Cholangiocarcinoma: refers to extrahepatic bile duct malignant tumors originating from the confluence of the left and right hepatic ducts to the lower end of the common bile duct. Primary cholangiocarcinoma is less common, accounting for 0.01% to 0.46% of ordinary autopsies, 2% of autopsies of tumor patients, and 0.3% to 1.8% of biliary tract surgeries. In Europe and the United States, gallbladder cancer is 1.5 to 5 times more common than cholangiocarcinoma. According to Japanese data, cholangiocarcinoma is more common than gallbladder cancer. The male to female ratio is about 1.5 to 3.0. The age of onset is mostly between 50 and 70 years old, but it can also occur in young people.
Treatment methods for hilar gallbladder disease:
1. Strive to achieve early detection! Early examination and early diagnosis are the fundamental way to comprehensively improve the treatment effect
With the With the expansion of community medical care and the implementation of regular physical examinations, it is possible to detect certain high-risk subjects early; combined with multiple laboratory tests, including genetic diagnosis, and multi-department collaboration, we strive to prevent omissions and misdiagnosis; obstructive jaundice is not necessarily an early diagnosis Therefore, we should pay close attention to the scanning of relevant imaging methods (especially MRCP and PET) to further determine the location and diagnosis of lesions, so that therapeutic surgical measures can be implemented early to reverse the passive situation. The choice emphasizes combining preoperative examination with comprehensive surgical exploration, comprehensive analysis, and making correct decisions.
2. Pay attention to perioperative treatment
In addition to paying attention to preoperative preparation. In addition to the support and supplementation of physical energy consumption, water, salt, and nutritional status, for patients with long-term, severe jaundice, especially those who may undergo extensive liver, gallbladder, and pancreatic resection, preoperative evaluation of liver function and analysis based on specific objects It is very important to increase initiative and reduce blindness. Sometimes, local conditions can be resected during surgical exploration, but the systemic condition and liver reserve status may be unbearable, that is, efforts to resection should be abandoned. On the contrary, sometimes local conditions seem difficult. However, patients who are fully prepared before surgery can still undergo complex major surgeries smoothly. It can be seen that sufficient and effective preoperative preparation is the prerequisite for ensuring the safety of surgery, reducing complications, and reducing surgical mortality. Commonly used and main indicators include:
Basic functional status of the liver: total bilirubin above 256 μmol/L; serum albumin below 35g/L; lean and malnourished; low prothrombin activity If the prothrombin time is less than 60%, the prothrombin time is prolonged for more than 6 seconds, and it is still difficult to correct after a week of vitamin K injection, these are hard indicators of poor liver function. At this time, it is not suitable to perform combined liver surgery, especially liver or pancreatic resection of more than half of the liver is contraindicated. "Case cases with a long course of disease should be especially cautious.
The indocyanine green clearance test (ICGR) has been used for a long time and is still practical. This dye is excreted through bile after being ingested by hepatocytes. It neither binds to hepatocytes nor participates in enterohepatic circulation. It is non-toxic and can also be used in hyperbilirubinemia. Inject ICG 0.5mg/kg body weight once, 10- Measure the retention rate in the blood after 15 minutes and it should be less than 10%. The clearance rate per minute for normal people is 14% to 28%.
Use CT to measure the volume of the liver to be resected. Calculate the volume of the liver to be resected. Preserving liver volume is especially suitable for radical resection of hilar cholangiocarcinoma to be expanded.
The above is the basic content of preoperative liver function assessment, which is very important and should be paid attention to.
3. Controversy over preoperative jaundice reduction and drainage
Do not advocate jaundice reduction and drainage: (1) The mortality rate and complication rate have not been reduced after jaundice reduction surgery; (2) Preoperative jaundice reduction and drainage are not advocated: Endoscopic nasobiliary drainage (ENBD) is difficult to succeed; (3) Preoperative percutaneous transhepatic external biliary drainage (PTECD) poses a great threat to complications, especially embedded biliary infection.
It is advocated to reduce the risk of biliary tract infection. Drainage: (1) Extended radical resection requires good preoperative preparation and jaundice reduction is necessary; (2) Preoperative decompression for 3 weeks is better than 1 week or 2 weeks; (3) Endothelial system function and coagulation ability There is a significant improvement; (4) Prostaglandin metabolism at the cellular level is beneficial to alleviating liver damage; (5) It is beneficial to the safety of massive liver resection and points out that the reasons for not decompressing are unconvincing because they are. None of the data includes major or definitive liver surgery.
This argument is beneficial. "In China, major radical surgery is planned for cases with total bilirubin higher than 256Lmol/L." Or jaundice reduction and drainage before massive liver resection are mostly considered to be beneficial and necessary. The complications of preoperative PTCD in a large group of jaundice reduction cases at Peking Union Medical College Hospital are very low, and are beneficial after major surgery.
Looking at the development trend of increasing radical or extended radical surgeries, it is necessary to strengthen diagnostic and treatment measures: (1) reliable positioning diagnostic data; (2) reliable assessment of systemic and liver function status; (3) If the jaundice lasts for less than 1 month, the liver function is good, and large-scale liver resection is not planned, it is not necessary to reduce the jaundice before surgery! Drainage; (4) If the jaundice is severe and lasts for a long time (more than 1 month), the liver function is poor, and surgery is required. When dealing with major surgery, jaundice reduction and drainage should be performed first. Moreover, although jaundice reduction and drainage are effective, all aspects of the situation have not improved significantly, and the decision to undergo major surgery should also be made with caution; (5) Overseas, in cases where jaundice reduction has been successful, At the same time, some people use interventional embolization of the portal vein trunk on the diseased side to promote the atrophy of the diseased side liver and the hyperplasia of the healthy side liver, which is not only beneficial to the operation, but also beneficial to reducing the complications of postoperative hepatic malcompensation, which can be used as a reference. These are all expected to be summarized and matured in practice.
4. Standardization of surgical decisions
This is a process of continuous summary and improvement, and it requires scientific standardization in academic and technical aspects to improve the treatment effect and reduce complications. disease, reduce surgical mortality, and combine it with postoperative comprehensive treatment to improve the scientific nature and initiative of clinical treatment and reduce blindness and randomness. A special topic specification and a large-scale survey! Registration is feasible, and demonstration and specification based on this are also necessary. You should also pay attention to your diet.
Wishing you a speedy recovery