结直肠癌同时性肝转移同期手术切除疗效分析

目的 分析结直肠癌同时性肝转移患者行同期手术切除原发灶和肝转移灶的近期及远期效果,探讨同期手术是否存在优势.方法 回顾性分析行手术治疗的53例结直肠癌同时性肝转移患者的临床资料,根据肝转移灶切除时间的不同,分为同期手术组(同期组)40例,分期手术组(分期组)13例,评价两组患者的手术效果.结果 同期组和分期组患者的手术时间分别为(212.9±72.3) min和(326.5±140.2)min,术中失血量分别为(337.5±298.0) ml和(594.6±430.5) ml,术后住院时间分别为(16.2±8.1)d和(25.8±8.5)d,差异均有统计学意义(均P＜0.05).同期组和分期组患者手术并发症的发生率分别为25.0％和53.8％ (P =0.053).两组均无手术死亡患者.同期组患者1、3、5年生存率分别为95.0％、57.0％和37.4％,中位生存时间为40.0个月,中位无病生存时间为14.0个月;分期组患者l、3、5年生存率分别为92.3％、58.7％和36.7％,中位生存时间为38.0个月,中位无病生存时间为13.0个月.两组患者生存时间差异无统计学意义(P＞0.05).结论 同期手术是治疗可切除的结直肠癌同时性肝转移患者安全、有效的措施,与分期手术比较,术中出血少,并发症发生率低,术后住院时间短.     

同时性结直肠癌肝转移患者治疗策略探讨

背景与目的:肝切除术是治疗同时性结直肠癌肝转移获得长期生存的希望.但如何选择肝切除术的手术时机,存在较大的争议,本研究探讨同时性结直肠癌肝转移的手术治疗策略.方法:选择上海东方肝胆外科医院和上海长海医院1995年1月至2005年12月收治的经手术治疗的83例同时性结直肠癌肝转移患者,其中37例行一期手术,46例行分期手术,比较两组手术并发症、死亡率、术中失血量、住院时间、生存率、中位生存期、无瘤生存期及肝转移癌复发率.结果:一期手术组手术并发症发生率为24.3%,分期手术组为19.6%(P=0.601).两组均没有手术死亡.一期手术组术中平均失血量为462 mL,分期手术组为574mL(P=0-312).一期手术组平均住院时间为19 d,分期手术组为36 d(P=0.001).一期手术组l、3、5年生存率分别为86.5%、54.1%和27.0%,分期手术组分别为89.1%(P-0.713)、52.2%(P=0.865)和23.9%(P=0.746).一期手术组中位生存期为40个月,分期手术组为37个月(丹0.075).一期手术组中位无瘤生存期为12个月,分期手术组为11个月(P=0.532).一期手术组肝转移癌复发率为35.1%,分期手术组为30.4% (P=0.650).结论:同时性结直肠癌肝转移患者有选择的一期手术切除原发病灶及肝转移病灶是合理的.     

腹腔镜一期切除治疗直肠癌合并同时性肝转移

目的 总结腹腔镜一期切除治疗直肠癌合并肝转移患者的临床效果.方法 23例直肠癌合并同时性肝转移患者在行腹腔镜直肠癌切除的同时,行肝转移瘤切除,并与同期18例开腹一期切除直肠癌及肝转移瘤患者进行对比研究.全部患者术后均定期全身化疗.结果 所有患者均顺利行直肠癌切除和肝转移瘤切除,腹腔镜组无中转开腹,两组患者均无手术死亡.腹腔镜组和开腹手术组的手术时间分别为(350±45)min和(342±38)min(P>0.05),术中出血量分别为(275±96)ml和(590±85)ml(P<0.01),住院时间分别为(12±1.5)d和(16±2.5)d(P<0.05).腹腔镜组有1例患者手术中输血200 ml,而开腹手术组平均术中输血(500±100)ml(P<0.01).腹腔镜组患者的1、3、5生存率分别为82.6%、43.5%和8.6%,开腹手术组分别为77.8%、38.9%和0,差异无统计学意义(P>0.05).结论 腹腔镜一期切除直肠癌合并同时性肝转移癌安全可行,具有创伤小、恢复快的优点,患者的生存期与开腹一期切除相当.     

保留肝实质的治疗方式在结直肠癌肝转移手术切除中的应用分析

  目的   探讨保留肝实质的治疗方式在结直肠癌肝转移（colorectal liver metastases, CRLM）手术切除中的意义。  方法   回顾性分析北京大学肿瘤医院2000年1月至2016年5月手术切除的CRLM患者377例, 根据手术方式分为保留肝实质（parenchymalsparing hepatectomy, PSH）组305例和大范围肝切除（major hepatectomy, MH）组72例。比较两组患者的临床特征、手术情况、术后并发症及预后。  结果  PSH组肝转移灶个数少于MH组, 差异比较具有统计学意义（P=0.000）。全组采用PSH治疗的患者占80.9%, 且随时间增长逐渐增多。PSH组手术时间比MH组短（177.5 minvs.220 min, P=0.000）, 手术出血比MH组少（150 mLvs. 300 mL, P=0.000）, 术后并发症发生率比MH组低（47.4%vs.64.8%, P=0.008）。PSH组与MH组患者的总生存（overall survival, OS）时间、肝内无复发生存（hepatic recurrence free survival, HFRS）时间差异无统计学意义。PSH组患者复发后接受局部治疗的比例明显增加（42.8%vs.25.6%, P=0.040）, 复发患者中接受局部治疗的患者生存期明显延长（58个月vs.24个月, P=0.000）。  结论  CRLM患者手术时采用PSH的治疗方式肝内复发率更低, 安全性更高, 复发后再次接受局部治疗的可能性明显增加, 是推荐的治疗模式。      

Ⅲ Ⅳ型肝门胆管癌扩大肝切除临床疗效分析*

目的:探讨扩大肝切除对Bismuth-Corlette Ⅲ、Ⅳ型肝门胆管癌的临床疗效。方法:回顾性分析蚌埠医学院第一附属医院2008年1 月至2015年5 月61例Bismuth-Corlette Ⅲ、Ⅳ型肝门部胆管癌患者的临床资料。其中扩大肝切除组行半肝及以上肝切除和（或）联合尾状叶切除术22例;局限肝切除组行肝门区不规则肝切除术39例。结果:扩大肝切除组患者相比局限肝切除组手术时间长、术中出血量多。扩大肝切除组患者并发症发生率低于局限肝切除组患者;扩大肝切除组无围手术期死亡患者,局限肝切除组有2 例围手术期死亡患者;扩大肝切除组R 0 切除21例,R 0 切除率为95.5%（21/ 22）,局限肝切除组R 0 切除20例,R 0 切除率为51.3%（20/ 39）,差异具有统计学意义（P < 0.05）;扩大肝切除组1、3、5 年生存率分别是77.27% 、36.36% 、13.64% ;局限肝切除组1、3、5 年生存率分别是69.23% 、20.51% 、1.64% ,差异具有统计学意义（P < 0.05）。 结论:Bismuth-Corlette Ⅲ、Ⅳ型肝门部胆管癌扩大肝切除可以有效提高患者的R 0 切除率和生存率,改善患者的预后。      

结直肠癌伴肝转移91例患者的多因素预后分析

目的：探讨结直肠癌同时性肝转移患者的预后相关因素。方法：采用多因素回归分析方法回顾性分析了91例结直肠癌同时性肝转移患者的生存因素。结果：91例结直肠癌同时性肝转移的患者中位生存期为16.8个月,1年生存率为61.54%,3年生存率为14.79%,5年生存率为8.87%。单因素分析显示原发灶手术、肝转移分期、介入治疗、放射治疗、物理治疗、化疗和新药使用与患者的生存期显著相关;多因素分析显示,肝转移分期、原发病灶手术切除、介入治疗、物理治疗对患者的预后有显著影响,是结直肠癌同时性肝转移影响预后的主要因素。结论：对于结直肠癌同时性肝转移的患者应积极切除原发病灶,进行介入、物理等综合治疗可以提高患者的生存期。     

淋巴结阴性结肠癌伴同时性肝转移患者的临床病理因素分析*

目的:分析淋巴结阴性结肠癌患者发生同时性肝转移的危险因素,提高高危患者随访的效率和早诊率。方法:回顾性分析2008年1 月至2012年12月就诊北京肿瘤医院胃肠肿瘤中心并且行手术治疗的140 例淋巴结阴性结肠癌患者临床病理资料,通过单因素和多因素分析,研究淋巴结阴性结肠癌同期肝转移的高危因素。结果:140 例淋巴结阴性结肠癌患者同期肝转移13例（9.2%）,61.5%（8/ 13例）的患者伴有不全性结肠梗阻,6 例患者接受原发灶和肝转移灶同期手术治疗。单因素分析和多因素分析均提示脉管浸润（P = 0.010）和术前CEA 水平异常（P = 0.004）是淋巴结阴性结肠癌患者发生同时性肝转移的独立危险因素。结论:淋巴结阴性结肠癌存在较高的同时性肝转移风险,脉管浸润和术前CEA 水平异常是这类患者发生同期肝脏转移的高危因素,对具有该特征的患者在就诊时或根治术后应该针对性地检查肝脏情况,避免漏诊。      

结直肠癌同时性肝转移同期切除切口与近期预后探讨

目的:结直肠癌同时性肝转移（synchronous colorectal liver metastases ，sCRLM ）同期切除时，切口是外科医生需要考虑的技术问题。本研究旨在探讨切口对同期切除近期预后的影响。方法:回顾性分析2009年1 月至2014年12月北京大学肿瘤医院肝胆胰外Ⅱ科37例同期切除的sCRLM 患者的临床数据。结果:Mercedes 切口（Mer）组19例，正中切口（Mid）组18例。2 组间患者一般情况、大体积肝切除比例、手术时间、术中出血量、术中第一肝门阻断时间无显著性差异。正中切口组中直肠患者更多（P < 0.001）。 2 组共发生并发症11例（32.4%），其中Mer组9 例（47.4%），Mid组3 例（16.7%），两组比较无显著性差异（P = 0.08）。 术后住院时间 Mer组（22.1 ± 9.5）d，Mid组（17.2 ± 6.7）d，两组比较无显著性差异（P = 0.08）。当患者 BMI（bodymassindex）< 25时，并发症Mer组5 例（38.5%），Mid组0 例（0%），两组比较有显著性差异（P = 0.046）。 术后住院时间Mer 组（22.1 ± 10.5）d，Mid组（15.7 ± 5.3）d，P = 0.051。结论:sCRLM 患者进行同期切除时，正中切口可以满足术野暴露要求，相比Mercedes 切口，对直肠术野的暴露更有优势；当BMI<25时，正中切口可能会有更好的近期预后。      

结直肠癌同时性肝转移的预后因素分析

目的 探究结直肠癌同时性肝转移患者的临床病理特点,并分析影响其预后的相关因素,以期指导外科治疗决策.方法 回顾性分析中山大学附属第一医院自1994年8月至2009年12月收治的结直肠癌同时性肝转移患者231例,分析其预后与临床病理凶素的关系.结果 确诊时合并肝转移患者占同期结直肠癌患者总数的8.46%(231/2732).该组患者1、3、5年生存率分别为70.2%、21.9%,和11.4%,中位生存时间19个月.单因素分析显示:肿瘤周径(P=0.017)、浆膜侵犯(P=0.000)、肝转移分期(P=0.000)、浸润深度(P=0.010)、肿瘤分化程度(P=0.007)、手术方式(P=0.000)和化疗(P=0.041)影响患者预后.肝转移H1组患者1、3和5年生存率分别为88.4%、39.7%和21.3%,肝转移H2组分别为64.1%、15.7%和7.8%,肝转移H3组分别为55.0%、9.2%和0.0%(P<0.01).根治性手术组患者1、3和5年生存率分别为84.6%、37.9%和19.8%.姑息手术组分别为60.2%、24.0%和0.05%,减状手术或者未手术组1、3、5年生存率分别为37.0%、0.09%和0.0%(P<0.01).Cox回归模型多因素分析显示,只有肝转移分期(P=0.000)和手术方式(P=0.010)是结直肠癌肝转移患者的独立预后因素.结论 结直肠癌肝转移分期影响预后.应早期发现和诊治.对于结直肠癌仅有肝转移的患者应尽可能手术切除原发灶和肝转移病灶.化疗可以改善姑息术后患者的预后.     

结直肠癌肝转移外科治疗体会

[目的]探讨结直肠癌肝转移的外科治疗效果及对临床生存时间的影响。[方法]回顾性分析1998年1月至2007年1月结直肠癌肝转移患者行外科手术治疗22例的资料。[结果]术后随访存活1年者19例，存活3年者9例，存活5年及以上者5例。10例同期行肝切除者平均生存期26个月，7例分期行肝切除者平均生存期30个月。术后发生并发症3例，无手术死亡。[结论]掌握外科手术时机和适应证，积极行肝切除术并创造条件提高手术切除成功率，是提高结直肠癌肝转移患者存活率的关键。     

Safety of Simultaneous Bowel and Liver Resections for Colon and Rectal Cancer

The synchronous presentation of primary colorectal cancer and colorectal liver metastasis (CLM) occurs in 23-51 % of all colorectal cancer patients at the time of diagnosis. The optimal treatment of patients with synchronous primary colorectal cancer and CLM has been controversial for decades. Here, the available literature regarding staged versus simultaneous resection of synchronous CLM is reviewed in terms of the perioperative and prognostic outcomes. Recent studies support the safety of a simultaneous approach for the resection of synchronous CLM, demonstrating an equivalent or better short-term outcome compared with a staged approach. The postoperative mortality following either simultaneous or staged resections is reportedly less than 5 %. The long-term prognosis following a simultaneous approach is comparable to that following a staged approach. Most series have demonstrated equivalent overall and disease-free survival periods, regardless of the timing of the resections. An increased perioperative risk following simultaneous major hepatectomies, compared with minor resections, was proposed by several authors. In addition, the operative procedures for multiple liver metastases have changed over time toward a parenchymal-sparing approach, providing better prognostic outcomes than major hepatectomies. The available evidence indicates that comparable short-term as well as long-term outcomes can be expected regardless of a staged or simultaneous resection of synchronous CLM. However, minor resections of colorectal liver metastases can reduce the perioperative risks, providing room for a repeated treatment approach.     

Strategies for the treatment of synchronous liver metastasis.

AIM: Observe the outcomes after complete simultaneous or delayed resection of synchronous liver metastasis (SLM) from colorectal cancer (CRC). METHODS: From 1994 to 2005, 119 patients were diagnosed with CRC and SLM; 57 patients had simultaneous resection (group I) and 62 patients had staged resection (group II). Perioperative chemotherapy was considered completed if all expected cycle were administrated. RESULTS: Overall survival rates of group I-group II at 1, 3 and 5 years were respectively 91%-93% (p=0,3), 59%-57% (p=0,09) and 32%-25% (p=0,06). The median survival time of group I-group II were respectively 46 months-40 months (p=0,07). There was no statistical difference on survival regarding location of metastasis (p=0,09) or primary tumor location (p=0,2). Patients with simultaneous or staged resection receiving optimal treatment (R0 liver surgery and complete chemotherapy) were respectively 89% and 67% (p=0,04). Twenty three patients developed isolated liver recurrence with higher frequency in staged patients (26% vs 9% p=0,03) without impairment of survival. CONCLUSIONS: Because of postoperative morbidity and prolonged tiring treatment, many patients having staged resection were under treated. However we did not observe statistical difference on survival but we supported that simultaneous resection has to be prefer to achieve an optimal treatment. Lung and bone metastasis are the new challenge for oncologists.     

Synchronous resection of colorectal primary and hepatic metastasis

Up to 50% of the over 140,000 new colorectal cancer patients will present with synchronous colorectal cancer and liver metastasis. Surgical management of patients with resectable synchronous colorectal hepatic metastasis is complex and must consider multiple factors, including the presence of symptoms, location of primary tumor and liver metastases, extent of tumor (both primary and metastatic), patient performance status, and underlying comorbidities. Possible approaches to this select group of patients have included a synchronous resection of the colorectal primary and the hepatic metastases or a staged resection approach. The available literature regarding the safety of synchronous versus staged approaches confirms that a simultaneous resection may be performed in selected patients with acceptable morbidity and mortality. Perioperative mortality when minor hepatectomies are combined with colorectal resection is consistently ≤5%. Perioperative morbidity varies considerably following both synchronous and staged resections. However, the bulk of the existing literature confirms that simultaneous resections are both feasible and safe when hepatic resections are limited to <3 segments. Data regarding the oncologic outcomes following synchronous versus staged resections for Stage IV colorectal cancer are more limited than those available regarding postoperative morbidity and mortality. The available data suggest equivalent overall and disease-free survival regardless of timing of resection. Experience with minimally invasive combined colorectal and hepatic resections is extremely limited to date and consists exclusively of small single center series. The potential benefits of a minimally invasive approach will await the results of larger studies.Key Words: Colorectal cancer, colorectal liver metastases, synchronous resection     

直肠癌局限性肝转移的手术及术后经门静脉途径灌注化疗的疗效分析

目的 探讨直肠癌局限性肝转移的手术及术后经门静脉途径灌注化疗的安全性和有效性。方法 对40例直肠癌局限性肝转移患者行手术治疗,其中同时性肝转移患者18例行同时性手术。术后随机分组行前瞻性对照研究,A组22例行门静脉途径灌注化疗,B组18例行周围静脉化疗,随访观察治疗效果。结果 所有病人均安全度过围手术期,无严重并发症,A组术后生存率和复发率均优于B组,差异有统计学意义〔P＜0.05〕。结论 直肠癌局限性肝转移行手术治疗效果好;直肠癌同时性肝转移者采用同时性手术是安全可行的;术后经门静脉途径化疗可进一步提高疗效。     

Combined colon and hepatic resection for synchronous colorectal liver metastases

BACKGROUND AND OBJECTIVES: The surgical strategy for the treatment of resectable synchronous hepatic metastases of colorectal cancer remains controversial. This study was performed to assess the outcome of combined resection of colorectal cancer and liver metastases. METHODS: The perioperative data, morbidity, and survival of the patients who underwent combined colon and liver resections for synchronous colorectal liver metastases from 1988 to 1999 were compared to the parameters of the patients who underwent colon resection followed by resection of liver metastases in a staged setting. RESULTS: 198 hepatic resections were performed, of which 112 procedures in 103 patients were done for metastatic colorectal carcinoma. Twenty six patients (25%) had combined hepatic and colon resection and were compared to 86 patients with metachronous metastases who underwent colon and hepatic resection in the staging setting. Postoperative morbidity was 27 and 35%, respectively. There was no hospital mortality in the combined group vs. 2.3% in the staged group. Blood loss, intensive care unit (ICU) stay and length of postoperative stay (LOS) were similar in both groups. The 5 years cumulative survival of the group after combined surgery was 28% vs. 27% of the group after isolated hepatic resections (P = 0.21). CONCLUSION: Combined colon and hepatic resection is a safe and efficient procedure for the treatment of synchronous colorectal liver metastases. It can be performed with acceptable morbidity and no perioperative mortality. The survival after combined procedure is comparable to the one achieved after staged procedure of colon resection followed by liver resection.     

Is resection of periampullary or pancreatic adenocarcinoma with synchronous hepatic metastasis justified?

BACKGROUND: To date, no consensus has been reached regarding which primary tumor subtypes are managed appropriately with hepatic metastectomy. Specifically, the role of hepatic resection for metastatic periampullary or pancreatic adenocarcinoma remains controversial. METHODS: Between 1995 and 2005, 1563 patients underwent surgical resection for periampullary carcinoma (n=608 patients) or pancreatic adenocarcinoma (head, n=905 patients; tail, n=50 patients). Data on demographics, operative details, primary tumor status, and-when indicated-extent of hepatic metastasis were collected. RESULTS: Of the 1563 patients who underwent resection of periampullary or pancreatic adenocarcinoma, 22 patients (1.4%) underwent simultaneous hepatic resection for synchronous liver metastasis. The primary tumor site was ampullary (n=1 patient ), duodenal (n=2 patients), distal bile duct (n=2 patients), or pancreas (head, n=10 patients; tail, n=7 patients). The majority of patients (86.4%) had a solitary hepatic metastasis, and the median size of the largest lesion was 0.6 cm. Hepatic metastectomy included wedge resection (n=20 patients), segmentectomy (n=1 patient), and hemihepatectomy (n=1 patient). After matching patients on primary tumor histology and location, the median survival of patients who underwent hepatic resection of synchronous metastasis was 5.9 months compared with 5.6 months for patients who underwent palliative bypass alone (P=.46) and 14.2 months for patients with no metastatic disease who underwent primary tumor resection only (P<.001). Pancreatic (median, 5.9 months) versus nonpancreatic (median, 9.9 months) primary tumor histology was not associated with a difference in survival in patients who underwent resection of synchronous liver metastasis (P=.43). CONCLUSIONS: Even in well selected patients with low-volume metastatic liver disease, simultaneous resection of periampullary or pancreatic carcinoma with synchronous liver metastases did not result in long-term survival in the overwhelming majority of patients.     

FOLFOX和FOLFOXIRI方案在结直肠癌肝转移术后患者中的应用

目的 比较FOLFOXIRI（folinic acid, 5-fluorouracil, oxaliplatin and irinotecan）和FOLFOX（folinic acid, 5-fluorouracil and oxaliplatin）两种化疗方案在肠癌肝转移同期手术切除患者中的有效性及安全性。方法 回顾性分析2008年1月至2011年7月结直肠癌伴肝转移同期手术切除患者60例,分为两组,分别接受FOLFOXIRI或FOLFOX两种化疗方案,观察不良反应以及1、2、3年无病生存期（DFS）和总生存期（OS）,采用Kaplan-Merier进行生存分析。结果 接受FOLFOXIRI或FOLFOX两种化疗方案的60例患者,不良反应包括白细胞下降、血小板下降、贫血、恶心呕吐、腹泻、肝肾功能损害、神经毒性、口腔黏膜炎、脱发,FOLFOXIRI组在白细胞减少及腹泻方面有更高的不良事件发生率,其余不良反应与FOLFOX组相仿。两组患者1、2、3年无病生存率分别为73.3%、43.3%、26.7%和60%、13.3%、10%,其中2、3年DFS存在统计学差异。两组患者1、2、3年总生存率分别为86.7%、73.3%、36.7%和83.3%、50%、13.3%,其中3年OS差异有统计学意义（P=0.024）。结论 FOLFOXIRI和FOLFOX两种化疗方案安全有效,FOLFOXIRI组在白细胞减少及腹泻方面有更高的不良事件发生率,但更具远期生存优势。     

Outcome after Simultaneous Resection of Gastric Primary Tumour and Synchronous Liver Metastases: Survival Analysis of a Single-center Experience in China

Background: The optimal surgical strategy for the treatment of synchronous resectable gastric cancer livermetastases remains controversial. The aims of this study were to analyze the outcome and overall survival ofpatients presenting with gastric cancer and liver metastases treated by simultaneous resection. Materials andMethods: Between January 1990 and June 2009, 35 patients diagnosed with synchronous hepatic metastasesfrom gastric carcinoma received simultaneous resection of both primary gastric cancer and synchronous hepaticmetastases. The clinicopathologic features and the surgical results of the 35 patients were retrospectively analyzed.Results: The 5-year overall survival rate after surgery was 14.3%. Five patients survived for more than 5 yearsafter surgery. No mortality has occurred within 30 days after resection, although two patients (5.7%) developedcomplications during the peri-operative course. Univariate analysis revealed that patients with the presenceof lymphovascular invasion of the primary tumor, bilateral liver metastasis and multiple liver metastasessuffered poor survival. Lymphovascular invasion by the primary lesion and multiple liver metastases weresignificant prognostic factors that influenced survival in the multivariate analysis (p=0.02, p=0.001, respectively).Conclusions: The presence of lymphovascular invasion of the primary tumor and multiple liver metastases aresignificant prognostic determinants of survival. Gastric cancer patients without lymphovascular invasion andwith a solitary synchronous liver metastasis may be good candidates for hepatic resection. Simultaneous resectionof both primary gastric cancer and synchronous hepatic metastases may effectively prolong survival in strictlyselected patients.