| Background and purpose: Hilar cholangiocarcinoma (HCCA) is the most common tumor of biliary system and also be called Klatskin tumor. For the complicated anatomic structure and the feature of easily involving the peripheric blood vessel, nerve, lymph and hepatic tissue by tumor early, so the early diagnosis difficult, the rate of resection low, and the prognosis poor. The diagnosis and treatment of morden medicine is developing rapidly, but it was not achived the apparente improvement on the diagnosis, treatment and curative effect of HCCA .Consequently, it is necessary to emphasize the study about clinical manifestation, pathology, imageology and interventional therapy of HCCA.In this study, we retrospectively analyzed the clinical manifestation, laboratory date, pathology of percutaneous transhepatic cholangiobiopsy( PTCB), imaging information of 72 patients. The upper data and suitable interventional process of different type of HCCA were discussed, and to explore the new pathway of making early diagnosis and elevating curative effect.Material and methods: From April 2001 to December 2006,in all consecutive 203 patients with obstructive jaundice performed interventional therapy, the data of clinic, laboratory, imageology and interventional therapy of 72 patients(male 43, female 29, aged 26-88, mean 62.10±13.19) with HCCA performed percutaneous transhepatic cholangiography(PTC), percutaneous transhepatic cholangiodrainage (PTCD)and PTCB was collected. The clinical manifestation included icteric skin and sclera, upper abdominal pain, abdominal distention and loss of appetite, bilirubinuria, porcelain clay stool, body weight loss, hyperpyrexia and algor and so on, serum total bilirubin increased notably.Utilizing the technique of PTC, PTCD, PTCB or/and metal stent insertion, we performed biliary tract visualization, biopsy and reliefing the obstruction of biliary tract.The clinical classification was performed according to imaging appearance, we used the Huang Zhiqiang's typing method based on the Bismuth's method, including five type according to the primary location of tumor. Type I and II was classified as group A for involving the common hepatic duct (CBD) but not hepatic duct (HD), and type III,IV and V is classified as group B for involving the CBD and HD.Analysis of clinical data: All the patient's main clinical manifestation, primary complaint, the interclass distribution of the primary complaint is or not icterus and the period of primary complaint-hospitalization, the period of primary complaint presented non-icterus to icterus were collected and analyzed.Analysis of laboratory data: 2 ml venous blood was collected performed liver function in preoperative 1 day, postoperative 3 day, 1 week, 2 week. We analyzed the serum total bilirubin of different stage, and analyzed the result of bacteriology cultivation of bile, collecting in the subturminal of biliary obstruction during interventional therapy, then a interclass analysis performed.Analysis of pathological data: We study the interclass distribution, the relation between the degree of cell differentiation and clinical classification.Analysis of imaging data: Double-blind analysis method was adopted to analyze the imaging data. Two salty radiologists made retrospective analysis the data one after another, they measure the obstructive length of CHD, HDs and the oral diameter of sub-intro-hepatic bile duct with compasses and straight-edge. Refer to the diameter of catheter in PTCD and calculated the practical numerical value. The coincident results are recorded. The observed imaging information included: (1)the length of the stenosis; (2)dilatation grade of sub-intro-hepatic bile duct; (3)the feature of dynamic enhanced CT; (4)atrophy of liver lobe.Analysis of interventional therapy: The approach of interventional therapy included: (1)internal and external drainage, stent placement; (2)internal and external drainage; (3)external drainage; (4)stent placement; (5)transcatheter arterial infusion(TAI)or transcatheter arterial chemoembolization (TACE).The approach, therapeutic effect, complications, length of stay have been analyzed, a contrasting study about the therapeutic effect was made between the approach of half-drainage and double-drainage. We estimated the therapeutic effect of interventional therapy with the change of perioperative serum total bilirubin.All of the data are analyzed by SPSS10.0 statistical package. Age, length of stay, serum total bilirubin and the other measured data were represented with the mean±deviation, the mean value of interclass was analyzed with paired t-test for dependent samples or two-sample t-test for independent samples, incidence rate was analyzed with chi-square test or Fisher's exact test of probabilities. The data of perioperative serum total bilirubin was analyzed with analysis of variance of repeated measurement data and LSD t-test. A P value of 0.05 or less considered to indicate a significant difference.Results: 1. The primary complaint of 66.7% HCCA was upper abdominal pain, abdominal distention and loss of appetite, but not icterus, more non- icterus in group B and more icterus in group A. The non- icterus was longer than non-jaundice in course of disease, and it was 4 days to 3 years of non- icterus to icterus, median 51 days, 33 (68.9%) exceeding 1 month.2. The result of pathology was including of well-differentiated adencarcinoma (54.6%), moderately and poorly adencarcinoma (34.9%).It was not significant on the proportion of moderately and poorly adencarcinoma between group A and B (p> 0.05), and it was statistical significance on the positive rate of bile bacteriology cultivation between well-differentiated adencarcinoma and moderately and poorly adencarcinoma(p < 0.05).3. The obstruct length of type V was longer than the others, and the obstruct length of CHD was longer than the HD(p<0.05). It was not statistical significance between the length of CHD and HD in type III and IV(p>0.05).The obstruct length of CHD in type V was longer than in type III and IV (p< 0.05), but no statistical significance in the obstruct length of HD(p>0.05).It was statistical significance between the obstruct length and whether wholly obstructive(p>0.05).Contrasting middle, short-segment obstruction, the period of from primary complaint to hospitalization was longer in long-segment(p < 0.05). The dilatation grade of sub-intro-hepatic bile duct was not statistical significance between left and right hepatic(p > 0.05). HCCA showed uneven or annuliform enhancement in contrast-enhanced CT, leision could be manifested distinctly in delayed phase, hepatic lobar atrophy was more common in HCCA with portal vein invaded(p<0.05). It was not statistical significance between clinical classification and hepatic lobar atrophy.4. Serum total bilirubin was descended significantly after interventional therapy. The data is not statistical significance between group A and B in same period(p> 0.05), the effect was not statistical significance between half-drainage and double-drainage. The rate of complication in group B was higher than group A(p<0.05), the length of stay was not statistical significance between group A and B(p>0.05). The length of stay in 2 simple stent placement of type V is shorter than the others.Conclusion : The early clinical manifestation,features of imaging,method of interventional therapy is associated deeply with the clinical classification of HCCA. We may make the early diagnosis on the basis of paying attention to the early clinical manifestation,then perform the corresponding interventional therapy according to the clinical classification. Contrasting to the method of double-drainage, half-drainage achieve the same effect of eliminating jaundice and less complication,should be regard as the main method of PTCD.
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