以功能保留为核心的胆道肿瘤多阶段治疗体系：微创、动态功能评估与康复整合

Function-preserving multistage management for biliary tract cancers: integration of minimally invasive surgery, dynamic functional assessment, and rehabilitation

摘要:

胆道肿瘤的长期生存仍依赖R₀切除，但梗阻性黄疸、胆管炎、肝储备不足及系统治疗相关肝损伤，使围手术期风险集中于“胆汁淤积—感染—功能衰竭”链条，单纯依赖微创技术难以弥补由此带来的功能代价。基于最新指南与循证证据，本文提出以“功能可切除性”为核心的胆道肿瘤多阶段诊疗路径，涵盖转化/新辅助治疗、术前功能再评估、功能导向手术以及术后康复与长期随访。术前决策以未来肝残余“体积+功能”综合评估为基础，必要时联合^99mTc-mebrofenin SPECT/CT及吲哚菁绿（ICG）清除试验进行区域功能定量，并通过选择性胆道引流、感染控制、营养与凝血优化及门静脉栓塞建立“功能安全窗”。术中整合ICG荧光、术中超声及三维重建以提高R₀切除率并优化重建质量；术后依循加速康复外科理念管理，以肝切除后肝功能衰竭、术后临床相关胰瘘及患者报告结局为核心终点评价疗效。该路径强调“功能优先、微创其次”，通过动态评估、主动干预与结局量化的闭环管理，在保证肿瘤学根治性的同时最大程度保留器官功能与生活质量。

Abstract:

Radical resection remains the cornerstone of long-term survival in biliary tract cancers (BTC). However, obstructive jaundice, cholangitis, impaired hepatic reserve, and treatment-related liver injury concentrate perioperative risks along a "cholestasis-infection-functional failure" cascade, and minimally invasive access alone cannot offset these functional costs. Based on current guidelines and emerging evidence, we propose a multistage care pathway centered on the concept of functional resectability, encompassing conversion/neoadjuvant therapy, preoperative functional reassessment, function-oriented surgery, and postoperative rehabilitation with long-term follow-up. Preoperative decision-making is anchored to combined "volume-plus-function" evaluation of the future liver remnant. When necessary, regional liver function is quantified using ^99mTc-mebrofenin SPECT/CT and indocyanine green clearance testing, while selective biliary drainage, infection control, nutritional and coagulation optimization, and portal vein embolization are applied to establish a functional safety window. Intraoperatively, indocyanine green fluorescence imaging, intraoperative ultrasound, and three-dimensional planning are integrated to facilitate R₀ resection and optimize reconstruction. Postoperatively, ERAS-based management is adopted, and key endpoints-including post-hepatectomy liver failure, clinically relevant postoperative pancreatic fistula, and patient-reported outcomes-are used to evaluate treatment benefit. This pathway emphasizes a "function-first, minimally invasive second" strategy, forming a closed loop of dynamic assessment, proactive intervention, and outcome measurement to maximize functional preservation and quality of life while maintaining oncological radicality.