肝門部領域胆管癌に対する左・右三区域切除術の適応とその意義
肝門部領域胆管癌（PHC）に対する術式は，右側優位型に対する右側肝切除（右肝切除，右三区域切除），左側優位型に対する左側肝切除（左肝切除，左三区域切除）に大別され，原則として尾状葉切除が併施される．右三区域切除は，右側優位のBismuth 4型の腫瘍で左側胆管浸潤が左門脈臍部右縁に及ぶ場合に考慮される．PHCに対する右三区域切除の根治性は高いが，肝切除率が最も高く（肝切離面積は最小），術後肝不全のリスクは高い．一方，左三区域切除は，右肝切除とほぼ同等の肝切除率であるが，右肝の脈管，胆管には解剖学的破格が多く，手術手技の難度も高く，術後合併症発生率が高い．左三区域切除は左肝切除と比較し，右後区域...
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| Published in | Tando Vol. 29; no. 5; pp. 889 - 898 |
|---|---|
| Main Authors | , , , , , |
| Format | Journal Article |
| Language | Japanese |
| Published |
日本胆道学会
2015
Japan Biliary Association |
| Subjects | |
| Online Access | Get full text |
| ISSN | 0914-0077 1883-6879 |
| DOI | 10.11210/tando.29.889 |
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| Abstract | 肝門部領域胆管癌（PHC）に対する術式は，右側優位型に対する右側肝切除（右肝切除，右三区域切除），左側優位型に対する左側肝切除（左肝切除，左三区域切除）に大別され，原則として尾状葉切除が併施される．右三区域切除は，右側優位のBismuth 4型の腫瘍で左側胆管浸潤が左門脈臍部右縁に及ぶ場合に考慮される．PHCに対する右三区域切除の根治性は高いが，肝切除率が最も高く（肝切離面積は最小），術後肝不全のリスクは高い．一方，左三区域切除は，右肝切除とほぼ同等の肝切除率であるが，右肝の脈管，胆管には解剖学的破格が多く，手術手技の難度も高く，術後合併症発生率が高い．左三区域切除は左肝切除と比較し，右後区域胆管のsurgical marginが得られやすく，左側優位のBismuth 4型の腫瘍で肝予備能が良好である症例に適応となる．術前の肝門部領域の3D解剖の十分な把握と肝予備能評価が重要なポイントとなる． |
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| AbstractList | 肝門部領域胆管癌（PHC）に対する術式は，右側優位型に対する右側肝切除（右肝切除，右三区域切除），左側優位型に対する左側肝切除（左肝切除，左三区域切除）に大別され，原則として尾状葉切除が併施される．右三区域切除は，右側優位のBismuth 4型の腫瘍で左側胆管浸潤が左門脈臍部右縁に及ぶ場合に考慮される．PHCに対する右三区域切除の根治性は高いが，肝切除率が最も高く（肝切離面積は最小），術後肝不全のリスクは高い．一方，左三区域切除は，右肝切除とほぼ同等の肝切除率であるが，右肝の脈管，胆管には解剖学的破格が多く，手術手技の難度も高く，術後合併症発生率が高い．左三区域切除は左肝切除と比較し，右後区域胆管のsurgical marginが得られやすく，左側優位のBismuth 4型の腫瘍で肝予備能が良好である症例に適応となる．術前の肝門部領域の3D解剖の十分な把握と肝予備能評価が重要なポイントとなる． 要旨:肝門部領域胆管癌(PHC)に対する術式は, 右側優位型に対する右側肝切除(右肝切除, 右三区域切除), 左側優位型に対する左側肝切除(左肝切除, 左三区域切除)に大別され. 原則として尾状葉切除が併施される. 右三区域切除は, 右側優位のBismuth4型の腫瘍で左側胆管浸潤が左門脈臍部右縁に及ぶ場合に考慮される. PHCに対する右三区域切除の根治性は高いが, 肝切除率が最も高く(肝切離面積は最小), 術後肝不全のリスクは高い. 一方. 左三区域切除は, 右肝切除とほぼ同等の肝切除率であるが, 右肝の脈管, 胆管には解剖学的破格が多く, 手術手技の難度も高く, 術後合併症発生率が高い. 左三区域切除は左肝切除と比較し, 右後区域胆管のsurgical marginが得られやすく, 左側優位のBismuth 4型の腫瘍で肝予備能が良好である症例に適応となる. 術前の肝門部領域の3D解剖の十分な把握と肝予備能評価が重要なポイントとなる. The operative procedure for perihilar cholangiocarcinoma (PHC) should be selected not only by the longitudinal tumor extension to the bile duct and tumor invasion to the major hilar vessels, but also functional reserve of the future remnant liver. Right trisectionectomy (RTS) is the most extended resection among the standard resectional procedures (RTS, right hemihepatectomy, left trisectionectomy (LTS) and left hemihepatectomy). Despite the recent advance in surgical techniques and perioperative patient care, RTS is still considered to be associated with high mortality due to hepatic failure. Meanwhile, LTS is recently performed more frequently in patients with Bismuth type IV tumors of left side predominance in a specialized center. LTS can produce a longer resection margin for the right posterior sectional bile duct. However, LTH may be technically demanding with association to the high postoperative morbidity. Both hepatic trisectionectomy for PHC may be highly skillful and difficult procedures among the hepatobiliary surgeries. For successful surgery, careful evaluation of 3D hilar anatomy and also the functional reserve of future remnant are crucial. Herein, clinical significance of RTS and LTS for PHC is discussed, as well as the important 3D anatomical variations for these procedures. 肝門部領域胆管癌（PHC）に対する術式は，右側優位型に対する右側肝切除（右肝切除，右三区域切除），左側優位型に対する左側肝切除（左肝切除，左三区域切除）に大別され，原則として尾状葉切除が併施される．右三区域切除は，右側優位のBismuth 4型の腫瘍で左側胆管浸潤が左門脈臍部右縁に及ぶ場合に考慮される．PHCに対する右三区域切除の根治性は高いが，肝切除率が最も高く（肝切離面積は最小），術後肝不全のリスクは高い．一方，左三区域切除は，右肝切除とほぼ同等の肝切除率であるが，右肝の脈管，胆管には解剖学的破格が多く，手術手技の難度も高く，術後合併症発生率が高い．左三区域切除は左肝切除と比較し，右後区域胆管のsurgical marginが得られやすく，左側優位のBismuth 4型の腫瘍で肝予備能が良好である症例に適応となる．術前の肝門部領域の3D解剖の十分な把握と肝予備能評価が重要なポイントとなる． |
| Author | 古川, 勝規 大塚, 将之 清水, 宏明 加藤, 厚 宮崎, 勝 吉富, 秀幸 |
| Author_FL | Miyazaki Masaru Furukawa Katsunori Shimizu Hiroaki Yoshitomi Hideyuki Kato Atsushi Ohtsuka Masayuki |
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| References | 8) Matsumoto N, Ebata T, Yokoyama Y, et al. Role of anatomical right hepatic trisectionectomy for perihilar cholangiocarcinoma. Br J Surg 2014; 101: 261-268 1) 江畑智希, 横山幸浩, 菅原 元, ほか. 肝門部胆管癌に対する右側・左側肝切除の選択. 胆道 2014; 28: 36-42 22) Nagino M, Nimura Y, Nishio H, et al. Hepatectomy with simultaneous resection of the portal vein and hepatic artery for advanced perihilar cholangiocarcinoma: an audit of 50 consecutive cases. Ann Surg 2010; 252: 115-123 10) Neal CP, Mann CD, Pointen E, et al. Influence of hepatic parenchymal histology on outcome following right hepatic trisectionectomy. J Gastrointest Surg 2012; 16: 2064-2073 11) Young AL, Prasad KR, Toogood GJ, et al. Surgical treatment of hilar cholangiocarcinoma in a new era: comparison among leading Eastern and Western centers, Leeds. J Hepatobiliary Pancreat Sci 2010; 17: 497-504 14) Yokoyama Y, Nishio H, Ebata T, et al. Value of indocyanine green clearance of the future liver remnant in predicting outcome after resection for biliary cancer. Br J Surg 2010; 97: 1260-1268 7) Nagino M, Kamiya J, Arai T, et al. "Anatomic" right hepatic trisectionectomy (extended right hepatectomy) with caudate lobectomy for hilar cholangiocarcinoma. Ann Surg 2006; 243: 28-32 21) Shimizu H, Hosokawa I, Ohtsuka M, et al. Clinical significance of anatomical variant of the left hepatic artery for perihilar cholangiocarcinoma applied to right-sided hepatectomy. World J Surg 2014; 38: 3210-3214 26) Yoshioka Y, Ebata T, Yokoyama Y, et al. Supraportal right posterior hepatic artery: an anatomic trap in hepatobiliary and transplant surgery. World J Surg 2011; 35: 1340-1344 6) Esaki M, Shimada K, Nara S, et al. Left hepatic trisectionectomy for advanced perihilar cholangiocarcinoma. Br J Surg 2013; 100: 801-807 15) Miyazaki M, Kato A, Ito H, et al. Combined vascular resection in operative resection for hilar cholangiocarcinoma: does it work or not? Surgery 2007; 141: 581-588 27) Uesaka K. Left hepatectomy or left trisectionectomy with resection of the caudate lobe and extrahepatic bile duct for hilar cholangiocarcinoma. J Hepatobiliary Pancreat Sci 2012; 19: 195-202 9) Kishi Y, Madoff DC, Abdalla EK, et al. Is embolization of segment 4 portal veins before extended right hepatectomy justified? Surgery 2008; 144: 744-751 18) Hirano S, Kondo S, Tanaka E, et al. No-touch resection of hilar malignancies with right hepatectomy and routine portal reconstruction. J Hepatobiliary Pancreat Surg 2009; 16: 502-507 24) Ohkubo M, Nagino M, Kamiya J, et al. Surgical anatomy of the bile ducts at the hepatic hilum as applied to living donor liver transplantation. Ann Surg 2004; 239: 82-86 19) Tamoto E, Hirano S, Tsuchikawa T, et al. Portal vein resection using the no-touch technique with a hepatectomy for hilar cholangiocarcinoma. HPB (Oxford) 2014; 16: 56-61 23) Abbas S, Sandroussi C. Systematic review and meta-analysis of the role of vascular resection in the treatment of hilar cholangiocarcinoma. HPB (Oxford) 2013; 15: 492-503 25) Shimizu H, Sawada S, Kimura F, et al. Clinical significance of biliary vascular anatomy of the right liver for hilar cholangiocarcinoma applied to left hemihepatectomy. Ann Surg 2009; 249: 435-439 13) Neuhaus P, Thelen A, Jonas S, et al. Oncological superiority of hilar en bloc resection for the treatment of hilar cholangiocarcinoma. Ann Surg Oncol 2012; 19: 1602-1608 5) Natsume S, Ebata T, Yokoyama Y, et al. Clinical significance of left trisectionectomy for perihilar cholangiocarcinoma: an appraisal and comparison with left hepatectomy. Ann Surg 2012; 255: 754-762 2) Govil S, Reddy MS, Rela M. Surgical resection techniques for locally advanced hilar cholangiocarcinoma. Langenbecks Arch Surg 2014; 399: 707-716 20) Ozden I, Kamiya J, Nagino M, et al. Clinicoanatomical study on the infraportal bile ducts of segment 3. World J Surg 2002; 26: 1441-1445 12) Paik KY, Choi DW, Chung JC, et al. Improved survival following right trisectionectomy with caudate lobectomy without operative mortality: surgical treatment for hilar cholangiocarcinoma. J Gastrointest Surg 2008; 12: 1268-1274 3) Nagino M, Ebata T, Yokoyama Y, et al. Evolution of surgical treatment for perihilar cholangiocarcinoma: a single-center 34-year review of 574 consecutive resections. Ann Surg 2013; 258: 129-140 4) Hosokawa I, Shimiu H, Yoshidome H, et al. Surgical Strategy for Hilar Cholangiocarcinoma of the Left-Side Predominance: Current Role of Left Trisectionectomy. Ann Surg 2014; 259: 1178-1185 17) Rela M, Rajalingam R, Shanmugam V, et al. Novel en-bloc resection of locally advanced hilar cholangiocarcinoma: the Rex recess approach. Hepatobiliary Pancreat Dis Int 2014; 13: 93-97 16) Neuhaus P, Jonas S, Bechstein WO, et al. Extended resections for hilar cholangiocarcinoma. Ann Surg 1999; 230: 808-818 |
| References_xml | – reference: 6) Esaki M, Shimada K, Nara S, et al. Left hepatic trisectionectomy for advanced perihilar cholangiocarcinoma. Br J Surg 2013; 100: 801-807 – reference: 22) Nagino M, Nimura Y, Nishio H, et al. Hepatectomy with simultaneous resection of the portal vein and hepatic artery for advanced perihilar cholangiocarcinoma: an audit of 50 consecutive cases. Ann Surg 2010; 252: 115-123 – reference: 10) Neal CP, Mann CD, Pointen E, et al. Influence of hepatic parenchymal histology on outcome following right hepatic trisectionectomy. J Gastrointest Surg 2012; 16: 2064-2073 – reference: 13) Neuhaus P, Thelen A, Jonas S, et al. Oncological superiority of hilar en bloc resection for the treatment of hilar cholangiocarcinoma. Ann Surg Oncol 2012; 19: 1602-1608 – reference: 1) 江畑智希, 横山幸浩, 菅原 元, ほか. 肝門部胆管癌に対する右側・左側肝切除の選択. 胆道 2014; 28: 36-42 – reference: 14) Yokoyama Y, Nishio H, Ebata T, et al. Value of indocyanine green clearance of the future liver remnant in predicting outcome after resection for biliary cancer. Br J Surg 2010; 97: 1260-1268 – reference: 24) Ohkubo M, Nagino M, Kamiya J, et al. Surgical anatomy of the bile ducts at the hepatic hilum as applied to living donor liver transplantation. Ann Surg 2004; 239: 82-86 – reference: 12) Paik KY, Choi DW, Chung JC, et al. Improved survival following right trisectionectomy with caudate lobectomy without operative mortality: surgical treatment for hilar cholangiocarcinoma. J Gastrointest Surg 2008; 12: 1268-1274 – reference: 4) Hosokawa I, Shimiu H, Yoshidome H, et al. Surgical Strategy for Hilar Cholangiocarcinoma of the Left-Side Predominance: Current Role of Left Trisectionectomy. Ann Surg 2014; 259: 1178-1185 – reference: 3) Nagino M, Ebata T, Yokoyama Y, et al. Evolution of surgical treatment for perihilar cholangiocarcinoma: a single-center 34-year review of 574 consecutive resections. Ann Surg 2013; 258: 129-140 – reference: 8) Matsumoto N, Ebata T, Yokoyama Y, et al. Role of anatomical right hepatic trisectionectomy for perihilar cholangiocarcinoma. Br J Surg 2014; 101: 261-268 – reference: 2) Govil S, Reddy MS, Rela M. Surgical resection techniques for locally advanced hilar cholangiocarcinoma. Langenbecks Arch Surg 2014; 399: 707-716 – reference: 17) Rela M, Rajalingam R, Shanmugam V, et al. Novel en-bloc resection of locally advanced hilar cholangiocarcinoma: the Rex recess approach. Hepatobiliary Pancreat Dis Int 2014; 13: 93-97 – reference: 7) Nagino M, Kamiya J, Arai T, et al. "Anatomic" right hepatic trisectionectomy (extended right hepatectomy) with caudate lobectomy for hilar cholangiocarcinoma. Ann Surg 2006; 243: 28-32 – reference: 27) Uesaka K. Left hepatectomy or left trisectionectomy with resection of the caudate lobe and extrahepatic bile duct for hilar cholangiocarcinoma. J Hepatobiliary Pancreat Sci 2012; 19: 195-202 – reference: 5) Natsume S, Ebata T, Yokoyama Y, et al. Clinical significance of left trisectionectomy for perihilar cholangiocarcinoma: an appraisal and comparison with left hepatectomy. Ann Surg 2012; 255: 754-762 – reference: 23) Abbas S, Sandroussi C. Systematic review and meta-analysis of the role of vascular resection in the treatment of hilar cholangiocarcinoma. HPB (Oxford) 2013; 15: 492-503 – reference: 18) Hirano S, Kondo S, Tanaka E, et al. No-touch resection of hilar malignancies with right hepatectomy and routine portal reconstruction. J Hepatobiliary Pancreat Surg 2009; 16: 502-507 – reference: 21) Shimizu H, Hosokawa I, Ohtsuka M, et al. Clinical significance of anatomical variant of the left hepatic artery for perihilar cholangiocarcinoma applied to right-sided hepatectomy. World J Surg 2014; 38: 3210-3214 – reference: 15) Miyazaki M, Kato A, Ito H, et al. Combined vascular resection in operative resection for hilar cholangiocarcinoma: does it work or not? Surgery 2007; 141: 581-588 – reference: 20) Ozden I, Kamiya J, Nagino M, et al. Clinicoanatomical study on the infraportal bile ducts of segment 3. World J Surg 2002; 26: 1441-1445 – reference: 9) Kishi Y, Madoff DC, Abdalla EK, et al. Is embolization of segment 4 portal veins before extended right hepatectomy justified? Surgery 2008; 144: 744-751 – reference: 26) Yoshioka Y, Ebata T, Yokoyama Y, et al. Supraportal right posterior hepatic artery: an anatomic trap in hepatobiliary and transplant surgery. World J Surg 2011; 35: 1340-1344 – reference: 19) Tamoto E, Hirano S, Tsuchikawa T, et al. Portal vein resection using the no-touch technique with a hepatectomy for hilar cholangiocarcinoma. HPB (Oxford) 2014; 16: 56-61 – reference: 25) Shimizu H, Sawada S, Kimura F, et al. Clinical significance of biliary vascular anatomy of the right liver for hilar cholangiocarcinoma applied to left hemihepatectomy. Ann Surg 2009; 249: 435-439 – reference: 11) Young AL, Prasad KR, Toogood GJ, et al. Surgical treatment of hilar cholangiocarcinoma in a new era: comparison among leading Eastern and Western centers, Leeds. J Hepatobiliary Pancreat Sci 2010; 17: 497-504 – reference: 16) Neuhaus P, Jonas S, Bechstein WO, et al. Extended resections for hilar cholangiocarcinoma. Ann Surg 1999; 230: 808-818 |
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| Snippet | 肝門部領域胆管癌（PHC）に対する術式は，右側優位型に対する右側肝切除（右肝切除，右三区域切除），左側優位型に対する左側肝切除（左肝切除，左三区域切除）に大別され，原則として尾状葉切除が併施される．右三区域切除は，右側優位のBismuth... 要旨:肝門部領域胆管癌(PHC)に対する術式は, 右側優位型に対する右側肝切除(右肝切除, 右三区域切除), 左側優位型に対する左側肝切除(左肝切除, 左三区域切除)に大別され. 原則として尾状葉切除が併施される. 右三区域切除は,... The operative procedure for perihilar cholangiocarcinoma (PHC) should be selected not only by the longitudinal tumor extension to the bile duct and tumor... |
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| StartPage | 889 |
| SubjectTerms | Bismuth classification Bismuth分類 extended hepatectomy hilar cholangiocarcinoma 肝葉切除 肝門部領域癌 |
| Title | 肝門部領域胆管癌に対する左・右三区域切除術の適応とその意義 |
| URI | https://www.jstage.jst.go.jp/article/tando/29/5/29_889/_article/-char/ja http://mol.medicalonline.jp/en/journal/download?GoodsID=dw1tando/2015/002905/004&name=0889-0898j https://cir.nii.ac.jp/crid/1390282679324207488 |
| Volume | 29 |
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| ispartofPNX | 胆道, 2015/12/31, Vol.29(5), pp.889-898 |
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