外科からみた胆道癌

Surgical Treatment for Carcinoma of the Extrahepatic Bile Duct

　肝外胆道の悪性腫瘍の中には，早期発見が困難で，黄疸発現時にすでに病変がかなり進行し，診断確定時には根治手術不能の場合があり，また切除が可能であっても，その手術手技が比較的困難な上に，閉塞性黄疸によるriskが悪いなどのために，一般に手術成績は悪い．

　特に上部胆管癌は，従来その解剖学的位置関係から根治的切除術は困難であると考えられてきた．事実，切除不能の症例が多いのであるが，積極的に切除する方針で臨めば，切除可能の症例があり，教室においては最近切除例が増加している．

　Forty-eight patients with primary bile duct carcinoma seen at the second Department of Surgery, Nagasaki University Hospital, for a eight-year period from 1969 to 1976 are reviewed. There were 31 men and 17 women. The ages ranged from 39 to 79.

　Preoperative diagnosis was made in 46 patients by means of percutaneous transhepatic cholangiogram (PTC), endoscopic retrograde cholangiopancreaticogram, selective celiac angiogram, and cytologic examination of the bile.

　PTC was performed in 44 patients and the findings were divided into six groups based on the shape of stenosis or obstruction of the lesion. The tumor was most frequently resected in patients with either U-shaped or papillary-shaped form. Cytologic examination of the bile revealed positive results for carcinoma in 24 out of 34 patients in whom the bile was obtained preoperatively by PTC.

　Surgical treatment was performed in 23 patients with radical excision of the tumors, in 21 with external drainage, in two with internal drainage, and in two with celiotomy only.

　Operative mortality rate in the resectable group was 17.8 per cent (4 out of the 23 patients) and 44 per cent in the unresectable group.

　With regard to methods of treatment and prognosis of the lesion, the patients were divided roughly into three groups depending upon the site of the tumor in the extrahepatic ductal system; upper group: tumor arising at or near the confluence of the hepatic ducts; middle group: tumor from the common hepatic duct down to the upper border of the pancreas; lower group: tumor in the intrapancreatic portion of the common bile duct.

　Out of the 21 patients in the upper group, only five underwent radical excision. Left hapatic lobectomy was required in one patient or resection of the right branch of the portal vein in another. Intestinal continuity was reconstructed in four out of the five patients with anastomosis of either right or left hepatic duct to the P loop of the defunctionalized jejunum associated with ligation of the right or left hepatic duct. Operative death of resectable cases in this group showed 20 per cent (one out of the five patients).

　Of the 21 patients in the middle group, seven were treated by local excision and end-to-end anastomosis of proximal common hepatic duct to the intestine or to the distal common bile duct without mortality, five underwent pancreatoduodenectomy with two operative deaths, and nine were treated palliatively. The six patients in the lower group were treated by pancreatoduodenectomy. One patient died within one month postoperatively.

　The survival period in the upper group was less than 18 months except one who is living two months after resection of the tumor at the time of this report. Of the 12 patients in the middle group, eight lived for less than 13 months and four are living at the postoperative period from 3 to 16 months. Of the six patients in the lower group, four died within 15 months after operation and two are living each at one year and nine months, and six years postoperatively.

　The 25 patients who underwent palliative operation regardless the site of the tumor died within 16 months after operation, and the average survival period was 3.3 months.