前入路绕肝提拉法对右半肝切除术中中心静脉循环肿瘤细胞的影响

目的:探讨前入路绕肝提拉法右半肝切除对术中肿瘤细胞释放的影响.方法:选择2008-01/2011-06我院收治的拟行右半肝切除患者40例,随机分为常规肝切除组和前入路绕肝提拉法肝切除组,分别于手术开始前(切皮前)、术中离断肝实质之前(前入路绕肝提拉法组为分离肝后隧道、安置绕肝带、分离结扎右侧肝动脉和门静脉后;常规肝切除组为游离肝周韧带,Pringle法阻断第一肝门后)、肝肿瘤切除后3个时间点,自中心静脉置管处抽取血样,行循环肝源性细胞检测.比较两组患者中在各时间点检测结果阳性患者的比例.结果:前入路绕肝提拉法组和常规法组术前检测结果阳性患者比例无显著差异(2/18vs1/19,P>0.05).术中肝切除前,前入路绕肝提拉法组中心静脉血样肝源性细胞检测结果阳性患者显著少于常规法组(20%vs55%,P=0.022);肝肿瘤切除后,前入路绕肝提拉法组中心静脉血样肝源性细胞检测结果阳性患者亦显著少于常规法组(40%vs80%,P=0.010).结论:前入路绕肝提拉法较常规法肝切除可减少术中肿瘤细胞的血源性播散,理论上减少了肝癌术中肿瘤细胞医源性播散,降低了术后转移复发的风险.     

肝癌的综合治疗及肿瘤抗血管联合疗法

肝癌死亡率极高,发病隐匿,且85%合并肝硬化不能耐受手术.肝动脉化疗栓塞术(trans-catheter arterial chemoembolization,TACE)是不能手术切除肝癌的首选治疗方法之一,但由于门静脉血供的残存,单纯TACE难以使肿瘤细胞完全坏死,术后癌细胞残留是复发的根源.放疗亦作为治疗肝癌的常规手段,但其促进肿瘤血管新生,因而促使大肝癌放疗抗拒和放疗后复发、转移.而抗血管治疗能够抑制肿瘤血管形成,降低血管通透性,提高内皮细胞对放射的敏感性及促进瘤细胞凋亡和减少肿瘤内的乏氧细胞数,从而抵抗放射抗拒.综上,与单一的手术、化疗、放疗及抗血管治疗相比,肝癌的综合治疗能提高患者生存率,改善预后.治疗策略的制定需要掌握不同肿瘤的生物学特性,权衡各种治疗方案的利弊.     

同步辐射成像技术应用于HCCLM3细胞裸鼠肝脏移植瘤新生血管形态学研究的初步实验

目的 应用同步辐射微血管造影技术进行裸鼠离体肝细胞癌肿瘤新生血管的形态学研究. 方法 建立高转移人肝癌细胞HCCLM3裸鼠肝脏移植瘤模型.肝脏移植瘤模型建立第28天,取模型鼠6只,随机分为2组(每组3只).第1组裸鼠经腹腔内注射戊巴比妥钠麻醉后开腹,经下腔静脉留置管,手动推注硫酸钡悬浮液,直至肝脏及肝肿瘤表面血管呈白色,结扎肝脏的血管和胆管后切除肝脏,浸泡在甲醛溶液里,准备成像.离体裸鼠肝癌新生血管成像在上海光源(SSRF)X射线成像与生物医学应用光束线站(BL13W)进行.第2组裸鼠腹腔内注射戊巴比妥钠麻醉后,开腹取肝肿瘤标本,行病理学检查,包括HE染色及免疫组织化学CD31、CD34和F8染色. 结果 同步辐射微血管造影结合显微CT获得了高质量的肿瘤新生血管图像,图像显示正常肝血管结构被迅速生长的肿瘤组织取代,可以清晰观察到肿瘤新生血管的形态特征及生长状况,肿瘤周围血管丰富、扭曲,瘤内血管稀疏,与免疫组织化光学显微图像所示肿瘤新生血管分布特征相似.同步辐射成像技术能分辨肿瘤内部最细的血管直径约20μm. 结论 采用硫酸钡作为造影剂,利用同步辐射微血管造影技术显示裸鼠肝肿瘤新生血管的方法可行.     

292例巨大肝癌的手术切除治疗

目的:探讨巨大原发性肝癌手术切除治疗的可行性和安全性。方法:分析292例巨大肝癌手术切除治疗的效果、并发症和术后复发的相关因素。结果:巨大肝癌临床和病理特点:①肝硬化程度轻,健侧肝脏不同程度代偿性增大。②发病年龄较小。③肝癌巨大而未发现肝内转移,肿瘤与肝内及肝周大血管关系紧密,但多为推压关系。术中离断肝实质时间为(16.8±6.8)分钟,肝缺血时间为(20.1±3.8)分钟,失血量为(581±395)ml。术后无围手术期死亡。无胆汁漏、腹腔内大出血、腹腔内严重感染、凝血机能障碍等严重并发症。术后1、2、3和5年生存率分别为78.9％、52.9％、32.8％和18.5％。复发相关因素主要为门静脉癌栓、肿瘤包膜、包膜浸润、手术彻底性、术中出血量、肝硬化程度。结论:掌握适当的适应症,注意术中操作和围手术期处理,巨大肝癌行手术切除术治疗安全可行并且有效。     

肝脏恶性血管外皮瘤误诊为肝转移癌1例

肝脏恶性血管外皮瘤是一种罕见的肿瘤,本例患者为男性,57岁,有中上腹胀痛不适,CT发现左肝占位,2年前曾因食管癌行手术治疗.术前被误诊为转移性肝癌,经手术行左肝肿瘤切除及胆囊切除术后行病理检查,最终确诊为肝脏恶性血管外皮瘤.     

脾切除贲门周围血管离断术治疗470例门静脉高压症疗效分析

目的总结脾切除贲门周围血管离断术治疗不合并肝癌及胆管癌的门静脉高压症患者的疗效。方法对不合并肝癌及胆管癌的门静脉高压症患者行脾切除贲门周围血管离断术并随访470例,其中肝炎后肝硬化436例,占92．8％。结果出血患者424例,手术止血率为993％（421／424）,围手术期病死率为1．4％（6／424）,主要死亡原因是上消化道出血、肝肾功能衰竭;急症及择期手术424例,预防手术46例,预防手术嗣手术期无死亡。平均随访时间4年,出血患者术后复发出血率为3．2％（15／470）,预防手术后无出血,肝性脑病发生率为1．9％（9／470）。结论脾切除贲门周围血管离断术防治门静脉高压症引起的上消化道出血效果好。合理选择手术适应证及手术时机、完全彻底断流、术后早期抗凝及近端脾静脉结扎预防术后肝外门静脉系统血栓形成是提高手术疗效的必要措施。     

联合肝脏离断和门静脉结扎二步肝切除术治疗结直肠癌肝转移的研究现状

目前,结直肠癌肝转移的最佳治疗策略仍是根治性手术切除,而对于巨大肿瘤或者多发肿瘤患者,常常面临肝切除术后残余肝脏体积不足的问题,容易出现术后肝衰竭等严重并发症。联合肝脏离断和门静脉结扎二步肝切除术(ALPPS)是一种新颖的二步肝切除术,可使残余肝在一期术后快速增生,增加肝脏肿瘤的可切除性,降低术后肝衰竭的风险。虽然ALPPS可实现肿瘤R0切除,延长患者生存期。但因其较高的术后并发症率和病死率饱受争议,结合国内外相关研究,对ALPPS在结直肠癌肝转移中的应用现状及临床价值进行阐述。     

原发性肝癌的介入治疗

肝癌的介入治疗主要包括二部分:经皮血管治疗技术及经皮非血管治疗技术,前者主要包括经肝动脉栓塞化疗术及经肝动脉门静脉结合栓塞化疗术;后者则指在超声(US)、CT、MR引导下经皮穿刺瘤内局部治疗,包括瘤内药物注射与物理损毁治疗。1肝癌的血管内介入治疗肝癌血管内介入治疗的最主要手段为经肝动脉栓塞化疗术。主要适用于以右叶为主或肝内多发病灶以及术后复发而无法手术切除的肝癌。经肝动脉栓塞化疗有以下作用:1阻断肿瘤血液供应,使肿瘤严重缺血坏死而缩小。2提高局部化疗药物浓度,增强抗肿瘤效应,减少化疗药物毒副作用。3破坏肿瘤的血…     

原发性肝癌转化治疗指征与选择策略

原发性肝癌发病隐匿,早期无特异性症状,多数患者确诊时已属中晚期,符合根治性切除术的患者20%-40%.目前外科切除仍是原发性肝癌主要根治性治疗手段,但由于肝功能失代偿、肿瘤体积过大、剩余肝体积过小、肝内多发转移、癌栓侵及大血管或胆管、远处转移等因素限制手术切除或肝移植.近年来,随着原发性肝癌发生、发展机制研究的不断深入,外科技术和器械发展,以及新的分子靶向药物、免疫治疗药物的研制,使得一部分无法手术切除或肝移植的原发性肝癌患者经过转化治疗,改善肝功能、缩小肿瘤体积、使脉管癌栓缩小或消失、促进剩余肝脏体积代偿性增大,最终得以手术切除或肝移植,极大提高了原发性肝癌治疗效果和患者生存期.     

腹腔镜在联合肝脏离断和门静脉结扎二步肝切除术中的应用现状及研究进展

联合肝脏离断和门静脉结扎二步肝切除术(ALPPS)作为肝胆外科的一项创新性术式,其潜在的刺激剩余肝叶短期内增生突破了手术禁忌。随着临床经验的积累以及术式的优化,其临床应用取得了一定进展,腹腔镜技术的应用为其发展提供了新的前景,虽然目前还有许多问题需要进一步探索和解决,但ALPPS拓宽了手术切除适应证,让较晚期巨大肝癌患者获得手术切除的机会。该文就目前腹腔镜在ALPPS中的应用现状和研究进展作一综述。     

The repeated hepatectomy for frequent recurrence of hepatic metastasis from gastrointestinal stromal tumor of the stomach

Although in recent years hepatic resection has become a safe procedure, there are few data on repeat liver resection for hepatic metastases from gastrointestinal stromal tumor. A 60-year-old Japanese man underwent partial gastrectomy and extended right hepatectomy for gastrointestinal stromal tumor of the stomach with liver metastasis. However, liver metastasis recurred at the interval of less than 1 year. Therefore, the patient underwent a total of six liver resections. The liver resections comprised four R0, one R1 and one R2 resection. To our knowledge, six times for liver resection performed on one patient is a maximum. This patient survived 43 months after the first surgery. Despite frequent recurrence of hepatic metastasis from gastrointestinal stromal tumor, repeated hepatectomy provides a survival benefit if complete removal of all tumorous masses appears possible.     

Major hepatic resection reduces the probability of intrahepatic recurrences following resection of colorectal carcinoma liver metastases

BACKGROUND/AIMS: The use of major versus limited hepatic resection for colorectal carcinoma liver metastases remains controversial. We evaluated the role of major hepatic resection in managing patients with colorectal carcinoma liver metastases. METHODOLOGY: We performed a retrospective analysis of 102 patients undergoing either major (n = 61) or limited (n = 41) hepatic resection for colorectal carcinoma metastases. Major hepatic resection was defined as segmentectomy or more extensive hepatic resection; limited hepatic resection was defined as non-anatomic removal of the liver tumor plus a rim of normal parenchyma. The median follow-up period was 94 months. RESULTS: Patients undergoing major hepatic resection had larger hepatic tumors than those undergoing limited hepatic resection (p < 0.001, Fisher's exact test). The cumulative probability of intrahepatic recurrences after major hepatic resection was significantly lower than that after limited hepatic resection (p = 0.010, log-rank test). Major hepatic resection independently reduced the probability of intrahepatic recurrences (p = 0.043, Cox's proportional hazards model). Limited hepatic resection frequently resulted in recurrences within the same segment or the same lobe of the remnant liver. CONCLUSIONS: Major hepatic resection is more effective in reducing the risk of intrahepatic recurrences than limited hepatic resection in patients with resectable colorectal carcinoma liver metastases.     

Laparoscopic extended right hepatectomy for posterior and completely caudate massive liver tumor (with videos)

<正>To the Editor: Liver tumor may occur in any hepatic segment or lobe, and thus the liver resection is individualized as per the location and size of the tumor. In addition, the resection of the posterior and caudate lobes of the liver is especially difficult amongst all types of hepatectomy. Kawaguchi et al. believed that the laparoscopic resection of right posterior liver lobe was a difficult surgical procedure [1].     

Near total hepatectomy in two steps for surgical treatment of liver metastasis of colorectal tumor

Liver resections for metastases of colorectal carcinomas are generally accepted. The 5-year survival rate is higher than 30 percent. Major resections can be performed safely with normal remnant liver. The liver regenerates following extended hepatectomies or other major resections. Authors operated on a 57-year-old man for a secondary liver tumor. The primary tumor was in the colon sigmoideum and sigma-resection was made at another hospital 16 months before. The metastasis was in the right lobe of the liver. Authors performed right extended hepatectomy. After systemic chemotherapy, 4.5 months later a new metastasis developed in the left lobe. Despite locoregional chemotherapy, chemoembolization and radiofrequency treatment, the tumor was still growing so a left lobectomy was performed. The patient is macroscopically tumor-free 17 months after the first hepatic resection. The interest in this case is that segments IV to VIII were removed first time, and segments II and III at the second liver resection. Liver regeneration after the first resection made the second operation possible. Only segment I of the original segments remained. Utilizing the regeneration of the liver we can make an effort to perform a complete tumor ablation in two steps.     

Resection of a locally advanced hilar tumor and the hepatic artery after stepwise hepatic arterial embolization： A case report

We herein report a case of a hilar tumor with extensive invasion to the proper hepatic artery, which was successfully treated with a radical resection in a 57-year-old female patient after a stepwise hepatic arterial embolization. She underwent right colectomy and partial hepatectomy for advanced colon cancer two years ago and radiofrequency ablation therapy for a liver metastasis one year ago, respectively. A recurrent tumor was noted around the proper hepatic artery with invasion to the left hepatic duct and right hepatic artery 7 mo previously. We planned a radical resection for the patient 5 mo after the absence of tumor progression was confirmed while he was undergoing chemotherapy. To avoid surgery-related liver failure, we tried to promote the formation of collateral hepatic arteries after stepwise arterial embolization of the posterior and anterior hepatic arteries two weeks apart. Finally, the proper hepatic artery was occluded after formation of collateral flow from the inferior phrenic and superior mesenteric arteries was confirmed. One month later, a left hepatectomy with hepatic arterial resection was successfully performed without any major complications.     

Spontaneous Rupture of Hemangioma of the Liver: Treatment with Transcatheter Hepatic Arterial Embolization

A case of spontaneous rupture of a cavernous hemangioma of the liver with a successful hepatic resection after transcatheter hepatic arterial embolization is reported. Twenty-eight cases of spontaneous rupture of hepatic hemangioma have been reported in the medical literature. Each of the cases (19 adults and nine children) were reviewed, including the present one reported here. Surgical treatments were carried out on 20 patients, of whom only five survived. Ruptured hemangiomas ranged in size from 3.0 to 25.0 cm, and many were located on the inferior surface of the liver. Surgical resection should be considered for a large hepatic hemangioma located on the inferior surface of the liver if the tumor has a high probability of rupture. Once the hemangioma has ruptured, emergent hepatic resection is recommended for low-risk patients, whereas high-risk patients should receive transcatheter hepatic arterial embolization prior to elective hepatic resection.     

肝脏神经内分泌肿瘤报道1例并文献回顾

背景肝脏可疑恶性肿瘤行手术切除后病理诊断肝脏神经内分泌肿瘤(hepatic neuroendocrin neoplasmas,HNENs)病例,此病例易与肝癌混淆,了解转移性和原发性HNENs的特性,对临床治疗手段有很好的指导意义.病例简介一名56岁男性患者体检发现肝脏占位性病变复查腹部增强CT提示肝脏转移性恶性肿瘤可能;胃部包块考虑良性.手术切除胃部包块并行术中冰冻病理检查提示梭形细胞肿瘤;完整切除肝脏包块术后石蜡病理检查结果提示NENs(G2),患者术后恢复佳.结论本文报道了一例HNENs,考虑转移性.术前诊断不能排除肝脏转移性恶性肿瘤可能.通过对患者病情的详细分析,最终行手术切除治疗并行病理检查确诊.同时我们对HNENs相关文献进行了分析,进一步了解原发和转移性HNENs的临床特征、治疗方案以及预后,以期对此类疾病有更深入的了解,对临床治疗方案决策做证据支撑作用.     

Complete remission of disease for 5 years following initial and repeat resection of the liver for the removal of 22 metastases of colorectal origin

Although liver resection is accepted as the only available treatment that regularly produces long-term survival with possible cure in patients with colorectal carcinoma metastatic to the liver, controversy appears to exist regarding the surgical indication for patients with more than four nodules. Similarly, it may be arguable to perform a repeated hepatic resection for a patient who developed multiple recurrent liver metastases with a short disease-free period after the initial liver resection. During the last 7 years, we have adopted constantly the aggressive surgical approach to patients with colorectal carcinoma metastatic to the liver if the number of tumor nodules identified preoperatively were less than ten and irrespective of the length of disease-free period after the previous resection. Here we report on a patient who underwent hepatic resection twice at an interval of 3 months and in whom a total of 22 metastatic nodules (6 in the initial hepatic resection and 22 in the repeated resection) were removed. The patient is now alive and remains disease-free, 5 years after the first liver resection.     

Intrahepatic micrometastases around liver metastases from gastric cancer

Background/Purpose

We aimed to clarify the association between the presence of micrometastases around liver metastases from gastric cancer and the results of hepatic resection. In addition, we investigated the influence of E-cadherin and matrix metalloproteinase (MMP)-7 expression on the development of micrometastases.

Methods

Micrometastases around liver metastases were examined microscopically in 31 metastatic liver tumor specimens resected from 17 patients who had undergone hepatic resection for liver metastases from gastric cancer. E-cadherin and MMP-7 expression in the primary gastric tumor, the liver metastases, and the micrometastases were examined immunohistochemically.

Results

Hepatic micrometastases were present in around 48% of the liver metastases, accounting for 59% of the patients. The tumor recurrence rate in the remnant liver after hepatic resection was significantly higher, and survival significantly poorer, in patients with such micrometastases than in those without. Micrometastases tended to appear around the liver metastases that had reduced E-cadherin expression. Most of the micrometastases in the lymph ducts and sinusoids showed reduced E-cadherin expression. MMP-7 expression was not correlated with the presence of micrometastases.

Conclusions

About half of the hepatic metastases from gastric cancer had seeded off micrometastases, and the presence of these micrometastases was associated with a poorer result of hepatic resection. Reduced E-cadherin expression in metastatic liver tumors may be associated with the development of micrometastases.