1. Radical resection
With the development of imaging diagnosis technology, the progress of surgical technology and the change of treatment attitude, the surgical resection rate of the disease has been significantly improved. Before 1985, the surgical resection rate of the disease was only 10%, but now the surgical resection rate can reach 64. 1%. Only complete surgical resection of hilar cholangiocarcinoma can provide the only cure opportunity for patients, and its effect on improving the quality of life of patients is far superior to various drainage methods. Therefore, the treatment of hilar cholangiocarcinoma should adopt a positive surgical attitude and try to remove the tumor.
Radical resection includes extrahepatic biliary tract resection, "skeletonization" of blood vessels on the hepatoduodenal ligament, extensive resection of fibrous adipose tissue, nerves and lymph on the duodenal ligament, and resection of a liver lobe to reconstruct hepatobiliary jejunostomy if necessary. Most hilar cholangiocarcinomas have caudate lobe infiltration, and those who invade the confluence or the left and right hepatic ducts must remove the caudate lobe. It is considered that caudate lobectomy is one of the main related factors affecting the long-term survival of patients with hilar cholangiocarcinoma.
Nagino and others advocated hepatectomy plus caudate lobectomy, and reported 193 cases, including tumor resection 138 cases, including hepatectomy plus caudate lobectomy 124 cases, portal vein resection1case and hepatopancreaticoduodenectomy 16 cases. The in-hospital mortality rate was 9.9%( 12 cases), 97 cases were cured and resected, and the 3-year survival rate was 42.7%. The 5-year survival rate was 25.8%. It is considered that active hepatectomy can improve the prognosis on the basis of correctly estimating the degree of invasion.
2. Palliative surgery
2. 1 left intrahepatic cholangiojejunostomy
Generally, the dilated left lateral lobe bile duct is found on the left side of sickle ligament, which is consistent with jejunum. This method is simple to operate, but generally it can only drain the left liver. Most of the inoperable hilar cholangiocarcinoma in our hospital are drained by this method or simultaneously with U-tube, and the whole hepatobiliary duct is drained through the lateral hole of U-tube to reduce jaundice.
2.2 Right intrahepatic cholangiojejunostomy
In recent years, many scholars have adopted right hepatic duct-gallbladder-jejunum anastomosis. This kind of internal drainage does not need to separate gallbladder, which is less invasive and relatively simple to operate.
2.3 catheter drainage
Biliary stent directly supports the narrow bile duct of the tumor segment, so that bile near the obstruction can pass through the patient's own bile duct to achieve the purpose of internal drainage. Methods of placing biliary stent include percutaneous transhepatic biliary puncture (PTD), duodenoscopy (ERCP), laparotomy and interventional therapy via external drainage tube. In recent years, with the development of interventional therapy technology, memory alloy stent has been placed in bile duct through liver puncture or in intrahepatic bile duct through laparotomy, and good results have been achieved. The alloy stent passes through the upper and lower ends of the tumor through the bile duct, so that the obstructed bile flows into the lower segment of the hepatic duct through the stent and enters the duodenum. However, the memory alloy stent is expensive, which is difficult to carry out in general primary hospitals.
3. Orthotopic liver transplantation (OLT)
Hilar cholangiocarcinoma has the characteristics of intrahepatic metastasis, slow growth and late extrahepatic metastasis, so some scholars have proposed it as a good indication for liver transplantation. The specific methods are orthotopic liver transplantation, bile duct reconstruction, Roux-Y anastomosis between common bile duct and recipient jejunum, and maximum resection of the patient's proximal bile duct to prevent recurrence.
Indications for liver transplantation for hilar cholangiocarcinoma are:
① Patients who have been diagnosed as UICCⅱ II and cannot be removed by laparotomy;
② R0 resection is planned, but only R 1 or R2 resection can be achieved due to tumor center infiltration (R0 resection: no cancer cells at the edge; R 1 resection: cancer cells can be seen under the marginal microscope; R2 resection: cancer cells can be seen at the edge);
③ Local recurrence of liver after operation. It is reported abroad that the postoperative survival rate of total hepatectomy plus orthotopic liver transplantation is not significantly different from that of radical resection group, and even better than that of radical resection group.