半肝血流阻断法与肝门阻断法在肝切除术中的应用效果比较

目的探讨不同血流阻断方案在原发性肝细胞癌患者手术中的效果,为肝切除术中最佳血流阻断方式的选择提供参考。方法回顾性分析2010-06~2017-06肝细胞癌行开腹肝部分切除患者78例,按手术中肝血流阻断方式分为两组:A组(半肝血流阻断)40例,B组(Pringle法肝门阻断)38例。对两组患者手术时间、术中出血量、术中血流阻断时间、术后血清丙氨酸转氨酶水平、术后早期并发症情况进行比较。结果A组中位手术时间为160.5 min,中位失血量为498.2 ml,中位血流阻断时间为33.7 min,B组依次为155.3 min、512.0 ml和31.6 min,两组差异无统计学意义(P0.05)。A组术后第1天、第3天、第7天的丙氨酸转氨酶水平低于B组(P0.05)。A组发生术后并发症5例(12.5%),其中胆瘘1例,肝断面出血1例,胸腔积液2例,切口感染1例。B组发生术后并发症8例(21.1%),其中胆瘘2例,胸腔积液3例,大量腹水3例。两组术后早期并发症发生率比较差异有统计学意义(P0.05)。结论半肝血流阻断法较传统Pringle法肝门阻断法在原发性肝细胞癌患者手术中可以减轻术后肝功能损害,降低并发症发生率,是肝癌肝切除术中一种安全、有效的血流控制方法,值得临床推广应用。     

腹腔镜下肝叶切除术14例报告

目的探讨腹腔镜肝切除术的可行性和安全性。方法回顾性分析我院2009年12月至2011年12月行腹腔镜肝切除术的14例肝占位患者的临床资料,其中原发性肝癌8例,肝转移癌1例,肝局灶性结节性增生1例,肝局灶性肝细胞脂肪变性1例,肝血管瘤3例。结果 14例均成功施行腹腔镜肝切除术,无中转开腹。其中8例行腹腔镜辅助肝部分切除术,6例行完全腹腔镜下肝部分切除术。左肝外叶切除3例,左半肝切除1例,肝局部切除10例。手术时间62~276 min,平均124.2 min。术中出血量40~550 ml,平均155.7 ml,住院时间8~15 d,平均10.8 d。所有患者术后均未发生严重并发症。8例原发性肝癌随访5~25个月,在随访超过1年的4例中,1例肿瘤复发后死亡,3例健在,1 a生存率为3/4。结论在掌握好手术指征的情况下,腹腔镜肝切除对于肝脏良恶性肿瘤的治疗是可行和安全的。     

止血技术在肝部分切除术中的应用

肝切除术已经成为常规手术,这得益于手术出血控制技术的不断发展。回顾了20年来肝切除术中止血技术的进展和应用。综合得出,充分的术前准备是首要条件,术中的入肝血流阻断、解剖性肝切除、切缝手段、降低中心静脉压以及适时适当的局部应用外用止血药物和材料是肝脏手术中控制出血的关键。     

Pringle法与肝下下腔静脉阻断联合Pringle法在肝脏巨大血管瘤切除术中的应用效果评价

目的评价两种不同的入肝血流阻断方式在肝脏巨大肝血管瘤切除术中的应用效果。方法选取2008年1月-2014年12月于天门市中医医院住院的肝脏巨大血管瘤患者20例,将其分为A、B两组,每组10例。A组采用Pringle法进行肝血流阻断,B组采用肝下下腔静脉阻断联合Pringle法阻断入肝血流。比较两组患者的手术时间、肝门血流阻断时间、术中出血量、输血率以及术后肝功能指标。计量资料组间比较采用t检验,计数资料组间比较采用Fisher精确检验。结果两组患者手术时间、肝门血流阻段时间比较,差异均无统计学意义(P值均0.05);B组患者的术中出血量、输血量及输血率明显低于A组,差异均有统计学意义(P值均0.05);与A组相比,B组患者术后第3天及第7天的ALT、AST及TBil水平均较低,差异均有统计学意义(P值均0.05);两组术后并发症发生率差异均无统计学意义(P值均0.05)。结论肝下下腔静脉阻断联合Pringle法阻断入肝血流在巨大血管瘤切除术中不仅能够减少术中失血量,而且有利于患者术后肝功能的恢复,值得在临床上推广应用。     

腹腔镜肝癌切除术(附27例报告)

经腹腔镜行肝癌切除术27例。其中10例行规则性肝叶切除，包括左半肝切除1例、左外叶切除7例、肝方叶切除2例，17例进行不规则性肝叶切除。7例由于术中出血（5例）或局部解剖困难（2例）中转开腹，无术中死亡。术中肝门阻断时间15—117min，平均54min；手术时间150—360min，平均240min。标本切缘距肿瘤边缘0．1—4．7em，平均1．1cm。2例术后出现腹水和肝性脑病。术后随访1．1—4．7a，8例术后复发，其中1例死亡，4例复发患者分别进行了原位肝移植、肝右叶切除、射频消融和肝动脉栓塞化疗。术后2a生存率64％。认为腹腔镜肝癌切除术实用、安全、有效。对位于肝脏边缘、肝脏表面或左半肝的恶性肿瘤可进行腹腔镜手术。     

腔镜超声引导下腹腔镜肝段切除术的临床应用

目的:探讨腔镜超声引导下腹腔镜肝解剖性肝段切除术的可行性、安全性与临床价值.方法:收集2005-01/2006-12我院行腹腔镜肝切除术患者20例,其中原发性肝癌13例、肝内胆管细胞癌1例、肝血管瘤3例、肝脏腺瘤1例,肝脓肿2例.所有病例均在全气腹条件下完成腔镜超声引导下腹腔镜肝解剖性肝段切除手术.结果:20例病例的手术时间平均188 min,出血量平均300 mL.术中未出现不能控制的并发症,术后平均住院8.6 d.结论:腔镜超声引导下以肝段为本的解剖性栽肝切除术更加符合肿瘤根治原则,值得在肝脏外科推广应用.     

经腹全肝血流阻断肝切除术

1990～1995年我院采用常温下经腹全肝血流阻断的方法完成各类肝切除术45例,其中肝细胞癌31例,27例合并肝硬变。肝母细胞瘤6例,巨大肝血管瘤4例,肝腺癌4例。男性34例,女性11例,年龄:1～70岁,平均48岁。手术方式:右三叶切除2例,左三叶切除2例,右半肝切除21例,左半肝切除8例,肝段切除9例,非解剖性局部切除5例。术中平均全肝血流阻断     

精准肝脏外科时代肝癌多学科治疗

<正>肝切除是目前肝细胞癌最主要的治疗手段之一,历经盲目肝切除、规则性肝叶切除、局部肝切除和解剖性肝段切除等阶段,现已进入精准肝脏外科时代[1]。精准肝切除不仅倡导外科技术的精细准确,而且注重以肝病和肝切除相关的病理和病理生理状态为依据指导术前评估和围手术期处理[2]。理论上讲,精准肝切除在彻底清除肝癌的同时,能够最大限度地保护剩余肝脏,减少肝癌术后转移和复发,但迄今尚缺乏高级别的循证医学证据说明精准与传统治疗方式对肝癌     

Belghiti悬挂法在解剖性半肝切除术中的应用

目的: 探讨Belghiti悬挂法在解剖性半肝切除术中的应用价值.方法: Belghiti肝脏悬挂法成功行半肝切除术患者28例, 并与未采用Belghiti肝脏悬挂法完成的解剖性半肝切除术患者22例比较, 分析评价患者术中相关指标和术后并发症.结果: 2组患者均无手术死亡, Belghiti悬挂组的术中失血量和输血量均较对照组显著减少(426.36±312.79 mL vs 526.58±251.32 mL;508.13±128.26 mL vs 735.13±216.79 mL, 均P<0.05). 2组的术后肝功能、并发症发生率、住院时间无显著差异.结论: Belghiti悬挂法可进一步提高半肝切除的安全性, 减少出血, 并且可在先不游离肝脏的情况下完成半肝切除, 更符合肿瘤外科的基本原则.     

规则肝切除术治疗复杂肝内胆管结石的临床体会

目的探讨复杂肝内胆管结石行规则肝切除术的临床效果。方法回顾性分析石首市人民医院2013年1-12月98例复杂肝内胆管结石患者的临床资料,分析患者肝内胆管结石分布特点、临床表现、手术范围、手术时间、并发症及手术治疗效果。结果98例患者均完成规则肝切除术,37例行胆总管切开取石T管引流加肝段切除,6例行左肝外叶切除,1例行左半肝切除,7例行右半肝单独肝段及联合肝段切除,45例行左右半肝肝段联合切除,2例行肝门部胆管整形后胆肠盆式吻合。围手术期未出现患者死亡,手术时间(65.0±5.0)min;术中出血量(83.0±6.2)ml,术后无结石残留患者。5例(5.1%)患者出现并发症,其中3例患者并发胆漏,2例患者并发肝脏创面渗血。3例患者术后病理检查发现肝内胆管癌。随访5年,11例(11.2%)患者术后结石复发。结论规则肝切除术治疗复杂肝内胆管结石患者安全且疗效较好,并发症少,结石复发率低,值得临床推广应用。     

Recurrence of autoimmune liver diseases after liver transplantation

Liver transplantation(LT) is the most effective treatment modality for end stage liver disease caused by many etiologies including autoimmune processes. That said, the need for transplantation for autoimmune hepatitis(AIH) and primary biliary cirrhosis(PBC), but not for primary sclerosing cholangitis(PSC), has decreased over the years due to the availability of effective medical treatment. Autoimmune liver diseases have superior transplant outcomes than those of other etiologies. While AIH and PBC can recur after LT, recurrence is of limited clinical significance in most, but not all cases. Recurrent PSC, however, often progresses over years to a stage requiring re-transplantation. The exact incidence and the predisposing factors of disease recurrence remain debated. Better understanding of the pathogenesis and the risk factors of recurrent autoimmune liver diseases is required to develop preventive measures. In this review, we discuss the current knowledge of incidence, diagnosis, risk factors, clinical course, and treatment of recurrent autoimmune liver disease(AIH, PBC, PSC) following LT.     

Role of liver transplantation in acute liver failure

Orthotopic liver transplantation is employed as salvage therapy for individuals who are unable to recover from acute liver failure. Prognostic models are helpful but not entirely accurate in predicting those who will eventually require liver transplantation. There are specific criteria for United Network for Organ Sharing category 1a (urgent) listing of these patients. Unfortunately, clinical deterioration develops rapidly and many require removal from the waiting list prior to transplantation. With advances in critical care management and surgical technique, 1-year post-transplant survival rates have improved to 60 to 80%. Alternatives to conventional orthotopic liver transplantation include living donor liver transplantation, ABO-incompatible grafts, and auxiliary liver transplantation. There are many ethical and psychosocial issues inherent to transplanting these sick patients due to the urgent nature of acute liver failure. Fortunately, the long-term survival and quality of life in these transplant recipients is good.     

Results of liver resection for primary liver cancer

At the Zhong Shan Hospital, Shanghai Medical University, between 1960 and 1991, liver resection was performed in 896 patients with primary liver cancer; local resection was performed in 552 patients (61.6%), left lateral segmentectomy in 114 (12.7%), left hemihepatectomy in 157 (17.5%), extended left hemihepatectomy in 19 (2.1%), right hemihepatectomy in 50 (5.6%), and extended right hemihepatectomy in 4 (0.4%). The overall operative mortality was 4.6%, but it was 22.0% in 1960–1970, 7.0% in 1971–1980, and 2.8% in 1981–1991. Encouraging changes in the prognostic pattern were observed when comparing the data for 1960–1970 (n=59), 1971–1980 (n=115), and 1981–1991 (n=722): the 5-year survival rate was 14.0%, 36.0%, and 50.8%, respectively, and the 10-year survival rate was 12.3%, 25.5%, and 40.8%, respectively. Significant differences in survival patterns were noted when these were analyzed on the basis of tumor size (≤5 vs >5cm), curative resection, tumor number, tumor capsule, and tumor emboli in the portal vein. In the entire series, 135 patients have survived for more than 5 years after resection, and 40 patients for more than 10 years after resection. One patient has survived for 32 years and is still alive, free of disease. The approaches to decreasing operative mortality and prolonging survival rate are discussed.     

Implication of normal liver enzymes in liver disease

Summary.  Chronic liver disease is usually asymptomatic until its late stages and also significant hepatic necroinflammation and fibrosis may be present in persistently normal ALT levels HBV, HCV carriers or similarly, in patients with nonalcoholic fatty liver disease. Given the large number of persons in the general population which may harbor a clinically significant liver disease behind the screen of normal alanine aminotransferase, more attention should be devoted to future research for alternative noninvasive markers of liver damage.