腹腔镜下中下段胆管癌根治术中联合肝动脉切除重建的疗效与安全性:附3例报告(附视频)OA北大核心CSTPCD

Background and Aims:In clinical practice,lower bile duct cancers are more commonly encountered among cancers in the middle and lower segments of the bile ducts.Lower bile duct cancers are generally treated with pancreaticoduodenectomy,while middle bile duct cancers can be managed with pancreaticoduodenectomy,radical resection of bile duct cancer,and choledochojejunostomy.Bile duct cancers in the middle and lower segments are more prone to invasion of the portal vein due to their proximity,whereas invasion of the hepatic artery is relatively less common due to its adventitial sheath.However,when hepatic artery invasion occurs,it poses higher technical challenges as it often requires combined hepatic artery resection and reconstruction to achieve R0 resection.Although hepatic artery resection and reconstruction are gradually becoming more mature in practice at present,there is a lack of experience in performing laparoscopic hepatic artery resection and reconstruction,and further accumulation is needed.Therefore,this study retrospectively analyzed the clinical data of three patients who underwent laparoscopic combined hepatic artery resection and reconstruction and evaluated the short-term results,so as to provide preliminary experience for clinical practice. Methods:The clinical data of three patients undergoing radical surgery combined with laparoscopic hepatic artery resection and reconstruction for middle and lower bile duct cancers in the Department of Hepatobiliary Surgery of the Second Affiliated Hospital of the Army Medical University from November 2021 to November 2022 were retrospectively analyzed. Results:Among the three patients,there was one female and two males,aged 61,65,and 69 years,respectively.Case 1 with a middle bile duct cancer underwent combined resection and reconstruction of the right hepatic artery and portal vein,bile duct cancer resection,bilioenterostomy,hilar cholangioplasty,and lymph node dissection,due to tumor invasion of the right hepatic artery and portal vein,and negative margins at the lower end of the bile duct.Case 2 had a lower bile duct cancer with tumor invasion of the replaced right hepatic artery and portal vein,and underwent combined resection and reconstruction of the replaced hepatic artery,portal vein,and laparoscopic pancreaticoduodenectomy(LPD).Case 3 had a lower bile duct cancer with tumor invasion at the gastroduodenal artery and hepatic artery bifurcation,and underwent laparoscopic combined hepatic artery resection and reconstruction along with LPD.After operation,case 2 developed a grade B pancreatic fistula with abdominal infection,which was improved after 12 d of treatment and was discharged after tube removal.Cases 1 and 3 both recovered well without pancreatic fistula or bile leakage,and follow-up examinations showed good blood supply to the hepatic artery.None of the three cases required unplanned readmission within 30 d.During follow-up,case 2 showed tumor marker elevation and recurrence 13 months after operation,while cases 1 and 3 showed no tumor recurrence at 1 year after operation. Conclusion:When middle and lower bile duct cancers are concurrently associated with invasion of the portal vein and hepatic artery,simultaneous hepatic artery/replaced right hepatic artery resection and reconstruction during portal vein resection can be performed to improve the resection rate of bile duct cancer,which is safe,feasible,and effective.