巨大肝癌的手术治疗(附106例报告)

目的 探讨巨大肝癌手术切除的可能性及手术方法。方法 106例巨大肝癌，肿瘤直径10—25cm，平均直径13cm。伴有肝硬化者占92．5％。全部病例均经手术治疗，采用右肋缘下或双侧肋缘切口，常温下间歇性阻断肝门，阻断时间15—20min，最多阻断2次。根据肿瘤部位及手术方式的不同，对第一、二、三肝门进行解剖。结果 全组无手术死亡，右侧胸腔积液32例，膈下感染2例，上消化道出血2例。经对症处理后均痊愈。随访1～2年，1年生存率75％(79／106)。结论 对于单发的巨大肝癌，应采用手术切除为主的综合治疗，巨大肝癌的切除是安全、可行的。     

原发性肝癌的局部切除治疗

局部切除治疗原发性肝癌36例，肝癌直径＞5．0cm30例，小于等于5．0cm6例，中位直径6．8cm，36例中右肝癌15例，中肝癌2例，左肝癌19例，行肝癌局部切除术后无肝功能衰竭发生，无手术死亡，1，3，5年生存率各72．3％，42．4％，30．3％，本资料表明局部切除治疗原发性肝癌手术并发症少，长期生存率满意，对肝硬化肝癌尤其适用。     

小肝癌早期诊断及外科治疗

1958．1～1995.12月经病理证实原发性肝癌共2639例。小肝癌(≤5cm，695例)与大肝癌(>5cm．1944例)统计比较表明，小肝癌组手术切除率高(为92.8％比61.8％)、手术死亡率低(为2．0％比86％)、肿瘤单结节者多(为783％比55.2％)、肿瘤包膜完整者多(为72．6％比37.0％）、门静脉自癌栓者少(为28．2％比45．0％)、生存率高(5年为61．3％比33.6％、10年为45.7％比261％)。小肝癌怍局部切除(545例)与肝叶切除(100例)．生存率无显著性差异（P>0.05)。结果表明．手术切除是小肝癌首选治疗方法．对合并肝硬变病人作局部切除替代肝叶切除是提高切除率和降低手术死亡率的关键。文中对小肝癌早期诊断及外科治疗经验作了讨论。     

肝切除治疗巨大肝癌的体会

肝切除治疗直径１０ｃｍ以上的巨大肝癌３８例．切除的标本湿重７５０～５０００ｇ．平均１０５０ｇ。全组无手术死亡。术后１、２、３ａ生存率分别为６３％、１０．５％和５．３％．延长患者生存时间的效果是明显的．并对肝切除治疗巨大肝癌的可行性及有关问题进行了讨论。     

小肝癌外科治疗远期结果

1958年1月至1993年12月经病理证实原发性肝癌共2030例，比较小肝癌（小于等于5cm,n=514)与大肝癌（＞5cm,n=1516)资料表明，小肝癌组手术切除率高（92．2％对49．1％），手术死亡率低（1．7％对5．2％），肿瘤单结节多（78．0％对53．4％），肿瘤包膜完整多（74．5％对35．8％），生存率高（5a,63.8%对36．6，10a:46.8%对28．5％），小肝癌作局部切除（n=440)。与肝叶切除（n=34)，生存率无显著性差异（P＞0．05），小肝癌切除后复发和转移作再手术共70例，比较1958－1970年（n=4),1971-1982年（n=66),1983-1993年n=444)三阶段小肝癌，疗效有所提高；5年生存率分别为25．0％，47．0％，64．6％，10年生存率分别为25．0％，30．3％，47．0％，小肝癌切除后生存5年以上共122例，生存0年以上24例，本文表明，手术除切是小肝癌首先治疗，对合并肝硬化病人作局部切除替代肝叶切除是提高切除率和降低手术死亡率的关键，对亚临床复发或转移，再手术是进一步提高疗效的途径。     

肝切除治疗单发巨大肝细胞癌疗效分析

目的探讨肝切除治疗单发巨大肝细胞癌的疗效及预后相关因素。方法回顾分析946例肝切除治疗单发大肝癌临床及随访资料。对279例肿瘤直径>10 cm的巨大肝癌与667例肿瘤直径大于5 cm小于等于10 cm的大肝癌中17项相关的临床病理因素进行单因素及多因素分析,比较两组生存率的差异,分析预后相关因素。结果巨大肝癌组肝切除术后的3年及5年生存率分别为29.3%及23.1%,明显低于大肝癌组的52.4%及41.9%。临床病理因素中巨大肝癌组术前γ谷氨酰转肽酶(γ-GT)水平、血清乙肝表面抗原(HBsAg)阳性率及肉眼癌栓的发生率高于大肝癌组(P<0.01)。多因素分析提示术前γ-GT水平及门静脉癌栓是巨大肝癌肝切除术后独立的预后相关因素。根据有无肉眼癌栓分组,巨大肝癌组中无癌栓组3年及5年的生存率为37.5%及29.3%,而有癌栓组3年及5年生存率只有6.9%及0%。结论肝切除是治疗单发巨大肝癌的有效手段,对无门静脉肉眼癌栓的病例,远期疗效更好。     

原发性肝癌并门静脉癌栓的治疗选择

目的 探讨肝癌并门静脉癌栓(PVTT)患者综合治疗的疗效。方法 5年来共收治176例肝癌合并PVTT的患者，手术组32例，行规则或不规则肝切术并术中门静脉取癌栓，门静脉或肝动脉置泵术；介入组144例，经肝动脉栓塞化学药物治疗。结果 手术组0．5，1，2年生存率分别为94％，50％，19％，术后常见并发症：暂时性肝功能不全44％(14／32)，右胸腔积液31％(10／32)，上消化道出血28％(9／32)等，无手术死亡。介入组0．5，1年生存率为35％，0。在介入组中，肝功能分级为I的患者34例在患者年龄，癌灶体积大小与手术组无明显差异，但其0．5，1年生存率(59％，0)显著低于手术组(94％，50％)。结论 PVTT患者能耐受手术者应积极肝癌切除并术中取栓治疗，术后经门静脉，肝动脉泵化疗或栓塞化疗能延长部分病人的生命，手术治疗优与介入治疗。     

巨大肝癌一期手术切除的临床分析

目的 探讨巨大肝癌一期手术切除的可能性。方法 1996年6月～2001年8月,共收治巨大肝癌63例(直径>10 cm),其中 27例施行了一期手术切除,手术切除率为 42.9％。结果 无1例手术死亡。术后并发症:胸腔积液 18例,伤口因脂肪液化而裂开4例,术后随访2～52个月,6个月累计生存率为96％,1年累计生存率为51.8％。8例生存期>2年,3例>4年。结论 巨大肝癌只要有完整的包膜或边界清楚,无转移迹象,能够耐受切除大手术者,均应考虑首选一期切除手术,这亦将有助于提高根治率。     

肝动脉、门静脉双管灌注化疗联合碘油乙醇注射治疗不能切除的原发性肝癌

目的：探讨肝动脉,门静脉双管灌注化疗联合碘油乙醇注射治疗不能手术切除的原发性肝癌的临床疗效。方法：138例经病理证实的不能手术切除的中晚期原发性肝癌患者,分为2组进行治疗：（1）经皮下埋植式药泵经肝动脉和门静脉双插管灌注化疗组（AVPC组,80例）;（2）经皮下埋植式药泵经肝动脉和门静脉双插管灌注化疗联合碘油乙醇注射治疗组（联合治疗组,58例）。结果：治疗后获得二期手术切除率为AVPC组2．5％,。联合治疗组12．1％（P＜0．05）,治疗后0．5,1,2年生存率AVPC组分别为56．3％,45．0％,21．2％。联合治疗线分别为81．0％,61．2％,39．6％,两组间0．1,1,2年生存率均有显著性差异（P＜0．05）,两组并发症率无明显差异,结论：联合治疗是治疗不能手术切除的原发性肝癌的有效方法,效果优于单纯双管灌注化疗。     

大肝癌个体化外科综合治疗应重视的关键问题

大肝癌指肿瘤直径>5 cm、≤10 cm,而>10 cm的则为巨大肝癌。按巴塞罗那分期标准这种大肝癌已进入中、晚期,不推荐手术治疗。然而,上海东方肝胆外科医院和武汉同济医院的临床实践证明,有些大肝癌病人经手术切除治疗,可获得很好的临床效果。我院治疗的2012例大肝癌回顾性分析显示,手术切除大肝癌的1、3和5年生存率分别为71.2%、58.8%和38.7%,疗效明显优于其他治疗方法。显然,巴塞罗那肝癌分期标准及最佳推荐治疗方案并     

肝癌并门静脉癌栓的外科治疗

目的:探讨术中连续门静脉灌注化疗治疗原发性肝癌并门静脉癌栓的治疗效果。方法:将38例肝癌并门静脉癌栓患者随机分为治疗组19例和对照组19例，治疗组术中实施连续门静脉灌注化疗+肝癌切除+癌栓取除术，对照组术中仅行肝癌切除+癌栓取除术。术后两组均行门静脉和/或肝动脉置管化疗。结果:A组与B组术后7 d和30 d的AFP阴性率间明显高于B组(P>0.05)，A组1，3年复发率显著低于B组(P<0.05)，1，3年生存率明显高于B组(P<0.05)。结论:术中连续门静脉灌注化疗+肝癌切除+癌栓取出术+术后门静脉和/或肝动脉置管化疗是治疗肝癌伴门静脉癌栓的一种效果较满意的方法。     

经皮射频消融术与腹腔镜肝切除术治疗原发性小肝癌的疗效及预后比较

目的:比较经皮射频消融术与腹腔镜肝切除术治疗原发性小肝癌的疗效及预后。方法:回顾性分析2012年1月—2014年12月间收治的140例原发性小肝癌患者资料,其中80例行射频消融术(消融组),60例行腹腔镜肝切除术(腔镜组)。比较两组患者术后血清肝功能指标与肿瘤标志物水平的变化、并发症发生率、根治率、复发率及生存率。结果:术前两组的基线资料、肝功能指标及肿瘤标志物水平均无统计学差异(均P0.05)。术后消融组肝功能指标先升后降,腔镜组则呈持续降低,消融组术后短期内丙氨酸氨基转移酶、天门冬氨酸氨基转移酶水平均明显高于腔镜组(均P0.05);两组术后肿瘤标志物水平均逐渐降低,两组间差异无统计学意义(均P0.05)。消融组术后并发症发生率明显低于腔镜组(3.75%vs. 20.00%,P=0.002)。两组根治率、复发率以及1、2、3年总生存率和无瘤生存率均无统计学差异(均P0.05)。结论:两种手术方式对原发性小肝癌的疗效及预后无统计学差异,射频消融术后并发症较少,但对短期肝功能存在一定损害。     

围手术期肝动脉栓塞化疗预防大肝癌术后复发的作用初探

目的：探讨围手术期肝动脉栓塞化疗（TACE）预防大肝癌切除术后复发的作用。方法：大肝癌切除术前4-8周（A组,n=30）、术后2-4周（B组,n=45)、术后4-6周（C组,n=30)实施TACE,同期未行TACE的大肝癌切除患者作为对照（D组,n=48)。结果：无严重手术并发症或TACE相关并发症;术后1年复发率：4组间差异显著（P＜0.025),其中B组和A组、B组和D组差异显著;6个月复发率：4组间差异显著（P＜0.005),其中B组和A组、B组和D组、C组和A组差异显著。结论：大肝癌切除术前TACE可能增加术后早期复发,不宜进行;术后2-4周早期实施TACE是预防大肝癌切除术后复发安全有效的方法。     

规则性或非规则性肝癌切除术治疗单发小肝癌的预后分析

目的分析规则性或非规则性肝癌切除术治疗单发小肝癌的预后情况。方法回顾性分析2009年2月至2014年2月我院诊治的58例单发小肝癌患者临床资料,将实施规则性切除术者纳入对照组(n=28),实施非规则性切除术者纳入观察组(n=30),术后均随访3年,比较两组手术时间、住院时间、术中出血量、切除肿瘤直径、切缘大小,测定两组手术前后血清白蛋白(Alb)、谷丙转氨酶(ALT)、总胆红素(TBIL)、直接胆红素(DBIL)水平,并对比术后1~3年内两组复发率、无瘤生存率、总生存率及并发症发生率。结果观察组手术时间(180.23±1.66)min短于对照组,观察组切除肿瘤直径(6.13±1.32)cm、切缘大小(2.71±0.15)cm小于对照组,两组住院时间、术中出血量比较无显著差异(P0.05);术后观察组血清Alb(32.18±1.06)g/L、ALT(26.29±0.11)μmol/L较对照组显著下降,观察组TBIL(18.29±1.33)μmol/L、DBIL(13.24±1.20)μmol/L明显高于对照组(P0.05);观察组术后1年、2年、3年复发率、无瘤生存率、总生存率与对照组同时点比较均无统计学意义(PO.05);观察组术后并发症发生率6.67%低于对照组28.57%(P0.05)。结论非规则性肝切除术治疗单发小肝癌具有手术时间短、切缘小、并发症发生率低优点,术后肝功能恢复较规则性肝切除术好,术后3年内复发率、无瘤生存率、总生存率与规则性手术比较无显著差异,值得在临床推广实践。     

Predictors of Long-Term Disease-Free Survival After Resection of Hepatocellular Carcinoma: Two Decades of Experience at Chang Gung Memorial Hospital

Background: Hepatocellular carcinoma (HCC) is a common disease in Taiwan. A high incidence of recurrence after hepatectomy is the most important cause of unsatisfactory results after resection of HCC. This study aimed to determine the clinicopathologic factors for predicting survival >5 years without recurrence in HCC patients treated with hepatectomy.Methods: The clinical features of 46 patients with surgically resected HCC who survived >5 years without recurrence (group A) were reviewed. Also, comparison was made with the clinical features and factors influencing the outcome of 1046 cases of resected HCC who survived <5 years both with and without recurrence and for >5 years with recurrence (group B).Results: Of 1092 cases of surgically resected HCC, 46 (4.5%) survived >5 years without recurrence. Univariate analysis revealed that absence of vascular invasion, satellite lesions, low histological grading of HCC, a lower rate of underlying liver cirrhosis, wider resection margins, and an uneventful postoperative course were frequent in group A patients compared with group B patients. Moreover, multivariate stepwise logistic regression analysis identified an absence of satellite lesions and an uneventful postoperative course as the two main independently significant predictors of HCC patients undergoing hepatectomy with long-term disease-free survival. The 1-, 3-, 5-, and 10-year survival rates of group A patients were 100%, 100%, 100%, and 84.1%, whereas those of group B patients were 73.5%, 47.9%, 29.0%, and 21.2%, respectively.Conclusions: An absence of satellite lesions and an uneventful postoperative course are the two main independent predictors for long-term disease-free survival in HCC patients undergoing hepatic resection.     

原发性肝癌外科手术过程无血切肝技术的应用

目的探讨原发性肝癌手术过程中无血切肝技术的应用及手术中失血量与预后的关系。方法回顾性统计分析1380例原发性肝癌手术切除病人的临床资料，再按照失血量分为4组，研究各组的输血量、术后并发症发生率、术后1周肝功能Child-Pugn分级、术后住院天数、术后长期存活率。结果手术过程输血量随出血量的增加而增加，各组间存在统计学差异（P〈0．01）；术后并发症的发生在出血量〉800ml时显著上升；手术后1周的肝功能（Child-Pugn评分）A级的在出血量少的前两组分别为93．7％和88．6％，而出血800～1200ml组为72．6o,4，出血〉1200ml组低至57．9％；肝功能分级组间差异非常显著（P〈0．01）；手术后住院天数随出血量增加，手术后恢复时间也增长；病人长期存活率出血量〉800ml组长期存活率显著低于出血量少组（P〈0．01）。结论无血切肝技术是控制手术过程中失血的有效方法，出血量的有效控制一定程度上预示手术后平稳恢复、长期生存。     

Clinicopathologic features and postoperative prognosis of multicentric small hepatocellular carcinoma

BACKGROUND: Assessment of clinicopathologic characteristics and postoperative prognoses for patients with multicentric hepatocellular carcinoma (HCC) is important to determine not only a need to operate, but also an appropriate treatment after hepatic resection. STUDY DESIGN: Between May 1990 and April 1998, among 116 patients with an initial hepatectomy for HCC measuring 3 cm or less in maximum diameter, 34 patients had multicentric HCC (MC group), and 82 patients had single nodular HCC (SN group). To clarify the clinicopathologic features of patients in the MC group versus the SN group, we compared both the clinicopathologic parameters and the postoperative prognosis after curative hepatectomy between the two groups. RESULTS: The percentages of patients positive for hepatitis B surface antigen and hepatitis C virus antibody were not significantly different between the two groups. No differences were noted in pathologic characteristics of the main tumor or tumor markers. On the other hand, in the MC group, the percentage of patients evaluated in a Child's classification as either B or C was significantly higher (p < 0.05) than that of patients in the SN group, indicating that patients with multicentric HCC have a poor hepatic functional reserve. Both survival and disease-free survival of patients in the MC group who underwent a curative hepatectomy did not differ statistically from those in the SN group. CONCLUSIONS: Our results indicate that hepatic resection is useful, even for patients with multicentric HCC, if a curative hepatectomy can be performed and liver function can be saved, despite their poor hepatic functional reserve.     

Efficacy of postoperative transarterial chemoembolization and portal vein chemotherapy for patients with hepatocellular carcinoma complicated by portal vein tumor thrombosis--a randomized study

OBJECTIVES: The aim of this single, randomized study was to explore the efficacy of postoperative transarterial chemoembolization (TACE) and portal vein chemotherapy (PVC) for patients with hepatocellular carcinoma (HCC) complicated by portal vein tumor thrombosis (PVTT) and to evaluate prognostic factors. METHODS: The study cohort consisted of 112 patients with HCC and PVTT randomly divided into three groups: Group A (37 patients), operation only; Group B (35 patients), operation plus TACE; Group C (40 patients), operation plus TACE and PVC. Disease-free survival rates and prognostic factors were analyzed. RESULTS: Most of the side effects and complications were related to the operation, catheters, and local chemotherapy and included liver decompensation (15.0%), catheter obstruction (11.6%), and nausea and loss of appetite (22.1%). The disease-free survival curve was significantly different among the three groups, as estimated by the Kaplan-Meier method (both P < 0.05). Group C showed a significantly higher disease-free survival rate than Group A (P < 0.05), but no statistical differences were found between group A and group B, and group B and group C (both P > 0.05). Tumor size, tumor number, PVTT location, and treatment modalities were independent prognostic factors (P < 0.05). CONCLUSION: Postoperative TACE combined with PVC may benefit the survival of patients with HCC complicated by PVTT in the short-term (less than 60 months), but long-term efficacy is not yet certain and needs to be confirmed by further studies.     

Laparoscopic hepatectomy for hepatocellular carcinoma

BACKGROUND: No reports exist on the role of laparoscopic hepatectomy in the short- and long-term outcomes of patients with hepatocellular carcinoma (HCC). We present our results from using laparoscopic hepatectomy for HCC and discuss the importance of this procedure. METHODS: To investigate the role of laparoscopic hepatectomy in the short- and long-term outcomes, 17 patients with HCC who underwent laparoscopic hepatectomy (laparoscopic hepatectomy group) were compared with 38 patients who underwent conventional open hepatectomy (open hepatectomy group) during the same period. RESULTS: No differences in operation time, blood loss, rate of blood transfusion, or incidence of postoperative complications were found between the two groups. The postoperative hospital stay for the laparoscopic hepatectomy group was significantly shorter than for the open hepatectomy group. With long-term prognosis, no difference was found in survival rate and disease-free survival rate between the two groups. No recurrence was found in the stump of the remaining liver after laparoscopic hepatectomy. CONCLUSIONS: Laparoscopic hepatectomy has resulted in a better short-term outcome after surgery than conventional open hepatectomy. The long-term prognosis in the laparoscopic hepatectomy group was similar to that in the open hepatectomy group. Therefore, laparoscopic hepatectomy can be a new alternative for treatment of cirrhotic patients with HCC when patients are strictly selected.     

Efficacy of Postoperative Transarterial Chemoembolization and Portal Vein Chemotherapy for Patients with Hepatocellular Carcinoma Complicated by Portal Vein Tumor Thrombosis—a Randomized Study

Objectives The aim of this single, randomized study was to explore the efficacy of postoperative transarterial chemoembolization (TACE) and portal vein chemotherapy (PVC) for patients with hepatocellular carcinoma (HCC) complicated by portal vein tumor thrombosis (PVTT) and to evaluate prognostic factors. Methods The study cohort consisted of 112 patients with HCC and PVTT randomly divided into three groups: Group A (37 patients), operation only; Group B (35 patients), operation plus TACE; Group C (40 patients), operation plus TACE and PVC. Disease-free survival rates and prognostic factors were analyzed. Results Most of the side effects and complications were related to the operation, catheters, and local chemotherapy and included liver decompensation (15.0%), catheter obstruction (11.6%), and nausea and loss of appetite (22.1%). The disease-free survival curve was significantly different among the three groups, as estimated by the Kaplan-Meier method (both P < 0.05). Group C showed a significantly higher disease-free survival rate than Group A (P < 0.05), but no statistical differences were found between group A and group B, and group B and group C (both P > 0.05). Tumor size, tumor number, PVTT location, and treatment modalities were independent prognostic factors (P < 0.05). Conclusion Postoperative TACE combined with PVC may benefit the survival of patients with HCC complicated by PVTT in the short-term (less than 60 months), but long-term efficacy is not yet certain and needs to be confirmed by further studies.