【文档说明】肝门胆管癌治疗进展课件.ppt，共(78)页，10.023 MB，由小橙橙上传

转载请保留链接：https://www.ichengzhen.cn/view-241473.html

以下为本文档部分文字说明：

HilarCholangiocarcinoma:CurrentManagement肝门胆管癌治疗进展目录1•定义2•病因3•病理分型4•诊断5•治疗◼AKlatskintumor(orhilarcholangiocarcinoma)isacholan

giocarcinomaoccurringattheconfluenceoftherightandlefthepaticbileducts发生于肝总管或左、右肝管及其汇合处的恶性肿瘤◼Proliferationofmalignantadenocarcinomaandfibrobl

ast组织学特征是恶性腺癌细胞和周围的粗纤维细胞增生◼specificsituationandinfiltratedgrowth发生部位特殊、呈浸润性生长◼Lowradicalresectionratewit

hhighoperationrisk根治性切除率低、手术风险大◼Ahard-to-treatdisease难以攻克的顽症之一HilarCholangiocarcinoma,KlatskinTumor肝门胆管癌EtiologyofHilarCholangiocarcinoma肝门胆管癌的病因◼目前

病因尚不清楚，与胆管慢性炎症、胆结石及胆汁淤积可能相关◼可能的病因：PSC原发性硬化性胆管炎Congenitalbiliarymalformations先天性胆道畸形，如多囊肝、胆总管囊肿、calori’s病等

Chroniculcerativecolitis慢性溃疡性结肠炎Parasiticinfections化学致癌物，如麝猫后睾吸虫、华支睾吸虫等Chemicalcarcinogens化学致癌物多囊肝溃疡性结肠炎PSC与胆道系统肿瘤◼263例原发性硬化性胆管炎，

观察时间从1999~2009，胆管癌发生概率为14%◼KristenMB等人发现，Mayo评分＞4，吸烟、酗酒、炎症性肠病病史患者更容易发生胆管癌BestPractice&ResearchClinicalGastroenterol

ogy2011RolesofClonorchisEndemicusInfectionasRiskFactorforCC华支睾吸虫是肝门胆管癌的易感因素JohnZ,etal.JournalofHepato-Biliary-PancreaticSciences,2014成虫卵

沼螺、涵螺、豆螺（第一中间宿主）包囊终末宿主保虫宿主淡水鱼第二中间宿主尾蚴长约10~25mm◼AhistoryofeatingrawfreshwaterfishandapositiveserologicresultforC.sinensi

sweresignificantlyassociatedwiththedevelopmentofCC◼食用淡水鱼史并且华支睾吸虫血清学试验阳性的患者，与肝门胆管癌的发生发展密切相关FreshwaterFishandClonorchisEndemicus淡水鱼与华支睾吸虫淡水鱼是华支睾吸

虫的第二中间宿主TheWaysofMetastasis转移途径Roland.Z,Hepatology,2012◼Hematogenousmetastasis血行转移肝内血行转移发生最早，也最常见，可侵犯门静脉并形成瘤

栓◼Lymphaticmetastasis淋巴转移可局部转移到肝门，淋巴转移仅占转移总数的12.6%◼Contactmetastasis接触转移一般较少发生邻近脏器的直接浸润，但偶尔也可直接蔓延、浸润至邻近组织器官，如膈、胃、结肠、网膜等◼M

etastasisalongnervefibers沿神经蔓延HilarCholangiocarcinoma—Diagnosis肝门胆管癌诊断方法Hilarcholangio-carcinomaClinicalmanifestation：pro

gressivepainlessjaundice进行性无痛性黄疸Imaging：CT,MRCP,ERCP,Bultrasonic,PET-CTTumormarker:CA199,CEApathology：ERCPbrushcyt

ology,biopsy毛刷细胞学检查，活检Diagnosis-CTCT诊断Diagnosis-MRIMRI诊断MRCPDiagnosis-MRCPMRCP诊断TheRoleofHistologicalDiagno

sis组织学诊断的作用Koeaetal,worldjournalofsurgery,2004Bucetal,HPB,2008◼ERCPbrushcytology(毛刷细胞学检查):thefirstchoice◼For

cepsbiopsyandfine-needleaspirationisnotmandatoryLowsensitivityRiskofmetastasis◼Resectionremainsthemostreliablew

aytoruleoutbiliarymalignancyDistributionofHilarCholangiocarcinoma肝门胆管癌分布MuradAljiffry,etal.WorldJGastroenterol,2009Hilarcho

langiocarcinoma◼5%~10%的胆管癌分布于肝内胆管◼60%~70%的胆管癌位于胆道系统的分叉处，即肝门胆管癌，是胆管癌的主要类型。◼20%~30%的胆管癌位于肝外胆管PathologyofHilarCholangioca

rcinoma病理分型HayashiS,etal.Cancer,1994sclerosing硬化型（70%）nodular结节型（20%）papillary乳头状（5%）Transmuralinvasio

n横向浸润，侵犯胆管及周围组织Longitudinalextension纵向浸润，粘膜和粘膜下的扩散肿瘤可向上胆管上下侵犯Lymphnodemetastasis淋巴结转移PathologySpreadmorefavorableprognosis预后较好majorityofcas

es主要类型名称分型或分期依据Bismuth-Corletteclassification:themostcommon肿瘤解剖学部位Gazzaniga分期（加扎尼加分期、T分期法）肿瘤部位，门静脉是否侵犯及有无肝叶萎缩

MSKCC改良T分期（MemorialSloan-KetteringCancerGenter）肿瘤对肝动脉和门静脉的侵犯程度AJCC（pTNM）分期术后病理结果ClaissificationandStaging分型分期Bismuth-Corlette

分型HenriBismuth,AnnSurg,1992IIIaIIIbIV临床最常用，有助于计划手术方式，但肿瘤分级程度与肿瘤可切除性和术后生存期长短之间无相关性ITumorsbelowtheconfluen

ceoftheleftandrighthepaticduct肿瘤位于胆总管上端IITumorsreachingtheconfluence肿瘤位于左右肝管分叉部IIIaTumorsoccludingthecommonhepaticductandeithertherightduct肿瘤累

及肝总管、汇合部和右肝管IIIbTumorsoccludingthecommonhepaticductandeithertheleftduct肿瘤累及肝总管、汇合部和左肝管IVTumorsinvolvingtheconfluenceandbo

ththerightandlefthepaticducts肿瘤累及肝总管、汇合部和同时累及左右肝管IIIIIIaIIIbIVBismuth-corletteclassificationBismuth5种分型G

azzaniga分期（T分期法）T分期发展于Bismuth-Corlette分期基础之上主要包括以下三个因素：◼1、肿瘤位置及胆管受累程度（参见Bismuth-Corlette分期）◼2、有无门静脉侵犯◼3、有无肝叶的萎缩T3

:Tumorsoccludingthecommonhepaticductorthesecondarybileduct,andinvolvingthehepaticportalveinoffside,orwiththecontralate

ralliveratrophy,orinvolvingthemainhepaticportalvein肿瘤侵及肝管汇合部并且双侧都侵袭至二级胆管或肿瘤单侧侵袭至二级胆管同时合并对侧门静脉受累；或肿瘤单侧侵袭至二级胆管

同时合并对侧肝叶萎缩；或肿瘤累及门静脉主干或者双侧门静脉均受累MSKCC改良T分期Classification&CriteriaT1:Tumorsoccludingthecommonhepaticductortheseconda

rybileduct肿瘤侵及肝管汇合部和（或）单侧侵袭至二级胆管T2:Tumorsoccludingthecommonhepaticductorthesecondarybileduct,andinvolvingtheipsilateralhepati

cportalvein肿瘤侵及肝管汇合部和（或）单侧侵袭至二级胆管,同时合并同侧门静脉受累和（或）同侧肝叶萎缩MSKCCisusedforassessingtheresectabilityoflivercarcinoma.

JarnaginWR.AnnSurg，2011AJCC分期原发肿瘤（T）Tis：原位胆管癌；T1:浸润肌层或纤维层；T2a:侵及胆管周围纤维组织；T2b:侵及胆管邻近肝实质；T3:侵犯单侧门静脉/肝动脉；T4:侵犯门静脉主干或双侧分

支；或肝总动脉；或双侧II级胆管；或单侧II级胆管加对侧门静脉或肝动脉浸润区域淋巴结（N）N0：无淋巴结转移；N1：局部淋巴结转移（胆囊管、胆总管、肝动脉、门静脉旁）N2:远处淋巴结转移（主动脉、肠系膜上动静脉、下腔静脉、腹腔动脉旁淋巴结转移；远处转移（M

）M0无远处转移；M1发生远处转移0期TisN0M0ⅠA期T1N0M0ⅠB期T2N0M0ⅡA期T3N0M0ⅡB期T1、T2或T3N1M0Ⅲ期T4任何NM0Ⅳ期任何T任何NM1AmericanJointCommitteeonCancer.

AJCCcancerstagingmanual.7thedPrognosticFactors预后因素情况很好，恢复不错肿瘤病理类型术前胆道引流术前定位与剩余肝胆红素水平术前CA199水平肿瘤浸润深度手术切除类型下腔静脉侵犯Prognosticfactor:preoperativeser

umCA19-9levels1、术前CA19-9水平是肝门胆管癌术后的独立预后因素术前CA19-9低于150U/ml的胆管细胞癌患者组术后生存显著优于术前CA19-9高于150U/ml组（P=0.000）Wen-KeCai1,IntJ

ClinExpPathol,2014术前CA199＜150U/ml术前CA199＞150U/mlRochaFG,etal.JHepatobiliaryPancreatSci,2010Preoperativeserumt

otalbilirubin>10mg/dlassociatedwithpoorprognsois术前胆红素>10mg/dl,直接影响术后生存率Prognosticfactor:preoperativeserumtotalbiliru

bin2、术前胆红素与预后Prognosticfactor:thevolumeofremnantliver3、准确的术前定位与剩余肝体积影响预后◼Precisevisualizationofanatomicstructures◼Multidirectionalasses

smentofbiliarybranchesandvessels◼AllowingimprovedoperativeplanningRyokoSasaki,TheAmericanJournalofSurgery,2011Thevolumeofremnantliverandprognosi

s剩余肝体积与预后关系RochaFG,JHepatobiliaryPancreatSci,2010通过48例患者的临床数据分析显示，剩余肝体积与预后具有显著相关性P=0.012LiuF,etal.DigDisSci,2010Y

ES：unrelievedbiliaryobstructionisassociatedwithhepaticandrenaldysfunctionandcoagulopathyNO：Preoperativebiliarydrainageisassociatedwith

anincreasedriskofcomplicationPreoperativebiliarydrainageremainscontroversialRecently,Metaanalysisindicatedpreoperativebiliarydrainag

ehadnobenefitPrognosticfactor:preoperativeBiliaryDrainage4、术前胆道引流Preoperativebiliarydecompressioninpatientwithcholangiocarcinoma肝门胆管癌患者术前胆道减压Ca

se-comparisonstudyMajorliverresectionswithoutPBDaresafeinmostpatientswithobstructivejaundice.Transfusionrequirementsandincidenceofpost

operativecomplications,especiallybileleaksandsubphreniccollections,arehigherinjaundicedpatients.WhetherPBD

couldimprovetheseresultsremainstobedetermined肝门胆管癌术前胆道减压能减少并发症发生率，但是否能提高预后结果仍需进一步研究◼20例黄疸患者作了肝切除但未行术前胆道引流◼27例

对照组患者肝切除但未黄疸患者◼结果发现：黄疸患者与无黄疸患者组病死率为（5%vs0%），肝衰发生率（5%vs0%），胆漏等并发症发生率（50%vs15%）Preoperativebiliarydrainage

oftheFLR(futureliverremnant)appearstoimproveoutcomeifthepredictedvolumeis<30%.However,inpatientswithFLR>or=30%,pre

operativebiliarydrainagedoesnotappeartoimproveperioperativeoutcomeRetrospectivestudy研究显示，当剩余肝体积＜30%时，术前胆道引流能提升肝门胆管癌患者预后，当剩余肝体积≥30%时，术前胆道引流对预

后影响无统计学差异◼从1997~2007年间的60例肝脏切除术后患者◼根据剩余肝体积选择性的使用术前胆道引流，65%的患者剩余肝体积≥30%（39/60）◼对照组中，肝体积≤30%（21/60），其中

有5人出现了肝体积不足，有4人死亡，并且缺少术前胆道引流（P=0.009）这篇meta分析包括10个研究711位肝门胆管癌，其中442位合并黄疸患者进行了术前胆管引流，233位黄疸患者未进行术前引流，临床数据分析不支持肝门胆管癌合并黄疸患者能从引流中

获益RetrospectivestudyMeta-analyse711casesAdvantagesanddisadvantagesofdifferentmethodsofbiledrainage不同胆管引流方法的优劣引流方法MaguchiHetal,JHepatobiliary

PancreatSurg,2007Prognosticfactor:histologicalclassification5、组织学分型影响预后分化程度与生存率SaxenaA,TheAmericanJournalofS

urgery,2011高分化患者组中分化患者组低分化患者组Prognosticfactor:Tumordepth6、肿瘤浸润深度及长期预后Tumordepthmoreaccuratelystratifiespatie

ntsandisabetterpredictoroflong-termoutcome肿瘤浸润深度是评估肝门胆管癌预后的一项重要指标deJongMC,etal.ArchSurg.2011肿瘤浸润深度＜5mm组肿瘤浸润深度＞5mm组Prognosticfactor:typeoflive

rresection7、肝切除类型与预后关系Konstadoulakis,TheAmericanJournalofSurgery,2008Righthepatectomyhadbettersurvival◼1998~2006年间的73位肝门

胆管癌患者◼51位患者进行了右半肝切除术◼22位患者进行了左半肝切除术◼5年生存率分别是48.9%和21.7%InvasionofIVCindicatespoorprognosis8、下腔静脉侵犯预示不良预后Konstadoulakis,TheAmericanJ

ournalofSurgery,2008下腔静脉侵犯患者术后生存率显著低于未侵犯者◼纳入本研究的73例患者中有3例（4%）出现了下腔静脉侵犯◼统计结果提示严重的不良预后肝门胆管癌外科治疗方法◼Patientsresected(solidline)hadbetteroverall

5-yearsurvival(35%)thanpatientsthatwerenotresected.Nounresectedpatient(dottedline)survivedto24monthsAlanW.Hemming,AnnSurg,2005手术切

除组非手术治疗组Surgicalresection外科切除SurgicalresectionisthebesttreatmentforhilarcholangiocarcinomaT.M.vanGulik,Europea

nJournalofSurgicalOncology,2011手术切除组患者术后生存率显著优于非手术组及肝移植组Actuarialsurvivalofpatientsunderwentresectionversusthosewerenotresected手术切除对生存率的影

响Precisesurgicalresectionforhilarcholangiocarcinoma肝门胆管癌的外科治疗IIIV根治性切除手术的范围和术式的选择IVIII可切除性的判断和手术规划的制订精确评估肝门胆管癌的侵袭范围精确评估

预留剩余肝脏功能和必需功能性肝脏体积明确围肝门部的脉管解剖肝门部胆管癌的诊断和治疗，2013肝门胆管癌切除的根治程度◼肿瘤根治术按照肿瘤切缘有无癌细胞，分为以下几种切除−R0指切缘无癌细胞，完整切除−R1切除指镜下见切缘有癌细胞−R2指肉眼可见切缘癌

细胞◼在肝门部胆管细胞癌的治疗中，尽量做到R0切除R0resectionsignificantlyimprovedsurvivalrate1、R0切除能显著提高术后生存率JunjieXiongetal.JournalofSurgicalResearch,2

014R0resectionimprovedsurvivalrate(P=0.037)NegativeresectionmarginisthekeyforR0resection:theroleofin

traoperativefrozensectionR0切除的关键是阴性切缘：术中冰冻检测的关键部位DarioRibero,etal.AnnSurg,2011◼术中冰冻检测切缘◼若切缘阳性,未达到R0切除◼此时如进一步切除并达

到R0切除，可提高生存率Survivalofpatientsresectednegativemarginsversusthosewhoresectedwithpositivemargins阴性切缘和阳性切缘患者生存率对比◼Patientsresecte

dwithnegativemarginshadabetter5-yearsurvivalof45%thanpatientsresectedwithpositivemargins,withnopatientresectedwithpositivem

arginssurvivinglongerthan40monthsAlanW.Hemming,AnnSurg,2005negativemarginspositivemargins2、No-touch-techniq

ueanden-bloc-resection不接触技术和整块切除PeterNeuhaus,etal.AnnSurgOncol,2012白线为切除线黑线为切除线Hilaren-bloc-resection优点：➢避免肿瘤

周围肝门部血管解剖➢门静脉切除提高了R0切除率欧洲外科学会主席PeterNeuhaus教授提出：BismuthⅢa和BismuthⅣ型，只有施行扩大右半肝和门静脉切除，才能达到理想的广泛切缘阴性和肿瘤不

接触原则的目标Hilaren-bloc-resectionincrediblyincreasethesurvivalofCC肝门部整块切除显著提高肝门胆管癌生存率PeterNeuhaus,etal.AnnSurgOncol,2012不接触技术、整块切除和广泛的切缘肿瘤阴性的三大肝门胆管癌外科手

术原则整块切除组显著优于普通肝切组Lymphnodedissectionimprovedprognosis3、彻底淋巴结清扫能提高预后YoungLA,JHepatobiliaryPancreatSci,2010范围：清扫肝十二指肠韧带的淋

巴结和结缔组织（12,12p,12b组）,胰头上、后淋巴结（胰腺上、后13a组），及肝总动脉周围淋巴结（8组）彻底清扫淋巴结与预后显著相关Lymphnodesmetastasis肝门胆管癌淋巴结转移名古屋大学附属医院110例肝门胆管癌手术切除患者30%~50%伴淋巴转移◼胆总管旁淋巴结（

42.7%）◼门静脉旁（30.9%）◼肝总动脉旁（27.3%）◼胰头十二指肠后（14.5%）KitagawaY,etal.AnnSurg,2001GroupI:无淋巴结转移；GroupII:局部淋巴结转移；GroupIII:腹主动脉旁淋巴结转移；A:镜检阳性；B:肉眼阳性+镜检阳性；C:

无法切除；GroupIII患者术后生存与淋巴结侵犯密切相关75casescclymphnodesmetastasisandprognosisVeronauniversity,Italy淋巴结转移及预后分析Alfred

oGuglielmi,JGastrointestSurg,2013术中切除淋巴结>3枚以上能提高生存期淋巴结阳性率>0.25提示预后不良淋巴结阳性预后不良4、尾状叶切除是R0切除关键GazzanigaGM,JHepatobiliaryPancreatSurg,2000行尾状叶切除未行尾状叶切除肝

门胆管癌尾状叶累及高达40%-98%，故尾状叶切除是R0切除的关键尾状叶胆管：可汇入左、右肝管及左、右肝管汇合处肝门胆管癌常累及肝尾状叶Resectionofcaudatelobeoflivergreatlyincreasethesurvi

val肝尾状叶切除能显著提高生存率尾状叶切除显著提高患者术后总体生存与无瘤生存率，改善Ⅲa和Ⅲb期患者预后KowAW,etal.WorldJSurg,2012来自韩国SamsungMedicalCenter针对127例患者的回顾性分析：尾状叶切除组尾状叶切除组Invasion

oftheportalveinisnottheoperativecontraindication5、门静脉侵犯不是手术禁忌征◼肝门胆管癌门静脉侵犯较多见（36%）◼门静脉切除能提高R0切除率（P=0.00

3）YoungAL,JHepatobiliaryPancreatSci,2010MechteldC.deJong,etal.Cancer,2012Therewasnosignificantdifferenceinsurvivalbetweenportalveinre

section(PVR)andNoPVR门静脉切除并不增加死亡率AlanWHemming,JAmCollSurg,2011门静脉切除组与非门静脉切除组术后生存无统计学差别238例肝门胆管细胞癌患者分别为R0、R0+PVR、R1、R2切除后

，与其他三组相比，R0+PVR组生存情况不如单纯R0切除（P＜0.001），与R1组生存情况相似（P=0.606），但优于R2组（P=0.047）WenlongYu,CellBiochemBiophys,2014◼R0切除合

并门静脉切除相比单纯R0切除降低了生存率◼合并门静脉切除的患者存在门静脉侵犯情况，情况较单独R0切除组差◼结论仍需大样本的临床病例验证CommontypesofthevesselreconstructionafterPV

R肝门静脉重建的常见类型PV-SMVPV重建方法例举利用Y形髂动脉行门静脉-脾静脉、门静脉-肠系膜上静脉吻合Hepaticarteryresectionandreconstruction6、肝动脉切除及

重建肝动脉侵犯肝动脉重建后吻合口Male,74ys，hepaticarteryinvasion,hepaticarteryresectionandreconstructionduringoperation

deSantibañesE,HPB,2012acb◼离断左、右肝动脉及右肝后动脉◼将左肝动脉端与右肝后动脉吻合◼重建完成后行左半肝切除两例肝门胆管癌BismuthⅢb期行左半肝切除+尾状叶切除，术中行肝动脉重建◼保证胆管良好血供◼无张力吻合◼连续(后壁连

续、前壁间断)◼5/6/7-0prolene或可吸收线◼不放置支架或T管Reconstructionofbileduct胆管重建的经验三支胆管重建胆肠吻合胆肠吻合结束典型病例1男，65岁，诊断为肝门胆管癌，行半肝切除术清扫淋巴结胆管重建典型病例2侵犯

肝脏男性,46岁，肝门胆管癌伴胰腺周围淋巴结转移，行胰十二指肠联合肝脏切除BismuthIVAfterHPD胰周淋巴结转移HPD术后达芬奇机器人辅助外科手术系统医生操作台床旁机械臂塔显示器达芬奇机器人

与肝胆外科手术车器械护士术者巡回护士麻醉师助手显示器Palliativetherapy姑息性治疗大多数肝门胆管癌患者并没有接受手术治疗的机会，解除胆道梗阻成为主要治疗目的，主要包括胆肠吻合旁路手术、内镜胆

道引流和经皮肝穿刺胆道引流。有效，并发症相对较多，适用于晚期患者，无法接受胆道支架患者ERCPPTCD胆肠吻合旁路手术安全，有效廉价，应用广泛有效，相对安全，适用于无法内镜胆道引流时WeberA,etal,WorldJGastroenterol,2007Appl

icationoflaparoscopyinthetreatmentofhilarcholangiocarcinomafield内镜治疗在肝门胆管癌领域的应用IzbickiJR,JGastrointestSurg,2012◼术前探查：能发现隐匿转移灶又减

少了手术创伤。应用腹腔镜探查结合MSKCC分期，发现36%的T2/T3期存在隐匿病灶。提示对T2/T3期患者选择性的应用腹腔镜探查具有一定价值◼手术治疗：技术上的局限性限制了采用微创技术治疗肝门胆管癌，

目前报道较少有报道借助机器人腹腔镜手术系统行右半肝切除联合胆道重建GiulianottiPC.JLaparoendoscAdvSurgTechA,2010肝门胆管癌支架引流金属支架长期通畅率和相对成本效益比塑料支架高，金属支架能保持通畅时间明显长于塑料支架者，尤其于不可切

除性肿瘤患者金属支架组塑料支架组JohnZ,BMCGastroenterol.2012通畅率对身体的肿瘤进行手术治疗和放疗的前后，应用化疗，使原发肿瘤缩小，提高治愈率而进行的化学药物治疗辅助化疗HepatobiliarySurg

Nutr.2014◼KevinC等人分析了63例肝门胆管癌患者的临床数据◼其中29例患者做了术前化疗，和体外化疗◼接受辅助化疗患者组的五年生存率（33.9%）显著高于未辅助化疗组（13.9%）（P＜0.001）Livertransplantationforhil

archolangiocarcinoma肝门胆管癌肝移植治疗EarlyStgage◼Poorprognosis，5-yearsurvivalrate:30%，tumorrecurrencerate:50%◼RelativecontradictionofLTMeye

retal,Transplantation,2000PoorprognosisIndicationoflivertransplantationforhilarcholangiocarcinomainMayoCl

inic梅奥医学中心的肝门胆管癌肝移植指征Include入选指征Reaetal.AnnSurg,20051、肝门胆管癌诊断：◼经导管活检或毛刷细胞学检查阳性◼CA199＞100mg/ml和（或）断层扫描有块状阴影并且胆管造影有恶性肿瘤结构◼FIS

H检测胆管染色体倍数并且胆管造影有恶性肿瘤结构2、胆囊管以上无法切除的肿瘤3、放射检查显示肿瘤直径≤3cm4、无肝内肝外转移5、肝移植的候选者MayoClinicProtocal外照射+5-Fu近距放射疗法口服卡培他滨（希罗达）移植前剖腹探查评估移植Reaetal.

AnnSurg,20051987-2008年美国359例胆管癌肝移植分析总生存率Mayo方案提出之前Mayo方案提出之后ReenaJ.Salgia,DigDisSci,2013Mayo方案的提出大大提高了肝门胆管癌肝移植

疗效1993~2010年美国12家采用新辅助疗法和肝移植治疗肝门胆管癌的移植中心数据分析EnverZerem,gastroenterology,2012移植后2年、5年和10年无复发生存率分别为78%、65%和59%SchüleS,Lange

nbecksArchSurg,2013德国一中心回顾性分析16例肝门胆管癌肝脏移植资料淋巴结转移患者生存率显著低于未转移者LT+NeoadjuvanttherapyLTLTResectionJohnnyC.Hong,ArchSurg,2011Th

eadvantageoflivertransplantation肝移植治疗的优势◼通过适当选择，肝移植疗效优于单纯手术治疗◼移植联合新辅助治疗（化疗等），疗效优于单纯移植JayZ,Hepatology,2012LiverTranspla

ntationforHilarCholangiocarcinomainOurCenter浙大一院肝门胆管癌肝移植病例beforeLT9yearspostLTYuBingsheng,male,57y,HilarCholangiocarcinoma,receive

dlivertransplantationonOctober25th,2005WangXiaoping,Male,51y,Hilarcholangiocarcinoma,receivedLTin1999

,Survival:16yearsLinHanbin,Male,46y,Cholangiocarcinoma,receivedLTin2000,Survival:15yearsLiverTransplanta

tionforCholangiocarcinomainOurCenter浙大一院肝门胆管癌肝移植病例通过严格掌握指征及合理治疗，肝门胆管癌通过肝移植可达长期生存Conclusion◼Surgicalresectionof

ferstheonlychanceforpotentialcurativetherapy.◼R0resectionisofutmostimportance.Standardtherapyconsists

ofextrahepaticbileductresection,hepatectomyandenbloclymphadenectomy◼Orthotopiclivertransplantationofferscomple

teresectionoflocallyadvancedtumorsinselectpatientgroups.◼SpecificpreoperativeinterventionsforpatientsincludeERCPandPTCD.◼Advanceddisease,andm

anypatientsreceivesystemictherapy(chemotherapy,radiationtherapy)toimprovesurvival.