清创性肝切除联合选择性向肝血流阻断治疗严重肝外伤

目的 探讨清创性肝切除联合选择性入肝血流阻断对严重肝外伤手术治疗价值.方法 总结清创性肝切除术联合选择性入肝血流阻断治疗严重肝外伤55例的临床病例资料,其中肝外伤Ⅲ级20例,Ⅳ级20例,Ⅴ级15例,伴肝周大血管损伤14例,合并其他伤35例.附加手术:肝间断缝合修补术7例,肝周纱布填塞3例,下腔静脉修补术5例,肝静脉修补术5例,肝静脉缝扎术4例,肝固有动脉结扎2例.其余患者开颅清创3例,胆囊切除6例,胆总管T管引流4例,脾切除术5例,胰体尾部切除2例,左肾切除术1例,胸腔闭式引流9例,小肠部分切除或修补4例,胃修补1例.结果 全组救治成功47例.术后并发症19例(34.5％),其中凝血功能障碍1例,腹腔内出血2例,肠梗阻1例,肝、肾功能不全4例,腹腔感染3例,伤口感染2例,肺部感染4例,胸腔积液10例,均经治疗痊愈出院.死亡8例(14.5％),死亡原因:失血性休克3例,重型颅脑伤1例;重型颅脑伤合并胃、小肠多处破裂1例,感染性休克1例,多器官功能衰竭2例.结论 清创性肝切除联合选择性入肝血流阻断是严重肝外伤手术救治的较好方法.     

严重肝外伤肝周填压止血的评价

严重肝外伤（Ⅲ、Ⅳ、Ⅴ级）包括广泛肝实质碎裂伤、肝叶断裂伤,和肝静脉／肝后腔静脉伤,在病人大出血的危急情况下施行深部肝实质缝合、选择性肝动脉结扎,清创性肝叶切除、血管修复和下腔静脉转流等确定性手术处理,死亡率很高,分别为７％（Ⅲ级）、３０％（Ⅳ级）和...     

严重肝外伤46例诊治体会

目的总结严重肝外伤的手术处理经验。方法回顾性分析我院2000～2010年46例接受手术治疗的严重肝外伤患者的临床资料,手术方式及术后疗效。结果参照AAST对肝脏外伤的分级:Ⅲ级28例,Ⅳ级12例,Ⅴ级6例。痊愈40例,死亡6例。结论手术是治疗严重肝外伤的有效方法,尽快救治失血性休克,术中彻底止血,充分引流以及预防术后并发症是治疗严重肝外伤的有效措施。     

选择性肝动脉结扎加肝周填塞在严重肝外伤手术中的应用

目的:探讨选择性肝动脉结扎加肝周填塞在严重肝外伤手术中的应用价值.方法:选取2007年1月-2012年12月严重肝外伤行手术治疗患者80例进行回顾性分析,其中以2010-2012年的43例作为观察组,2007-2009年的37例作为对照组.观察组采用选择性肝动脉结扎、肝裂伤创面缝合加肝周填塞治疗,对照组采用肝裂伤创面致密缝合治疗,观察两组手术情况和治疗效果.结果:观察组在手术时间、术中出血量、术后3d腹腔引流量和住院时间上明显少于对照组(P＜0.05);观察组治愈率明显高于对照组(P＜0.05),并发症发生率和病死率明显低于对照组(P＜0.05).两组均未出现肝功能衰竭表现.结论:选择性肝动脉结扎加肝周填塞应用于严重肝外伤手术是安全有效的,能够减少术中术后出血量,缩短手术及住院时间,提高患者治愈率,减少并发症的发生,减少临床用血量,效果显著,值得临床推广.     

肝动脉结扎加填塞法治疗广泛肝损伤12例分析

肝动脉结扎在肝脏广泛性损伤中的止血作用,近年来受到大多数外科学者的重视〔１〕,而纱布填塞治疗重度肝外伤因并发症较多曾被废弃,但近２０年来又被重新启用,现已被公认为是严重肝外伤处理的一项救命措施。我院外科自１９９４年１月～１９９８年１２月共手术治疗严重肝脏损伤（损伤程度≥Ⅲ级）３２例,其中施行肝动脉结扎加填塞法治疗１２例,现总结报道如下。一般资料本组１２例中,男８例,女４例,年龄８～６２岁,交通事故伤６例,高处坠落伤４例,爆炸伤１例,枪弹穿通伤１例。１２例中合并其它部位损伤９例,其中脑外伤３例,多…     

严重肝外伤术后并发症的防治

目的:探讨严重肝外伤术后并发症的防治。方法:采用深层褥式缝合。大网膜填塞,选择性肝动脉结扎,肝后纱布填塞及清创性肝部分切除,作为处理严重肝外伤的手术方式,共手术治疗53例严重肝外伤患者,同时治疗合并伤。结果:本后发生并发症16例(占30.2％),死亡10例(占18.9％),术后并发症是死亡的主要原因。结论:术中彻底止血,清创、引流,术后抗感染,严防MOF发生,是防治严重肝外伤术后并发症的根本措施。     

严重肝外伤的处理

目的　探讨严重肝外伤的手术治疗效果。方法　对24例严重肝外伤患者的临床资料进行回顾性分析。结果　24例中,肝外伤属Ⅲ级者9例,Ⅳ级10例,Ⅴ级4例,Ⅵ级1例。1例未及手术于抢救中死亡;23例手术治疗;肝缝合修补4例,大网膜填塞修补3例,不规则肝切除16例。同时行肺修补4例,脾切除3例,胰尾切除1例。23例手术者均治愈,未发生严重并发症者。结论　手术是治疗严重肝外伤的有效方法。手术方式的选择应根据患者的局部和全身情况,以及当时、当地医院的条件选择合理术式。加强伴发伤和术后处理对降低严重肝外伤的死亡率有重要意义。     

清创性肝切除治疗严重肝外伤

目的 评价清创性肝切除治疗严重肝外伤的疗效。方法 回顾性总结３４例施行肝切除术的严重肝外伤患者的临床资料,其中肝外伤Ⅲ级９例,Ⅳ级２１例,Ⅴ级４例。行清创性肝切除２３例,规则性肝切除１１例。结果 死亡８例,死亡率为２３．５３％。８例术后发生并发症。清创性肝切除死亡率明显低于规则性肝切除,２种术式间并发症发生率无显著差异。结论 清创性肝切除为治疗严重肝外伤的有效措施,清创性肝切除操作简单,失血量少,     

严重肝外伤45例治疗体会

目的总结在临床中严重肝外伤的诊断和治疗经验,提升对严重肝外伤的救治水平。方法回顾性分析2003年6月至2013年6月间我院收治的45例严重肝外伤患者的诊断和治疗方法,其中Ⅲ级35例,Ⅳ级8例,V级2例。结果在临床治疗的45例患者中,治愈40例,治愈率88.9%;死亡5例,病死率11.1%,术后出现并发症18例,均临床治愈。结论尽快纠正失血性休克、有效合理的手术方式、充分引流以及积极预防、治疗术后并发症是治疗严重肝外伤的有效手段。     

肝外伤37例死亡病例分析

近年来，国内外学者在对肝外伤特别是严重肝外伤处理方法的不断探索中积累了许多成功的经验，创伤处理新概念的确立和治疗方法的改进已使Ⅲ、Ⅳ级肝损伤的死亡率降至10％以下，1994年6月-2005年5月我院共收治肝外伤患者316例，死亡37例，现报告如下。     

HEPATIC RESECTION

In the four years between the beginning of 1979 and the end of 1982, 23 hepatic resections have been carried out for tumours, trauma, biliary access, cystic disease of the liver and spontaneous rupture. There have been four deaths amongst these 23 patients. The 23 resections were performed on 68 patients referred for possible surgery on their hepatic lesions. Right-sided hepatic resections and resections carried out under emergency circumstances were found to carry a significantly higher risk than all other resections. Of the various organ imaging methods available for assessment of hepatic tumours, CT scanning seems to be the most powerful. Liver surgery is probably best done in a limited number of units prepared to implement appropriate protocols of investigation and surgical management.     

THE AETIOLOGY AND MANAGEMENT OF HEPATIC METASTASES

Hepatic metastases are a common event in the metastatic spread of primary tumours and indicate advanced disease. However, the presence of hepatic metastases does not necessarily imply incurability; in selected patients resection of hepatic metastases may result in 5-year survival rates of 25–35%, usually in patients with colorectal liver metastases in whom solitary metastases are more frequent than with other primary tumours. However, hepatic metastases from Wilm's tumours, adrenal tumours, renal cell carcinoma, and neuroendocrine tumours may also be resected with similar success rates. A poor prognosis after resection of hepatic metastases is likely when there are more than three metastatic deposits, involved resection margins (often as a result of ‘wedge’ resections), when there is extrahepatic disease, or nodal involvement at the primary tumour site. Cyto-reductive procedures may provide excellent palliation and possibly long-term survival in selected patients with hepatic metastases unsuitable for resection. However, further study is required to establish the appropriate role for these treatments.     

HEPATIC TRAUMA IN AUCKLAND

A retrospective review of 102 cases of hepatic trauma in the Auckland area between 1979 and 1985 is presented. Particular attention has been focused on those cases where there was massive bleeding, and the prognostic factors that govern outcome have been determined. Mechanism and multiplicity of injury, and the presence of severe hypotension (systolic blood pressure < 80 mmHg) either at presentation or following induction of anaesthesia were the four most important determinants of prognosis. Blunt trauma caused 82% of these cases, with the mortality in this group being 27%. compared with 6% for penetrating trauma cases. The mortality of those patients who presented with a systolic blood pressure < 80 mmHg was 44% compared with 13% for those whose blood pressure was above 80 mmHg. Thirteen patients sustained severe bursting or avulsion-type injuries, in eight of whom extensive resection of formal lobectomy was performed with a survival of 88%. The remainder exsanguinated either pre-operatively (two patients) or before definitive hepatic surgery was begun (three patients). All patients with caval or retrohepatic venous injuries exsanguinated either pre- or intra-operatively. It is concluded that the mortality of liver injury from blunt trauma far exceeds that of penetrating trauma, and that severe hypotension at the time of presentation indicates a poor prognosis. A good outcome is possible in those patients who have a significant disruption of the liver architecture of one lobe following resection of devitalized tissue. Caval or retrohepatic venous-type injuries carry a grave prognosis.     

无血切肝术治疗原发性肝脏恶性肿瘤

目的 探讨无血切肝术在治疗常规手术方法难以切除的肝脏原发性恶性肿瘤中的价值。方法选择有肝切除手术适应证而以常规手术方法不能切除，或外院已作剖腹手术未能切除的肝脏原发性恶性肿瘤，加施无血切肝技术进行治疗６８例资料进行总结分析。结果 ６８例均完成无血切肝术，其中经腹常温下全肝血流阻断切肝术６６例，经胸腹联合切口常温下全肝血流阻断切肝术＋右肺下段转移癌切除术２例。施行右三叶肝切除３例，左三叶肝切除术２例     

肝包虫病的诊断与术式选择

目的：提高肝包虫病的诊断和治疗水平。方法：对452例肝包虫病的临床资料进行回顾性分析。结果：术前确诊449例（99．3％），误诊3例（0．7％），包虫破裂33例（7．3％）。包虫囊液皮试（Casoni试验）、B超、X线及放射性核素肝扫描有诊断价值。452例内囊均采用穿刺摘除，336例（74．3％）我囊腔缝合闭锁，79例（17．5％）外囊部分切除敞开，37例（8．2％）外事腔闭式引流。治愈451例（99．8％），死亡1例（0．2％）。结论：诊断肝包虫病的定位方法首选B超，包虫囊液皮试具有较高特异性，内囊穿刺摘除，外囊腔缝合闭锁及部分切除敞开，手术操作简单，疗效满意，并发症少。     

合理阻断肝脏血流切除累及肝门区肿瘤

目的探讨肝脏血流阻断技术在累及肝门区肿瘤切除中的合理应用。方法对采用第一肝门阻断法（Pringle法）和常温下全肝血流阻断法（THVE）相结合切除14例累及肝门区肿瘤的临床资料进行回顾性分析,统计肿瘤和肝门区血管的毗邻关系、阻断次数、阻断时间、术中出血量、输血量、术后并发症等指标。结果本组Pringle法平均阻断（4.2±2.0）次,第一肝门平均阻断时间（49.6±30.8）min;THVE平均阻断（1.8±0.4）次,平均阻断时间（18.8±7.4）min;术中出血量平均（1100±360）ml,输血量平均（800±220）ml;术中修补下腔静脉4次,主肝静脉2次,门静脉主干2次;术后检测ALT、胆红素有不同程度升高,经治疗2～3周后恢复正常,未发生肝功能衰竭、肝肾综合征等严重并发症。结论Pringle法与THVE法分步结合使用可增加肝门区肿瘤切除的安全性。     

HEPATIC CAVERNOUS HAEMANGIOMA: A 10 YEAR REVIEW

Between January 1981 and July 1991, 61 patients with hepatic haemangiomata were examined at Westmead Hospital. There were 14 males (22%) and 47 females (78%). The age range was 26–85 years with a median of 49 years. Forty-one had abdominal symptoms but these could be attributed to a haemangioma in only seven cases. There was at least one subcapsular lesion in 17 (28%). Six of the seven symptomatic lesions were subcapsular and five of these were giant haemangiomata (i.e. more than 4 cm in greatest diameter). One large symptomatic lesion was intrahepatic. No association was observed between hepatic haemangiomata and other hepatic or extrahepatic diseases. Haemangiomata were resected from six patients, four of whom were symptomatic. Symptoms improved in all four but did not resolve completely in any. Follow-up ranged from nil in five patients to 108 months in one. The median follow-up was 12 months after initial diagnosis. Ten patients showed evidence of change in their lesions or symptoms while under observation. Only three had worsening symptoms or suspected change in size of a haemangioma. This study highlights the benign, static nature of most hepatic haemangiomata. When this lesion is suspected, the diagnosis should be confirmed with ultrasound (US) and labelled red blood cell scanning (RBCS). Referral for evaluation by a specialist hepatobiliary surgery unit is necessary when symptoms are intolerable, increasing size is definitely demonstrated or the diagnosis is uncertain and cannot be established without specialized investigations. Bleeding into or from these lesions is rare.     

严重肝外伤的外科治疗

总结分析了近年来收治的３１例重度肝损伤的外科治疗,其中缝合修补２２例,清创性肝切除５例,不规则半肝切除４例。结果治愈２８例,占９０．３２％;死亡３例,占９．６８％。我们认为：提高重度肝损伤的治愈率及减少并发症发生率和降低死亡率的关键是：①早期诊断、早期治疗;在边抗休克的同时,尽快手术止血。②手术方式则根据术中情况进行合理选择。③术中充分暴露术野,为争在直视下彻底清创缝合,不留死腔。④腹中积血力争回     

PROLONGED HEPATIC ISCHAEMIA DUE TO LIVER INJURY: A CASE REPORT

A case is reported in which a young male who underwent right hepatectomy necessitated by gunshot wound to the liver, survived 2h 20min of normothermic hepatic ischaemia. This case extends the documented duration of hepatic ischaemia compatible with survival and documents the histopathology of the post-ischaemic liver.     

继发性肝癌的联合治疗

采用手术切除联合术后B超引导肝内门静脉区域化疗（简称PHPC）治疗胃肠道癌异时肝转移24例。随访4～54个月，结果：术后经3个疗程的PHPC，8例已存活肥18～48个月；13例分别经过2～11次的PHPC，已存活5～39p个月；另3例死亡。作者认为，对继发性肝癌采用手术切除配合术后B超引导的PHPC是一种延长患者生存期的有效联合治疗方案。