肝移植治疗原发性肝癌的探讨

目的：探讨原位肝脏移植在原发性肝癌治疗中的意义。方法：回顾分析2000年1月至2001年12月9例原发性肝癌行原位肝移植的临床资料。结果：术后生存大于6个月有6例（66.6％），生存大于12个月有4例（44.4％），平均存活时间11.5个月。与肝癌相关的死亡率为66％。术后复发依次为肝癌复发3例、骨转移2例、盆腔转移1例。结论：严格选择肝癌病人行肝移植；对肝硬化肝癌，肝移植是有效的治疗。     

肝癌肝移植围手术期死亡10例分析

目的 分析肝癌肝移植围手术期死亡的原因,总结肝癌切除术后行肝移植的临床经验。方法 回顾性分析2003年10月至2008年10月中山大学附属第三医院肝移植中心81例肝癌肝移植的临床资料,对其中10例围手术期（≤30d）死亡原因进行分析。 结果 肝癌切除术后病人肝移植总病死率为12.3%（10/81）。首次肝切除术后肝移植病死率为12.7%（9/71）;再次肝癌肝移植病死率为10%（1/10）。补救性肝移植病死率为10%（4/40）,超越补救性肝移植病死率16.1%（5/31）。肺部感染（6例）和术中腹腔大出血（5例）是围手术期的主要死亡原因。手术相关死亡5/10,5例术中腹腔出血量均＞10 000 mL。 结论 肝癌肝移植围手术期病死率仍较高;肺部感染和术中腹腔大出血是围手术期的主要死亡原因。     

肝癌患者在肝移植围手术期施行化疗的临床意义

肝癌患者在肝移植围手术期术前施行经肝动脉栓塞化疗（HACE）可以防治肝移植期间的肿瘤进展，提高肝移植手术成功率；且对较大的肿瘤可起到延缓生长，增加肝移植或肝切除手术机会，提高肝癌患者生存质量，同时延长无病生存期。肝移植术后辅助化疗作为消灭微小转移灶的一种手段已被应用于临床治疗观察，对改善肝癌患者肝移植后的生存率可能有效，亦有可能推迟肿瘤复发。因此，认为辅助化疗是一种安全、可行的治疗方法，但就其治疗效果还有待于大规模、多中心、前瞻性的随机对照研究验证。     

肝癌肝切除术的围手术期治疗

随着科学技术的迅速发展,原发性肝癌(简称肝癌)的各种治疗方法也再不断出现和完善,如多种介入治疗(经导管动脉化疗栓塞、B超引导下经皮无水酒精注射、高温生理盐水注射、微波治疗、多极射频治疗等)、冷冻治疗、激光气化、X线立体定向治疗、适形放疗和肝移植等,由于各种局部治疗和化疗均存在一定的不可靠性和不彻底性,所以迄今多数学者仍主张采用以手术切除为主的各种综合治疗方法,以提高肝癌患者的生存率。然而提高手术切除率和手术切除疗效,降低术后并发症和手术病死率以及术后复发率,除了与医学不断发展和手术技术逐步提高有关外,更重要…     

活体肝移植围手术期处理

目的 总结活体肝移植围手术期处理的经验。方法 对该院2001年1月至2002年12月完成的15例次(13例)活体肝移植围手术期的处理情况进行回顾性分析。结果 所有病例手术均获成功。13例供体术后均顺利康复．除1例在手术后1个月因拔除T管发生胆瘘外．其余均未出现严重并发症;受体生存率为92.3％(12／13)．已健康生存2个月～2年;移植物存活率为86.7％(13／15)。1例成人肝豆状核变性患者于术后72d死于不可逆转的严重排斥反应。术后并发肝动脉血栓形成2例．另1例再次行减体积肝移植．1例再次行全肝移植,均获长期生存;发生严重排斥反应1例,ARDS2例．细菌和(或)病毒感染6例,大量胸腔积液7例．胆瘘1例。结论 围手术期处理是活体肝移植术的关键之一,完善的围手术期处理是肝移植成功的必要条件。     

肝移植围手术期的液体治疗

自从上世纪六十年代Starzl开展的首例肝移植发展至今,其手术技术和各项治疗手段都取得了长足的进展,肝移植对晚期肝病和急性肝功能衰竭的患者是一种非常有效的治疗手段,使众多的患者获得了重生,但各种因素引起的严重的术后并发症影响了患者术后的生活质量和生存率。如何     

肝动脉灌注化疗栓塞治疗原发性中晚期肝癌48例

原发性肝癌(HCC)是我国常见的恶性肿瘤，近年来通过普查发现早期HCC的患者，进行以手术治疗为主的综合治疗，疗效显著提高。肝动脉栓塞灌注化疗(transeatheter arterial chemoembolization,TACE)是目前治疗中晚期HCC的有效手段。我们采用5-FU、丝裂霉素(MMC)、顺铂与碘化油充分混合行TACE治疗，取得良好效果。     

原发性肝癌合并糖尿病病人的围手术期处理

原发性肝癌（简称肝癌）是我国最常见的恶性肿瘤之一，就目前而言，手术切除仍是治疗肝癌的首选方法；然而，临床上可切除肿瘤的病人不足总数的20％［‘’。临床观察发现，肝癌合并糖尿病病人不断增加，糖尿病的存在增加了手术的危险性及手术前后处理的难度。本文总结了我院收治的34例肝癌合并糖尿病病人的围手术期处理的成功经验，提出了处理该类病人的基本原则和方法。现报告如下。1对象和方法1．1对象肝癌合并糖尿病病人34例，男30例，女4例，平均年龄59．97士8．75岁；28例已确诊糖尿病8．71士4．78年，其中20例口服降糖药物治疗，8例使…     

肝移植围手术期的管理

随着肝移植手术例数的逐年增加 ,手术技术日趋成熟 ,肝移植受者围手术期的治疗水平已成为肝移植手术成功的关键。尤其是一些合并肝外重要器官损害的终末期肝病患者 ,如合并肝肾综合征、肝性脑病、肝肺综合征、大量腹水、自发性细菌性腹膜炎等。如何在围手术期对这些并发症进行处理是目前肝移植医师较为关心的方面。一、合并肝肾综合征 (ＨＲＳ)受者围手术期处理ＨＲＳ是终末期肝硬化的常见并发症 ,其发生率约为 60 %～ 80 % ,肝移植是ＨＲＳ最根本的治疗途径。但合并有ＨＲＳ的肝移植受者术后死亡率较一般患者明显升高 ,最主要的死亡原因是…     

肝移植围手术期处理

肝移植手术已成为治疗终末期肝功能衰竭的有效手段，术式已定型。但除了手术技术问题外，围手术期的处理直接影响手术的成败，肝移植早期死亡绝大多数是在术后两周内，所以围手术期处理特别重要。围手术期处理根据肝移植不同的适应证及受者不同的病情有所区别，肝移植手术是特大手术，所以涉及的问题不仅复杂而且面广，限于篇幅，本文仅就肝移植围手术期可能出现的特殊问题作讨论。患者确定准备接受肝移植后，术前除了对患者肝脏还应对其他器官脏器功能和状况进行全面检查和评估，并尽可能调整患者全身一般情况，特别是改善营养状况和呼吸系…     

Bridging Locoregional Therapy for Hepatocellular Carcinoma Prior to Liver Transplantation

Introduction  The impact of locoregional therapy prior to liver transplantation for hepatocellular carcinoma utilizing either transcatheter arterial chemoembolization (TACE), yttrium-90 (⁹⁰Y), radiofrequency ablation (RFA), or resection prior to orthotopic liver transplantation (OLT) is largely unknown. We sought to examine locoregional therapies and their effect on survival compared with transplantation alone. Methods  A retrospective review of a prospectively collected database. Results  123 patients were included. Patients were analyzed in two groups. Group I consisted of 50 patients that received therapy (20 TACE; 16 ⁹⁰Y; 13 RFA, 3 resections). Group II consisted of 73 patients transplanted without therapy. Median list time was 28 days (range 2–260 days ) in group I, and 24 days (range 1–380 days) in group II. Median time from therapy to OLT was 3.8 months (range 9 days to 68 months). Twelve patients (24%) were successfully downstaged (8 TACE, 2 ⁹⁰Y, 2 RFA/resection). Overall 1-, 3-, and 5-year survival were 81%, 74%, and 74%, respectively. Survival was not statistically significantly different between the two groups (P = 0.53). The 12 patients downstaged did not have a significant difference in survival as compared with the patients who received therapy but did not respond or the patients who were transplanted without therapy (P = 0.76). Conclusion  Our report addresses locoregional therapy for hepatocellular carcinoma as a bridge to transplant. There was no statistical difference in overall survival between patients treated and those not treated prior to transplant. We provide further evidence that locoregional therapy is a safe tool for patients on the transplant list, does not impact survival, and can downstage selected patients to allow life-saving liver transplantation.     

原发性肝癌肝移植术后化疗效果的初步观察

目的：探讨原发性肝癌肝移植后化疗的安全性和疗效。方法：回顾性分析22例因原发性肝癌而行肝移植病人的临床资料，以求进一步探明肝癌的肝移植指征，术后化疗时机、化疗方案、化疗的副作用及化疗对近、远期生存率的影响。结果：2002年6月至2003年7月，共有22例原发性肝癌进行肝移植；18例最迟于术后5周内进行第1次全身化疗，累计完成化疗41次；其余4例因各种原因未行化疗，包括1例意外发现的癌和1例小肝癌。8例出现肝功能损害，6例发生白细胞减少，仅2例需重组人集落刺激生长因子治疗。结论：原发性肝癌是肝移植的一个主要适应证；结合术后化疗可延长复发时间，提高生存率；且病人可以安全耐受。     

Transarterial Chemoinfusion for Hepatocellular Carcinoma as Downstaging Therapy and a Bridge toward Liver Transplantation

Favorable outcomes after liver transplantation (LT) in patients with hepatocellular carcinoma (HCC) are well described for patients who fall within defined tumor criteria. The effectiveness of tumor therapies to maintain tumor characteristics within these criteria or to downstage more advanced tumors to fall within these criteria is not well understood. The aim of this study was to examine the response to transcatheter arterial chemoinfusion (TACI) in HCC patients awaiting LT and its efficacy for downstaging or bridging to transplantation. We performed a retrospective study of 248 consecutive TACI cases in 122 HCC patients at a single U.S. medical center. Patients were divided into two groups: those who met the Milan criteria on initial HCC diagnosis (n = 95) and those with more advanced disease (n = 27). With TACI treatment, 87% of the Milan criteria group remained within the Milan criteria and 63% of patients with more advanced disease were successfully downstaged to fall within the Milan criteria. In conclusion, TACI appears to be an effective treatment as a bridge to LT for nearly 90% patients presenting within the Milan criteria and an effective downstaging modality for over half of those whose tumor burden was initially beyond the Milan criteria.     

mTOR抑制剂对肝细胞癌肝移植患者术后生存的影响

目的研究肝细胞癌患者肝移植术后使用mTOR抑制剂为主的免疫抑制剂方案对肿瘤复发及生存期的影响。方法收集我中心2005年1月至2008年12月期间因肝细胞癌行肝移植手术的病例建立数据库。根据患者术后所使用的免疫抑制方案分为两组,单CNIs免疫抑制剂组和含西罗莫司(Rapa)组。按照术前肿瘤所符合的移植标准(米兰标准、UCSF标准以及超标准)对组内病例分层分析,对比各组病例之间在肿瘤复率发、无瘤生存期及总生存期方面的差别。结果对于米兰标准及UCSF标准患者,两组间在肿瘤复发率、无瘤生存期和总生存期方面差别无统计学意义;超标准患者两组无瘤生存率无显著差异,含Rapa组总生存期优于单CNIs组(P0.05)。结论超标准肝癌患者术后使用mTOR抑制剂对于延长患者生存期具有一定作用。     

Liver Transplantation for Hepatocellular Carcinoma: Beyond the Milan Criteria

Liver transplantation represents a cornerstone in the management of early‐stage hepatocellular carcinoma (HCC). Expansion beyond the Milan criteria for liver transplantation (1 lesion ≤ 5 cm, or 2 to 3 lesions each ≤ 3 cm) remains controversial. This review covers several key areas: (1) Recent developments and published data on expanded criteria for deceased donor and live‐donor liver transplantation, with emphasis on criteria that have been applied to preoperative imaging. (2) Independent testing of expanded criteria, where published data are largely limited to the proposed University of California, San Francisco criteria (1 lesion ≤ 6.5 cm, 2–3 lesions each ≤ 4.5 cm with total tumor diameter ≤ 8 cm). (3) Response to loco‐regional therapy and tumor downstaging. (4) The fundamental questions and answers in resolving the controversy over expanded criteria. The key issue pertains to whether acceptable outcome can be achieved on a broader scale beyond single center experience, which appears to support modest expansion beyond the Milan criteria. The foundation of the debate over expanded criteria may rest upon what the transplant community would consider to be the acceptable threshold for patient survival using expanded criteria, without causing significant harm to other transplant candidates without HCC.     

Harm and Benefits of Primary Liver Resection and Salvage Transplantation for Hepatocellular Carcinoma

Primary transplantation offers longer life‐expectancy in comparison to hepatic resection (HR) for hepatocellular carcinoma (HCC) followed by salvage transplantation; however, livers not used for primary transplantation can be reallocated to the remaining waiting‐list patients, thus, the harm caused to resected patients could be balanced, or outweighed, by the benefit obtained from reallocation of livers originating from HCC patients first being resected. A Markov model was developed to investigate this issue based on literature data or estimated from the United Network for Organ Sharing database. Markov model shows that primary transplantation offers longer life‐expectancy in comparison to HR and salvage transplantation if 5‐year posttransplant survival remains higher than 60%. The balance between the harm for resected patients and the benefit for the remaining waiting list depends on (a) the proportion of HCC candidates, (b) the percentage shifted to HR and (c) the median expected time‐to‐transplant. Faced with a low proportion of HCC candidates, the harm caused to resected patients was higher than the benefit that could be obtained for the waiting‐list population from re‐allocation of extra livers. An increased proportion of HCC candidates and/or an increased median time‐to‐transplant could lead to a benefit for waiting‐list patients that outweighs this harm.     

Repeat Liver Resection for Hepatocellular Carcinoma Complicating Primary Biliary Cirrhosis

The incidence of hepatocellular carcinoma (HCC) complicating primary biliary cirrhosis (PBC) is between 0.7% and 16%. Repeat liver resection for recurrent HCC complicating PBC is not usually performed and not published because this approach is not generally applicable due to liver dysfunction. We applied repeat liver resection for these diseases. Three patients were diagnosed with PBC. The first HCC was noted at a mean of 6 years (4–17 years) after diagnosis of PBC. The second HCC occurred at a mean of 2.5 years (0.4–3 years) after the first surgery. All patients were treated with curative resection on first and second surgery. The mean overall survival time after the first liver resection was 46 months. Repeat liver resection for recurrent HCC complicating PBC is an option and may improve the outcome.     

Liver Transplantation for Hepatocellular Carcinoma: Five Steps to Prevent Recurrence

Liver transplantation is the best treatment of patients with unresectable early hepatocellular carcinoma, allowing disease‐free survival rates of 60–80% at 5 years. Despite these good results, some 10% of recipients experience a posttransplant HCC recurrence, which leads to death in almost all patients. Recurrence is either due to the growth of occult metastases or to the engraftment of circulating tumor cells. It can be hypothesized that strategies to decrease the engraftment of circulating tumor cells could decrease the risk of recurrence and, in addition, extend access to transplantation to patients with more advanced HCC. These potential strategies can be schematized into five steps, including (1) selecting recipients with low baseline levels of circulating HCC cells, by adding biological markers (such as alpha fetoprotein or molecular signatures) to the accepted combination of morphological criteria; (2) decreasing the perioperative release of HCC cells, with careful perioperative handling of the tumors; (3) preventing the engraftment of circulating HCC cells by decreasing liver graft ischemia‐reperfusion injury, which has been shown to promote cancer cell engraftment and growth; (4) using anticancer drugs, including mammalian target of rapamycin inhibitors and (5) tuning immunity toward HCC clearance.