RU2314044C1 - Surgical method for treating hepatic hilus cholangiocarcinoma cases - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves carrying out hemihepatectomy within healthy tissue limits. Hepatic artery and portal vein are exposed with their branches using dissection from cancer infiltrate retaining tumor tissue plates on blood vessel walls. The carcinoma tissue left on the blood vessels and superficial metastases are subjected to cryodestruction by treating with liquid nitrogen applications at critical destruction temperature of -115±5°C with following spontaneous defrosting and immediately applying micrometastases cryodeposition in blood vessels zone exposed from infiltrate with their freezing 1 mm deep.

EFFECT: enabled radical operation being accomplished on non-operable patients; increased survival period with satisfactory life quality.

Description

The invention relates to medicine, namely to liver surgery, and can be used in the surgical treatment of portal cancer.

Helius cholangiocarcinoma (GCC) originates from the epithelium of the bile ducts, localized from the place where it flows into the common hepatic duct of the cystic duct to the beginning of second-order segmental hepatic ducts.

Localization of cholangiocarcinomas is divided into 3 types: intrahepatic, hilus and distal.

The clinical course and treatment varies depending on the type and location of cholangiocarcinoma.

- With intrahepatic cholangiocarcinoma, as with a primary liver tumor, the treatment consists in resection of the liver.

- Distal cholangiocarcinoma implies tumors that affect the pedicular and intrapancreatic parts of the common bile duct.

- Hylus tumors, affect the bifurcation region (gilius) of the hepatic ducts.

The diagnosis of HCC is established late when the bile ducts are occluded by the tumor and the patient develops jaundice.

MCCs often have infiltrating growth. They are difficult to treat surgically due to damage to the portal vein, hepatic artery. GCC is distributed along the nerve trunks and the adjacent vascular structures germinate.

According to the TNM system, MCC in stages 1-2 is not accompanied by infiltration of surrounding tissues, blood vessels and metastasis.

At stages 3-4, cholangiocarcinoma spreads outside the duct, always infiltrates and affects the surrounding fiber, and the adjacent main vessels and the hepatic parenchyma germinate.

Patients with stage 1-2 of the disease, when the process does not go beyond the bile ducts, turn only in 5-17% of cases. At the same time, they undergo radical operations: resection of the bile duct bifurcation with segment or hemihepatectomy and subsequent reconstructive surgery on the ducts - the formation of a biliodigestive anastomosis (Danilov M.V., Vishnevsky V.A. et al., 1983; Sedov A.P., 1999; Kent-Man Chu, Edward CS et al., 1997).

At stage 3-4, when there is an invasion of the hepatic artery and portal vein, the resectability level is very low, the operations are technically complicated, traumatic and long, because are associated with thin and prolonged preparation of the portal vein and its branches (V. Zhuravlev, 1992). According to the author, damage to the main portal vein trunk and bilateral damage to the branches of the portal vein are a contraindication for radical surgery. In this case, palliative resections of the hepatic ducts with transhepatic drainage and intraductal radiation therapy (Vishnevsky V.A., Kubyshkin V.A., Tarasyuk T.I., 2003), endoprosthesis replacement of the bile ducts in combination with intraluminal radiation therapy are performed predominantly (Makarov E.S., Dolgushin B.I. et al., 2003).

A known method for the treatment of cancer of the bile duct of the liver gate in stages I and II of the disease, described by A.P. Sedov in the monograph "Cancer of the proximal segments of the hepatic duct (Klatskin tumor)", Belgorod, 2003, which consists of 3 successive stages:

1. An operational study and the allocation of bile ducts with a tumor in the gates of the liver within healthy tissue boundaries.

2. Removal of the bile duct gates of the organ affected by the tumor.

3. The reconstruction phase.

Technique of operation: access - the upper median with the intersection of the right rectus abdominis muscle and the extension of the incision to the middle axillary line. During the audit, the size of the tumor, its lower and upper borders are determined. Produce cholecystectomy, mobilization of the hepatic duct, bifurcation, revision of the posterior wall of the ductal bifurcation for invasion by the tumor of the portal vein or its artery. With the index finger, bluntly, pushing the hepatic parenchyma along the lobar ducts, they are palpated, trying to reach the upper border of the tumor. Selecting the hepatic duct to the tumor from the elements of the hepatoduodenal ligament (GDS), an elastic catheter is held under it and it is raised up and to the left. They pass under the tumor in a blunt way, mainly with the finger, separating it from the vessels. After that, a longitudinal opening of the bile duct below the tumor is carried out, and then a thin recycle probe "recanalizes" the bifurcation of the right and left lobar ducts in series. An ascending cholangiography of the proximal biliary tree is performed, which determines the height of the duct occlusion and determines the clinical type of Klatskin tumor.

Then, the portal vein and hepatic artery are isolated and taken on the turnstiles, the duct is crossed below the tumor. The distal end is ligated in the supraduodenal part. The proximal end is bluntly mobilized (with the index finger) as much as possible (bifurcation and lobar ducts) in the tumor block if they are affected. Then cross the ducts within healthy tissues and remove the entire block.

The reconstruction phase is the application of a biliodigestive anastomosis.

In cases when the tumor reaches the segmental ducts of the left or right lobes, a resection must be performed corresponding to the affected lobe of the liver, and anastomosis with the bile ducts of the remaining lobe of the liver should be applied.

If a more significant technical complexity of performing this operation than anticipated is revealed during the operation, palliative intervention is performed.

The disadvantages of the method include the following:

1. At the stage of audit and visual-tactile determination of the process operability, it is not objective enough due to the subjective complexity of intraoperative diagnosis "blindly".

2. Mobilization of the tumor and determination of its upper border by blunt separation of the hepatic parenchyma is accompanied by significant bleeding, which requires additional hemostasis.

3. A palpation test does not adequately assess the proximal border of the tumor and the presence or absence of vascular invasion.

4. In the case of damage to the bifurcation and ducts of the right and left half of the liver for a considerable period of time, “blind” tumor excretion with possible invasion of the portal vein or hepatic artery by a finger may be accompanied by injured vessels with profuse or fatal bleeding.

5. Leaving part of the invasive tumor on the vessel wall is a palliative operation.

The palliative operation proposed by V. A. Vishnevsky and co-authors (Annals of Surgical Hepatology 2003. V.8. No. 2. - S.166-167) is accepted as the closest analogue of surgical treatment for hilus cholangiocarcinoma.

The main stages of the operation are as follows:

After completing the access (median laparotomy), an intraoperative revision is performed using intraoperative ultrasound (IOUS), and the level and boundaries of the bile duct lesion are determined.

When the tumor spreads to one of the lobar ducts and with the involvement of the segmental, a bile duct resection and hemihepatectomy are performed on the side of the greatest lesion.

In case of invasion of the portal vein tumor, a palliative resection of the hepatic ducts is performed, followed by the formation of a biliodigestive anastomosis and leaving a portion of the tumor tissue on the portal vein wall. In the postoperative period, patients undergo intraductal radiation therapy Jr 192.

The disadvantages of the method include the following:

1. In case of invasion of the vessel wall of the left and right branches of an artery or vein or its bifurcation, radical surgery is not feasible, since cancerous tissue remains on the vessel wall.

2. Intraductal radiation therapy of Jr 192 with partially excised bile ducts in the postoperative period does not guarantee targeted radical irradiation of the remaining cancerous tissue.

3. Intraductal radiation therapy, acting on the surrounding tissue, is accompanied by serious postradiation complications, requires special boxes with guaranteed protection of honey. staff and patients.

With these shortcomings, the survival rate of patients is 1 year - 37.5%, 3 years - 0%.

Tasks:

1. To increase the survival rate of this category of patients by increasing the radicalism of surgical treatment of gilius cholangiocarcinoma with invasion of the portal vessels of the liver.

SUMMARY OF THE INVENTION

In case of invasion of adjacent vessels of the portal portal gates of the liver, which is uneven in depth of damage to their membranes, hemihepatectomy is performed within healthy tissues, the hepatic artery and portal vein with their branches are isolated from the cancer infiltrate by dissection, leaving the “plate” of tumor tissue on the vessel wall. The cancer cells and surface micrometastases remaining on the vessels are subjected to cryodestruction with liquid nitrogen using the application method at a critical temperature of destruction to - 115 ± 5 ° C and subsequent spontaneous thawing and cryo-deposition of micrometastases by freezing in the infiltrate zone to a depth of 1 mm.

The technical result is the achievement of a radical destruction of cancerous tissue and cells remaining on the vessels, after their isolation from the tumor infiltrate, by cryodestruction (application and cryo-deposition) in predetermined modes, without tearing off the tissue of the vessel wall, which improves the survival of patients by 15-17%.

The method is as follows.

Access - median laparotomy.

The level of damage to the bile ducts, the presence of invasion of the hepatic artery, portal vein and its branches is determined using intraoperative ultrasound (IOUS) with a study of the volume and speed of blood flow in these vessels.

Mobilization of the liver is performed depending on the volume of resection - left-sided or right-sided hemi- or extended hemihepatectomy.

Next, the portal portal gates of the liver are mobilized. Hepatoduodenal ligament is taken on a holder. Bile ducts (choledochus) are isolated from the infiltrate, starting from its distal part at the border with healthy tissue, where it is ligated and crossed, departing from the border with the tumor by at least 5 mm. Then, the artery, the main trunk of the portal vein to the bifurcation and its branches, to the point of deep invasion into the vessel wall on the side of the remaining half of the liver is isolated by the method of dissection with precision. Perform hemihepatectomy. As a result, there remain elements of the hepatoduodenal ligament - the hepatic artery, the main trunk of the portal vein and its branch - the remaining half of the liver or part of it, with an undetermined “plate” of the cancerous tumor on it, at the site of the deepest invasion of the vessel wall.

Next, cryodestruction of the “plate” of the tumor on the vessel wall is performed by the application of the tip. As a refrigerant, liquid nitrogen is used. The optimal regime is: a freezing rate of -100 ± 10 ° C per minute to a critical temperature of destruction of -115 ± 5 ° C, with an exposure of this temperature for 4-5 minutes and subsequent arbitrary thawing at a rate of -14-16 ° C per minute. The area of tissue destruction is equal to the area of the applicator. The control of T ° is carried out by copper-constantan thermocouples.

Then, surface nitrogen cryo-deposition is carried out over the entire zone isolated from the infiltrate (artery and vein) to a freezing depth of up to 1 mm.

The operation is completed by transhepatic drainage of the remaining stump of the liver according to Seypol-Kurian.

The method was tested on 21 patients. No disease recurrence was observed within 3 years.

Example 1

Patient L. was admitted to the hospital with complaints of jaundice of the skin, general weakness, weight loss of 20 kg over the past 6 months.

From the anamnesis: considers herself a patient since 2003, when she first noted pain in the right hypochondrium, the examination revealed cholelithiasis, about which cholecystectomy was performed in 02.2004. Deterioration since the beginning of October 2004. Was sent to the RCCH. Ultrasound (November 16, 04): signs of focal neoplasm of the liver gate; according to the ultrasound picture, the disease of the common bile duct, dilatation of the intrahepatic bile ducts, regional lymphadenopathy, diffuse changes in the pancreas, condition after cholecystectomy cannot be excluded. After the necessary preoperative preparation was performed on November 17, 2004, an operation was performed in the amount of: Percutaneous transhepatic drainage of the intrahepatic bile ducts under ultrasound and Rg-control. 12/23/04, the surgery was performed in the amount of:

I stage. Extended right-sided hemihepatectomy (I, partially IV, V, VI, VII, VIII segments). Extirpation of the common bile duct. Cryodestruction of invasive tumor tissue of blood vessels of the gates of the liver. Transhepatic drainage according to Seypol-Kurian. Microgastrostomy according to Witzel. Lymphadenectomy of the GDS and the head area of the pancreas. Drainage of the subphrenic and subhepatic space on the right and the pelvic area. Duodenoplasty. Intraoperative study: the upper floor of the abdominal cavity in powerful adhesions after the previous operation. The hepatoduodenal ligament, the liver and its gates are precisely identified. The ligamentous apparatus of the liver is crossed on the right. A tumor lesion of the liver gate was revealed (gilius and below), where a tumor infiltrate of 5 × 4 cm of cartilage density was determined with an invasion of all elements of the hepatoduodenal ligament and higher, with spread to the right and left intrahepatic halves. Intraoperative ultrasound (IOUS), which confirmed the spread of damage to the bile ducts: up to 7-8 cm from the bifurcation on the right (gilius) upward with invasion of the portal vein branch and hepatic artery; on the left - at a distance of 3-4 cm with invasion of the portal vein branch. The left hepatic artery departs from the celiac trunk with a separate branch and, passing through the lesser omentum, supplies the left half of the liver separately from the right. It was decided to perform a radical operation with the removal of the right half of the liver. When mobilizing the liver gate, it is isolated and separated from the tumor with a defect of up to 3 cm in the wall of the duodenum (duodenum). A defect formed up to 4 cm in the wall of the duodenum after excision of its edges. Duodenoplasty of the anterior wall with single-row sutures was performed. Using the (harmonious) ultrasound scalpel, the parenchyma of the right and left halves of the liver was separated with partial removal of 4 and only 1 liver segment. Hemostasis. A tumor of the right half of the liver is selected along the edge of a healthy parenchyma, and then its right half is separated from the left. The distal part of the portal vein and its left branch were isolated from the dense cancerous infiltrate of the left half of the liver with great technical difficulties by the dissection method with trauma to its wall, the defects of which were sutured by the atraumatic needle PDS 5/0, leaving the tumor tissue on the wall of the left branch as “Plates” 2.0 × 1.5 cm. Cryodestruction of the “plate” of the tumor to -115 ° С was carried out with an applicator with a diameter of 25 mm with an exposure of 4 minutes. Defrosting is arbitrary. The choledoch and the left branch of the bile duct were excised to its healthy sites (edge biopsies were made along the edges of the resection for micrometastases), almost throughout only 4 segments in the gates of the liver. Transhepatic silicone drainage was performed through the remaining ducts of 2-3 segments along Seipol-Curian. The entire zone isolated from the infiltrate was treated with liquid nitrogen -110 ° C, with an exposure of 2 minutes, by cryo-spraying with arbitrary thawing. Superimposed microgastrostoma according to Witzel. Lymphadenectomy of the hepatoduodenal ligament and the area of the head of the pancreas (total 8 lymph nodes). Monitoring the tightness of the bile system, hemostasis.

PIP No. 13289-92 dated 12/29/04 (site of the tumor from portal vein bifurcation): tumor fragments of moderately differentiated adenocarcinoma, with severe dystrophic changes. Postoperative diagnosis: Gilius cholangiocarcinoma (type III-IV Bismuth - Corlett). Obstructive jaundice. Purulent cholangitis. Invasion of the vessels of the liver gate (Art. IIIA-IIIB by G. M. Gazzaniga) and hepatoduodenal ligament, invasion of the duodenum 12. Lymphadenitis of the hepatoduodenal ligament and pancreatic head region. Ascites. Condition after cholecystectomy 02.2004

II stage. After 10 months, the second stage was completed - reconstructive surgery - Laparotomy. Revision of the abdominal organs. Mobilization of the liver gate. The formation of hepaticoyunoanastomosis with a loop of the small intestine according to the method of Ru. Biopsy of the liver gate area. No relapse was detected.

Example 2

Patient Z. 35 years old was admitted to the clinic on 02.12.1999 with complaints of dull, aching pain in the right hypochondrium, jaundice of the skin, “skin itching”, weight loss of 10 kg per month, lack of appetite, severe weakness.

From the anamnesis: considers herself sick for 1 month, when she noted the above complaints.

Examined: Ultrasound from 02.12.99, In the area of the gate of the liver, a section of somewhat increased echogenicity size. 30 mm Conclusion: Volumetric formation of the liver gate.

FEGDS dated 03.12.99. Conclusion: Ulcer, cicatricial-ulcerative deformation of the duodenal bulb.

RCHP from 12/08/05: Cancer of the hepatic ducts in the region of the hilus.

CT of the liver 12/14/99, CT signs of neoplasm of the liver of the gate (bile duct).

I stage. Operation (12/22/1999 g). - Laparotomy. Left-sided extended hemihepatectomy with excision of the common bile duct, common hepatic artery, cryodestruction of the “plate” of the tumor of the common and right portal vein branches, transhepatic drainage according to Seypol-Kurian. Microgastrostomy according to Witzel. Cholecystectomy Lymph node dissection of the lymph nodes of the hepatoduodenal ligament.

“... Intraoperative research: in the portal portal of the liver there is a tumor that affects the triad of the left half of the liver with spread to the elements of the right half of the liver. Regional lymph nodes are enlarged to 2 cm, with palpation of a soft consistency. Mobilization of the left and partially right half of the liver. In the gate of the liver, the right and partially left bile ducts, as well as arteries, were isolated from the tumor infiltrate. They are ligated and crossed. The liver is dark green in color with an enlarged right half, the left is significantly reduced in size. The fiber of the hepatoduodenal ligament was removed and the portal vein was isolated, which is partially (1/2 / 3/2 of its circumference) located in the tumor infiltrate measuring 7 × 4 × 4 cm and its main part is located in the left half. An extended left-sided hemihepatectomy was performed. At the same time, the right branch of the portal vein was not completely separated from the tumor, a “plate” of tumor tissue 3.5 × 2.5 × 1 cm was left on it, which was subjected to cryodestruction from 2 points with an applicator 2.5 cm in diameter (T - 120 ° С ), with an exposure of 5 minutes at each point. Blood supply to the liver through the portal vein did not occur at this time, due to the formation of an ice clot. Darkened to a dark brown color. After arbitrary thawing, she restored color. A sharp change in the hemodynamics of the organ did not occur. During liver resection, up to 100 ml of white bile with pus and fibrin, as well as “loose” small black calculi, were secreted from “blocked” bile ducts, transhepatic drainage was performed after revision of the ducts of the VI-VII liver segments according to Seypol-Kurian. The entire zone isolated from the infiltrate was treated with cryo-spraying with liquid nitrogen of -110 ° C, with an exposure of 2 minutes, followed by arbitrary thawing. Made the imposition of microgastrostomy according to Witzel. Lymphatic dissection of the hepatoduodenal ligament, lymph nodes along the lesser curvature of the stomach and along the upper edge of the pancreas was performed ... The abdominal cavity was washed with an antiseptic ... ".

Stage II, reconstructive, 06/21/2000. Operation - Laparotomy. Hepaticojejunostomy on STD (replaceable transhepatic drainage) with a jejunum loop according to Ru. Biopsy of the “plate” of a former tumor that affects the right branch of the portal vein.

There is no intraoperative relapse of the disease. Histological examination No. 22755-51: Fragments of fibrous tissue with large cell infiltration in the thickness. There is no malignant growth in the preparations.

Medical and social effect: the developed method of radical surgical treatment of guillus cholangiocarcinoma with invasion of the tumor into the hepatic artery, portal vein and its branches, which belongs to stage IV according to the TNM classification, allows radical surgery in inoperable patients, to increase survival with a satisfactory quality of life with low economic costs.

Claims (1)

A method for the surgical treatment of gilius cholangiocarcinomas of the liver gates, including hemihepatectomy, excision of the affected liver ducts within healthy tissues and reconstructive procedures, characterized in that during invasion of adjacent vessels of the portal portal gates of the liver and uneven damage to their membranes, within healthy tissues after hemihepatectomy from cancer infiltration hepatic artery and portal vein with their branches are isolated, leaving “plates” of tumor tissues and superficial micro etastazy that expose cryodestruction by using liquid nitrogen application method - adjusted to the degradation temperature - 115 ± 5 ° C, with an exposure of 4-5 minutes, followed by spontaneous thawing and immediately thereafter carried krionapylenie micrometastases infiltration area to a depth of 1 mm.