结直肠癌肝转移的外科治疗

目的 探讨结、直肠癌肝转移的外科治疗。方法 对1993年1月至1999年1月的19例结、直肠癌肝转移患行外科治疗。其中6例同期切除。10例分期切除．1例肝动脉结扎加无水乙醇注射．2例通过肝动脉结扎加化学药物治疗(化疗)泵灌注化疗而获得二期手术切除机会、手术方式行肝不规则楔形切除16例,左半肝切除2例。结果 术后1、3、5年生存率分别为89％、58％、21％．6例同期肝切陈平均生存期23个月,10例分期肝切除的平均生存期为32个月。结论 掌握手术时机和适应证,积极进行肝动脉灌注化疗,提高手术切除成功率是提高存活率的关键．     

结直肠癌肝转移一期联合手术化疗的临床研究

目的探讨结直肠癌肝转移一期联合手术辅助化疗的有效途径及临床价值.方法回顾性分析一期联合手术切除原发癌及转移癌,经肝动脉门静脉双置泵栓塞灌注化疗,肿瘤局部注射无水酒精及热电疗法综合性治疗结直肠癌肝转移36例的临床资料.结果本组36例结直肠癌患者原发癌均获切除,其中一期切除肝转移癌17例,6例复发,4例再次手术切除.19例不能切除的转移性肝癌,行肝动脉门静脉双置泵栓塞灌注化疗,无水酒精注射和热电疗法.肿瘤直径平均缩小57%,其中4例因肿瘤缩小行二期手术切除.1、2、3年生存率分别为切除组94%,82%,65%;明显高于置泵组的74%,53%,32%(P<0.01).结论结直肠癌肝转移一期联合手术切除加肝动脉门静脉双置泵栓塞灌注化疗,是一种首选而有效的治疗方法.不能切除肝转移癌者,只要切除原发肿瘤,肝动脉门静脉置泵栓塞灌注化疗,可明显延长病人生存期,改善预后.     

同期肝切除治疗结直肠癌同时性肝转移

目的探讨结直肠癌同时性肝转移肝肠同期手术的疗效。方法回顾性分析1994年8月至2004年12月在我院行外科手术治疗的121例同时性结直肠癌肝转移患者的临床资料。结果在121例同时性结直肠癌肝转移患者中,99例行结直肠癌根治性切除术,剔除2例行原位肝移植患者后,同期肝切除组41例（A组）,对肝转移瘤行姑息外科治疗组56例（B组）,即转移瘤未能完全经手术切除者,A、B组患者性别、年龄、原发瘤部位、浸润深度、淋巴结转移等差异均无统计学意义,肝转移瘤数目（x^2=40.41,P＜0.05）、肝转移瘤分布（x^2=11.61,P＜0.05）差异有统计学意义;两组患者中位生存期分别为28.9个月、17.1个月,5年生存率分别为14％、0,其中A组患者中位无瘤生存期为19.5个月,1、3、5年生存率为93%、44%和14%。结论同期肝切除能为部分结直肠癌同时性肝转移患者提供治愈机会,对于合适的患者应力争行同期肝切除术。     

肝动脉结扎加插管化疗治疗大肠癌肝转移：附17例报告

为探讨大肠癌肝转移经肝动脉结扎加插管化疗的治疗效果。笔者对17例大肠癌肝转移不能手术切除的患者行肝动脉结扎加用5-氟尿嘧(5-Fu)或去氧氟尿苷(FUDR)加四氢叶酸钙(CF)，羟基喜树碱或顺铂和地塞米松通过肝动脉插管泵连续灌注化疗。17例行3～10个疗程化疗。平均生存15个月。1年内生存者5例，生存1～2年8例，生存2～3年4例，无超过3年者。仍在随访者4例，已生存3～18个月。提示肝动脉结扎加插管化疗是治疗大肠癌肝转移的有效办法。     

大肠癌肝转移的疗效分析

1985～1994年间以手术和病理证实的结、直肠癌458例，其中肝转移55例，占12％。多发转移灶占81．3％。其中肝转移灶切除平均生存43个月，而肝动脉栓塞化疗十免疫治疗、肝动脉化疗、门静脉化疗和全身化疗的平均生存期分别为21．2个月、16．4个月、14个月及12．4个月，未经治疗的生存期为5．4个月。认为转移灶切除并辅以综合治疗能明显延长生存时间。     

肝动脉结扎加插管化疗治疗大肠癌肝转移:附17例

为探讨大肠癌肝转移经肝动脉结扎加插管化疗的治疗效果.笔者对17例大肠癌肝转移不能手术切除的患者行肝动脉结扎加用5-氟尿嘧(5-FU)或去氧氟尿苷(FUDR)加四氢叶酸钙(CF),羟基喜树碱或顺铂和地塞米松通过肝动脉插管泵连续灌注化疗.17例行3～10个疗程化疗.平均生存15个月.1年内生存者5例,生存1～2年8例,生存2～3年4例,无超过3年者.仍在随访者4例,已生存3～18个月.提示肝动脉结扎加插管化疗是治疗大肠癌肝转移的有效办法.     

结直肠癌肝转移的转化治疗

对结直肠癌肝转移来说,手术是惟一的治愈手段。但80%的病人初始是不可切除的,将不可切除肝转移转化为可切除是提高结直肠癌总体存活率的关键。目前常用的转化手段有全身化疗（包括单纯化疗、化疗联合靶向药物等）、肝动脉灌注（HAI）、射频消融（RFA）、联合门静脉结扎或栓塞的分期肝切除、联合肝脏分隔及门静脉结扎的二步肝切除等。了解各种转化治疗的有效率和适应证是选择合适治疗的前提。     

结直肠癌肝转移的外科治疗

目的探讨结直肠癌肝转移的手术疗效。方法1996年8月～2000年8月手术治疗结直肠癌肝转移患者31例,行原发癌与转移癌同时切除者9例,结直肠癌根治术后6月再切除肝转移灶者18例;切除肝转移灶后2月再切除原发病灶者4例。原发灶行右半结肠切除5例,横结肠切除4例,左半结肠切除7例,Dixon术12例,Miles术3例。肝转移灶行左外叶切除5例,左半肝切除2例,右后叶切除4例,右前叶切除2例,左或右肝不规则切除18例。结果全组无手术死亡。术后粘连性肠梗阻1例,切口感染3例,经对症治疗后均痊愈出院。平均随访6.4(0.5～8)年,1、2、5年生存率分别为100%、80.6%、29.0%。同期手术者与分期手术者5年生存率分别为33.3%和27.3%,无统计学差异(P>0.05)。结论对结直肠癌肝转移患者应积极争取手术切除,术后可配合其他综合治疗;对原发灶早期诊断、早期手术治疗及辅助化疗有利于防止结直肠癌肝转移。     

结直肠癌同时性肝转移的同期手术切除

目的探讨同时性结直肠癌肝转移行同期切除原发瘤和肝转移瘤的安全性和有效性。方法回顾性总结分析从1981年5月至2005年11月在我院住院治疗的43例结直肠癌同时性肝转移同期手术的临床病理资料及结果并结合文献复习。结果43例患者中男性21例,女性22例,中位年龄52岁,手术持续中位时间180min。共30例术中输血,中位输血量800ml。术后总住院时间10—50d,中位时间15d。并发症发生率18．6％（8／43）,手术死亡率2．3％（1／43）。全组总的中位生存期为25个月,5年生存率19．1％。R0切除组的中位生存期48个月,5年生存率33．8％;非R0切除组的中位生存期为20个月,5年生存率7．6％。两组的生存时间经LogRank检验差异明显,P=0．002。结论同时性结直肠癌肝转移同期手术的安全性和有效性可以保证。对可切除的同时性结直肠癌肝转移应争取同期手术,并争取R0切除。     

大肠癌肝转移的放疗

结直肠癌肝转移的病人中,仅５％～１０％的高选择性无肝外转移者可进行手术切除,获得２０％～５０％的５年生存率,手术死亡率低于１０％［１］。对于那些不能进行手术切除的病人,需要选择另外的治疗方法。通常,大部分病人接受全身化疗,但是,最近更多地使用局部化疗、冷冻手术、射频组织消融、经皮乙醇注射、放疗、动脉栓塞和化学栓塞。但除了全身化疗以外,上述任何一种方法都不能作为常规治疗,而仅仅作为研究计划的一部分。本文仅对结直肠癌不能手术的肝转移的放疗进行综述。１　外照射常规放射治疗在肝转移的治疗中,由于肝脏耐受…     

Surgical treatment of liver metastases from colorectal cancer

We analyze our experience over a 10-year period in the surgical treatment of liver metastases from colorectal cancer. Between 01.01.1995 and 08.31.2005 189 liver resections were performed in 171 patients with liver metastases from colorectal cancer (16 re-resections - 2 in the same patient and a "two-stage" liver resection in 2 patients). In our series there were 83 patients with synchronous liver metastases (69 simultaneous resections, 12 delayed resections and 2 "two-stage" liver resection were performed) and 88 metachronous liver metastases. Almost all types of liver resections have been performed. The morbidity and mortality rates were 17.4% and 4.7%, respectively. Median survival was 28.5 months and actuarial survival at 1-, 3- and 5-year was 78.7%, 40.4% and 32.7%, respectively. Between January 2002 and August 2005 hyperthermic ablation of colorectal cancer liver metastases has been performed in 6 patients; in other 5 patients with multiple bilobar liver metastases liver resection was associated with radiofrequency ablation and one patient underwent only radiofrequency ablation for recurrent liver metastasis. In conclusion, although the treatment of colorectal cancer liver metastases is multimodal (resection, ablation, chemotherapy and radiation therapy), liver resection is the only potential curative treatment. The quality and volume of remnant liver parenchyma is the only limitation of liver resection. The morbidity, mortality and survival rates after simultaneous liver and colorectal resection are similar with those achieved by delayed resection. Postoperative outcome of patients with major hepatic resection is correlated with the surgical team experience. The long-term survival was increased using the new multimodal treatment schemes.     

Hepatic resections for bilobar liver metastases from colorectal cancer

The present study was performed to assess survival benefits in patients who underwent a hepatic resection for isolated bilobar liver metastases from colorectal cancer. Thirty-eight patients underwent a curative hepatic resection for isolated colorectal liver metastasis. Among them, 11 patients had bilobar liver metastases and 19 had a solitary metastasis. The remaining 8 patients had unilobar multiple lesions. We investigated survival in two groups those with bilobar and those with solitary metastatic tumors. Survival and disease-free survival were 36% and 18% at 5 years, respectively, in the patients with bilobar liver metastases, while these survivals were 43% and 34% in the patients with solitary liver metastasis. In the 38 patients, repeated hepatic resections were performed in 15 patients with recurrent liver disease. The 5-year survival and disease-free survival rates for these patients were 38% and 27%, respectively, after the second hepatic resections. Of the 11 patients with bilobar liver metastases, 5 underwent a repeated hepatic resection, and they all survived for over 42 months. Based on our observations, a hepatic resection was thus found to be effective even in selected patients with either bilobar nodules or recurrence in the remnant liver. Received: February 7, 2000 / Accepted: April 26, 2000     

Hepatic resection for colorectal metastases - a national perspective

BACKGROUND: Many consultant surgeons are uncertain about peri-operative assessment and postoperative follow-up of patients for colorectal liver metastases, and indications for referral for hepatic resection. The aim of this study was to assess the views the consultant surgeons who manage these patients. METHODS: A postal questionnaire was sent to all consultant members of the Association of Coloproctology of Great Britain and Ireland and of the Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland. The questionnaire assessed current practice for preoperative assessment and follow-up of patients with colorectal malignancy and timing of and criteria for hepatic resection of metastases. Number of referrals/resections were also assessed. RESULTS: The response rate was 47%. Half of the consultants held joint clinics with an oncologist and 89% assessed the liver for secondaries prior to colorectal resection. Ultrasound was used by 75%. Whilst 99% would consider referring a patient with a solitary liver metastasis for resection, only 62% would consider resection for more than 3 unilobar metastases. The majority (83%) thought resections should be performed within the 6 months following colorectal resection. During follow-up, 52% requested blood CEA levels and 72% liver ultrasound. Half would consider chemotherapy prior to liver resection and 76% performed at least one hepatic resection per year with a median number of 2 resections each year. CONCLUSIONS: A substantial proportion of patients are assessed for colorectal liver metastases preoperatively and during follow-up though there is spectrum of frequency of assessment and modality for imaging. Virtually all patients with solitary hepatic metastases are considered for liver resection. Patients with more than one metastasis are likely to be not considered for resection. Many surgeons are carrying out less than 3 resections each year.     

Liver resection in benign and malignant tumors]

Benign tumors of the liver, circumscribed hepatomas and solitary hepatic metastases from colonic cancer are treated by partial liver resection. In case of colonic cancer the hepatic metastasis is resected in a second operation. 20 cases of hepatic resections are reported. 10 right hepatic lobectomies, 1 left hepatic lobectomy and 9 minor resections were performed. Of the 11 patients treated by hepatic lobectomy, one (or 9%) died in the postoperative period (within 30 days after operation). Of the other 9 patients undergoing minor resections there was no death.     

Surgical resection of pulmonary metastases from colorectal adenocarcinoma. Special reference to repeated pulmonary resections

Pulmonary resection of metastatic lesions from colorectal adenocarcinoma was performed in 35 patients. The cumulative 5-year survival was 38%. The primary site of cancer was the colon in about half of the patients. Patients with a solitary metastasis or tumors smaller than 3 cm in diameter survived longer than did patients with multiple metastases or tumors larger than 3 cm but the differences were not significant. Other factors, including age, sex, histologic grade of tumor, location and stage of primary carcinoma, location of pulmonary metastases, disease-free interval, and type of pulmonary resection, had no apparent influence on survival time. The lung was the major site of recurrence following pulmonary resection. Seven patients underwent two or more pulmonary resections for metastasis from a colorectal carcinoma. At the time of last follow-up, four patients were alive and free of recurrent disease at 5, 34, 39, and 58 months after the second pulmonary resection. These data suggest that some patients will survive for a long time following pulmonary resection of colorectal metastases, and for highly selected patients, repeated pulmonary resection may further extend survival.     

结直肠癌同时性肝转移治疗46例分析

目的:探讨结直肠癌同时性肝转移的有效治疗方法。方法:对1996～2004年收治的46例结直肠癌同时性肝转移的临床资料和随访资料进行回顾性分析。根据治疗方法的不同分为3组:A组21例,为一期切除原发灶和肝转移灶并经肝动脉和门静脉置泵化疗者;B组15例,为单纯原发灶切除并经肝动脉和门静脉置泵化疗者;C组10例,为原发灶和肝转移灶均未能切除而仅行肝动脉和门静脉置泵化疗者。用KaplanMeier法对病人的生存时间作统计分析。结果:A、B、C3组术后中位生存期分别为38、20和13个月;各组之间术后生存时间的比较均有显著统计学差异(P<0.01)。结论:结直肠癌原发灶和肝转移灶一期手术切除并经肝动脉和门静脉置泵化疗的疗效最好;肝转移灶无法切除者能将原发灶切除并经肝动脉和门静脉置泵化疗也可取得较好的疗效;原发灶和肝转移灶未能切除而仅经肝动脉和门静脉置泵化疗的疗效相对较差。对结直肠癌同时性肝转移应采取以手术切除为主的综合措施进行积极治疗。     

Laparoscopic intra-arterial catheter implantation for regional chemotherapy of liver metastasis

In patients with unresectable metastatic disease confined to the liver, intra-arterial regional chemotherapy with implantable systems is an attractive option. Since April 1992, laparoscopic colorectal resections have been performed in our institution. Within this series of patients, three cases with bilateral liver metastasis from colon cancer were observed and underwent laparoscopic intra-arterial catheter implantation in the gastroduodenal artery for regional chemotherapy. In two patients the metastases were synchronous, and in both cases a laparoscopic colon resection was also performed, for tumors located in the cecum and in the sigmoid colon, respectively. The laparoscopic surgical technique for intra-arterial catheter implantation is described in detail. In this limited experience the procedure, from a purely technical point of view, was not considered difficult and was completed in 70 min on average. No complications were observed and the patient with metachronous liver metastasis was discharged on 3rd postoperative day.     

Resection of combined or sequential lung and liver metastases of colorectal cancer: indication for everyone?

Successful sequential resection of isolated hepatic and pulmonary metastases of colorectal cancer (crc) has been reported, however long-term results of large series are lacking. Therefore, we retrospectively analysed data of patients in whom sequential hepatic and pulmonary resection for metastases was performed. PATIENTS AND METHOD: From the records of our hospital we identified 25 patients (19.5 % of all patients operated for hepatic or 33 % for lung metastases due to crc) with colorectal cancer who had pulmonary and hepatic resection for metastatic disease between 1991 and 2002. 11 of these had primary colonic cancer and 14 rectal cancer. None of the patients died perioperatively. Long-term results were correlated with the staging of the primary tumour, the number of metastases, disease free interval between primary tumour operation and occurrence of metastatic disease. RESULTS: Five-year survival rate was 33.5 % following the resection of the first metastasis. Three year survival after resection of the second metastasis was 39 %. The disease free interval was 20 months (mean). Long-term results were clearly influenced by the disease free interval: < 1 year (n = 6) median 50 months after resection of the crc; > 1 year median 90 months (n = 19). Further on R0 resection was important for long-term survival: Median survival was 32.5 (+/- 4.1) months following resection of the second metastasis but only 9.9 months after R > 0 resection. CONCLUSION: These results confirm that sequential resection of hepatic and pulmonary metastases can be performed with curative intention provided a systemic spread of the disease is excluded. The surgeon's opinion of resectability should be obtained in patients with such metastases before the patient is scheduled for palliative conservative treatment.     

Survival after resection of multiple bilobar hepatic metastases from colorectal carcinoma

OBJECTIVE: To define the long-term outcome and treatment complications for patients undergoing liver resection for multiple, bilobar hepatic metastases from colorectal cancer. METHODS: A retrospective analysis of 165 consecutive patients undergoing liver resection for metastatic colorectal cancer was performed. Patients were divided into a simple hepatic metastasis group, consisting of patients with three or fewer metastases in a unilobar distribution, and a complex hepatic metastases group, consisting of patients with four or more unilobar metastases or at least two bilobar metastases. RESULTS: The 5-year survival rate was 36% for the simple group and 37% for the complex group. Multivariate analysis revealed that the number of hepatic segments involved by tumor and the maximum diameter of the largest metastasis correlated significantly with the 5-year survival rate. The surgical death rate was 4.9% for the simple group and 9.1% for the complex group; this difference was not significant. Multivariate analysis revealed that extended lobar resection and concomitant colon and hepatic resection were significant and independent predictors of surgical death. The combination of extended lobar resection and concomitant colon resection was used significantly more frequently in the complex group than in the simple group. CONCLUSIONS: Resection of complex hepatic metastases, as defined in this study, results in a 5-year survival rate of 37% and confers the same survival benefit as does resection of limited hepatic metastases. The surgical death rate for this aggressive approach is significantly higher if extended lobar resections are necessary and if concomitant colorectal resection is performed. Patients who have complex hepatic metastases at the time of diagnosis of the primary colorectal cancer and who would require extended hepatic lobectomy should have hepatic resection delayed for at least 3 months after colon resection.     

Pathologic support for limited hepatectomy in the treatment of liver metastases from colorectal cancer.

OBJECTIVE: The authors determined an appropriate surgical treatment for liver metastases from colorectal cancers. Clinicopathologic features of metastatic lesions of colorectal cancers were studied. SUMMARY BACKGROUND DATA: Major hepatic resection is the usual procedure for treatment of hepatic metastases from colorectal cancers. METHODS: Forty consecutive patients who underwent hepatic resections were prospectively studied, for a total of 89 metastatic liver tumors. RESULTS: Metastatic tumor often extended along Glisson's capsule, including invasion to the portal vein (9 cases), the hepatic vein (3 cases), the bile duct (16 cases), and the nerve (6 cases). The main tumor had small satellite nodules in only one patient, and there were no microscopic deposits in the parenchyma, even within 10 mm from the metastatic tumors. Fibrous pseudocapsule formation was observed in 28 patients. DISCUSSION: The rarity of intrahepatic metastasis from metastatic tumor supports nonanatomic limited hepatic resection as the procedure of choice for metastatic colorectal cancer in the liver. The spread via Glisson's capsule should be taken into consideration for complete tumor clearance.