutures that were originally sewn to the anterior wall of the hepatic duct opening were removed, and the leading edges of the incisions on the jejunum were sewed from the outside to the inside one by one. After all the sutures were completed, the sutures were knotted one by one, and the knots were tied. In the intestinal lumen, the intestinal mucosa is naturally inverted. Under normal circumstances, in addition to placing U-shaped tubes, we often put a T-shaped tube into other more expanded hepatic ducts. As an early bile drainage after surgery, it is usually removed in about 3 months, and the remaining U-shaped tubes are long. Time to place. Both the drainage tube and the drainage in the abdominal cavity should not pass through the main abdominal wall incision, but are also extracted through the puncture. Sometimes, when the upper cholangiocarcinoma is resected, there is only a dilated left hepatic duct and a right hepatic duct opening in the hilum, but the distance between the two is far and cannot be sutured. In this case, we also use separate The method of hepatic bile duct jejunostomy is repaired. That is, in the Roux-en-Y jejunum, two incisions corresponding to the left and right hepatic duct openings were made to the mesenteric margin, and the mucosa of the left and right hepatic ducts were anastomosed to the mucosa. When the anastomosis is performed, after the posterior layers of the two are anastomosed, the drainage tube is placed, and finally the anterior wall of the anastomosis is sutured. For such patients, we advocate long-term placement of the transmembrane silicone rubber U-shaped tube through the left and right hepatic ducts. The two ends of the U-shaped tube pass through the left and right hepatic ducts respectively. Both ends of the U-shaped tube are often perforated through the liver surface of the lower left lateral lobe and the lower right lobe. At the liver surface, it is advisable to sew the liver tissue around the drainage tube to avoid bile leakage after surgery. The U-shaped tube cuts one side of the hole in both the liver and the jejunum on both sides. After the U-shaped tube is placed, the left and right hepatic ducts and the jejunum are respectively anastomosed by using the suture on the original bile duct opening and passing through the cutting edge on the jejunal wall. Finally, the jejunum fistula is sutured at the hilum, making it natural and avoiding angulation and distortion. U-tube placement after removal of the upper cholangiocarcinoma can be selected according to the findings of the operation. 15. If a secondary hepatic duct on one side is found during surgical exploration, hepatic lobe resection or middle hepatectomy should be performed at the same time. Clinically, left hepatectomy is most commonly used. The surgical method is to cut off the lower end of the common bile duct and free gallbladder, separate the loose tissue between the posterior bile duct and the front of the portal vein, first cut off the right hepatic duct branch of the right end of the hepatic portal, and pull the gallbladder and common bile duct to the left to separate the right liver. The arteries and portal veins were right-handed, and the left venous part of the portal vein was separated. The portal vein trunk was partially blocked with a non-invasive vascular clamp, and then the left portal vein was severely severed. The opening on the portal vein was sutured with a 3-0 vascular suture. 16. From the left hepatic duct at the end of the cholangiocarcinoma to the later stage, often invading the left side of the portal vein and making it occluded, sometimes involving the junction with the portal vein trunk. At this point, the blood vessel wall of a part of the portal vein can be removed, and then sutured and repaired with a vascular suture, but care should be taken not to narrow the main lumen of the portal vein to ensure that the blood flow of the portal vein is smooth. 17. When the left portal vein and the left hepatic artery are cut off, the left lobe of the liver is in an ischemic state, and a clear dividing line appears between the left and right lobe. However, when the deep obstructive jaundice and the liver are severely cholestatic, the boundary line is also It may not be clear enough. The liver is usually cut off from the left side of the gallbladder bed to the left edge of the inferior vena cava. When the cholangiocarcinoma has invaded and the caudal lobe, it needs to be removed together with the caudate lobe. When the caudate lobe is removed, the short caudal vein of the caudal lobe to the inferior vena cava should be separated and cut, the inferior vena cava should be separated, and then the left hepatic liver should be removed. When the left lobe of the liver is resected, sometimes it is not in the mid-cleft of the liver. More commonly, it includes part of the right anterior lobe of the liver. Therefore, there may be 2 or 3 or more intrahepatic bile duct openings in the liver section. 18. If there are more hepatic bile duct openings in the liver section, it is generally difficult to match them one by one with the jejunum. The adjacent opening edges can be closed together, and then the hepatic duct opening collectively matches a jejunum fistula. A drainage tube is placed in the intrahepatic bile duct and is drawn through the jejunum. 19. If the hilar cholangiocarcinoma mainly invades the right hepatic duct, it is feasible to remove the left hepatic lobe, remove the left inner lobe and the right anterior lobe, or perform right hepatectomy or right tricuspid resection, but in this case, if the patient Severe jaundice, poor liver function, and poor general condition, the risk of surgery is large, should be carefully measured; if the risk is too large, it is appropriate to change to internal drainage or external drainage. complication In addition to the complications after major major surgery, the serious complications often associated with hilar cholangiocarcinoma resection are: 1. Infection can occur in the lower axilla, under the liver, and in the U-shaped tube. 2. A large amount of ascites. 3. Stress ulcer bleeding. 4. Bile leakage and even longer-term biliary fistula. 5. Biliary infection. 6. Liver and kidney failure, especially in patients undergoing extensive hepatectomy after cirrhosis or viral hepatitis.

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