Radical resection of proximal cholangiocarcinoma

Radical resection of proximal 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 1. The clinical diagnosis is that the upper cholangiocarcinoma involves the bifurcation of the hepatic duct. If there is no surgical contraindication and the patient's general health condition can tolerate surgery, radical resection should be selected. 2, there may be a surgical resection of one side of the liver or limited to 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, diagnosed as bile duct papillary adenoma, papillary adenocarcinoma, highly differentiated hepatic duct bifurcation cancer, if the first time without radical surgery, no surgical contraindications, it is feasible to re-surgical resection. Contraindications 1. Local metastasis of the tumor, 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 branches of bilateral hepatic ducts. 5. Angiography showed 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, suffering from viral hepatitis, diffuse damage to the liver parenchyma, extensive liver resection in radical resection requires very careful. 8, combined with acute cholangitis should first drain the bile duct to control infection, combined with acute cholangitis, radical resection and hepatectomy have a high mortality rate. 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 poor general condition can not be performed in time, should be careful to avoid infection and loss of water and electrolytes under drainage. If it can be drained through the endoscope, the effect is better than PTCD. 4, patients with significant weight loss and malnutrition, 1 week before surgery began to strengthen intravenous nutritional supplements, correct low potassium, low sodium, anemia, hypoproteinemia, vitamin K11 supplement. 5. Oral bile salt preparation. 6, antibiotics intestinal preparation. 7, oral administration of ranitidine 150mg before the night. 8, gastric tube and indwelling catheter. 9, preventive application of antibiotics, in view of obstructive jaundice patients, 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 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 by 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 pay attention to the presence or absence of ascites, peritoneal surface, omental implantation, metastatic cancer nodules, peritoneal metastasis usually occurs in the peritoneal surface of the hilar, sometimes along the falciform ligament, hepatic round ligament to Umbilical, peritoneal metastasis indicates that radical resection has not been performed. 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. 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. 7. Pull the free gallbladder and bile duct downward, hook the lower edge of the liver lobe, cut the liver capsule at the leading edge of the hepatic hilar, cut off the blunt dissection under the capsule, push the liver parenchyma, and push 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. 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. 9, the length of the right hepatic duct trunk is short, an average of about 0.84cm, so the bifurcation of the hepatic duct may involve the opening of the right anterior and posterior hepatic duct; in addition, about half of the right hepatic duct is split, 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. 10. The adjacent hepatic duct openings at the left and right ends of the hepatic hilum are sutured together by thin wires 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. 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, do a Roux-en-Y jejunum fistula, suture closure closed, the length of the palate is generally 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, and 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. 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 were cut 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. 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 late 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 on 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 armpit, under the liver, U-shaped tube out of the liver. 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 with extensive biliary cirrhosis after biliary cirrhosis or viral hepatitis.