原发性肝癌致阻塞性黄疸的手术治疗体会

目的探讨外科手术治疗原发性肝癌致阻塞性黄疸的方法及疗效。方法自1991年1月至2001年12月期间我院对17例原发性肝癌致阻塞性黄疸的患者进行外科手术治疗，其中行肝叶切除及胆总管切开取癌栓者14例，行同种异体原位肝移植术3例。结果患者平均生存时间为8个月，最长24个月。结论外科治疗原发性肝癌致阻塞性黄疸明显改善了患者生活质量，延长了生存时间。     

原发性肝癌伴胆管癌栓致阻塞性黄疸的外科治疗

目的探讨原发性肝癌伴胆管癌栓致阻塞性黄疸的外科手术治疗及其治疗效果。方法回顾性对15例原发性肝癌伴胆管癌栓致阻塞性黄疸行外科手术治疗的总结和分析。结果行左半肝切除 胆总管切开取癌栓术5例,行肿瘤切除 胆总管切开取癌栓术7例,行胆总管切开取癌栓 肝总动脉结扎3例,术后随访2年,平均生存时间为14.5个月,最长存活23个月。结论外科治疗明显提高了患者生活质量,延长了生存时间。     

TACE联合PEI治疗原发性肝癌血液循环性肝癌细胞的变化及意义

目的：探讨联合经肝动脉化疗栓塞术(TACE)及B超引导下肿瘤局部无水酒精注射术(PEI),治疗原发性肝癌周围静脉血液循环性肝癌细胞的变化及其意义.方法:应用巢式RT-PCR检测12例原发性肝癌患者血液循环性肝癌细胞,并经TACE及PEI联合治疗,观察其血液循环性肝癌细胞的变化.结果:血液循环性肝癌细胞表达阳性的5例原发性肝癌患者(41.67%),经TACE及PEI联合治疗后,其血液循环性肝癌细胞均转为阴性(100%,P<0.01).结论:联合TACE及PEI治疗原发性肝癌可有效地杀灭血液中播散的循环性肝癌细胞,可预防肝癌的复发和转移.     

原发性肝癌伴阻塞性黄疸的诊断及根治性手术治疗

目的探讨原发性肝癌致阻塞性黄疸的诊断和外科根治性手术治疗的方法及疗效。方法自1991年1月至2001年12月间对17例原发性肝癌致阻塞性黄疸的患者进行了诊断和外科根治性手术治疗。其中行肝叶切除及胆总管切开取癌栓者14例,行同种异体原位肝移植术3例。结果患者平均生存时间为8个月．最长存活时间为24个月。结论明确的诊断和根治性手术治疗是治疗伴阻塞性黄疸的原发性肝癌关键。     

胆管癌栓内镜治疗后阻塞性黄疸原因分析及处理

目的: 探讨HCC合并胆管癌栓内镜治疗后阻塞性黄疸的原因及其处理.方法: 对1999年1月至2003年6月间收治的23例采用内镜介入治疗的HCC合并胆管癌栓的患者进行跟踪随访,对其中18例患者在内镜治疗后加重或再度出现阻塞性黄疸的原因进行回顾性分析.结果: 本组术后黄疸的发生率为78.3%(18/23),原因为胆道出血16.7%(3/18)、胆管癌栓未得到有效清除44.4%(8/18)、肝门部胆管恶性狭窄27.8%(5/18)、胆管癌栓合并肝门部胆管恶性狭窄11.1%(2/18),内置管堵塞移位50%(9/18).结论: 胆管癌栓内镜治疗后阻塞性黄疸原因以内置管堵塞移位、胆管癌栓未得到有效清除和(或)合并肝门部胆管恶性狭窄最为常见,内镜治疗后早期阻塞性黄疸加重为胆道出血所至,及时对应处理可有效解除症状.     

胆囊切除术后胆道并发症的内镜处理

目的：探讨内镜在处理胆囊切除术后胆道并发症中的作用.方法:自1997年1月至2000年11月间,对胆囊切除术后出现腹痛和黄疸患者行ERCP,胆囊切除术后行ERCP的平均时间为95天.对明确为胆道并发症者,作以下治疗:①对于胆道残余结石,行EST或EPBD后取石.②对于胆管部分狭窄者,用内镜胆道扩张和内支架治疗.③对于胆总管完全横断者,行ERBD后继以外科手术.④对于胆漏者,行EST和ENBD治疗后辅以经皮腹腔引流.结果:224例胆道并发症者中,胆道残余结石169例(占75.4%),165例结石排出.胆总管部分狭窄37例(占16.5%),随访1年,25例均取得满意效果.胆总管完全横断12例(占5.4%),7例行ERBD,待黄疸减退后全部行外科手术.胆漏6例(占2.7%),5例避免再次外科手术,1例内镜治疗后2天症状无减轻而接受手术治疗.结论:胆囊切除术后临床上怀疑有胆道并发症,应尽早行ERCP检查.内镜对胆道残余结石和小的胆漏的疗效确切,对胆道部分狭窄的患者,首选内镜内支架治疗.     

原发性肝癌切除术后发生肝功能代偿不全的临床研究

目的: 探讨了解肝部分切除术后出现肝功能不全的可能原因. 方法: 将63例原发性肝癌患者分成3组,比较分析各组的手术后生存时间与生存率、术后复发率、术前、术后的主要肝功能指标,术后一年内出现肝功能不全的原因与频率,以及死亡患者的死亡原因与时间等. 结果: 平均随访时间为(25±21.3)个月,各组生存率无显著性差异,总复发率为56%(35/63),平均复发时间为17个月;术后死于复发癌的时间为(22±12.3)个月,死于肝功能不全的时间为(4.8±3.7)个月,术前肝功能储备差者,术后易发生代偿不全,术后早期死亡者大多由肝功能不全所致. 结论: 对原发性肝癌病人行肝部分切除术时,要充分了解肝功能储备,术后早期积极给予保肝治疗.     

皮下植泵灌注药物预防原发性肝癌术后复发

目的: 对比分析皮下植泵灌注化疗药物降低原发性肝癌术后肝内复发率,提高生存率的效果.方法: 95例原发性肝癌切除术后,同时皮下植泵,泵导管植入肝动脉、门静脉,术后定期通过药泵灌注化疗药物至肝脏(A组);行单纯肝癌切除术72例(B组);肝癌切除术加静脉化疗65例(C组).随访3年,比较3组的术后复发率和生存率.结果: 原发性肝癌术后皮下植泵组与对照组比较,术后3年的肝内复发率显著降低(P<0.01),生存率显著提高(P<0.01).结论: 皮下植泵定期灌注化疗是防止原发性肝癌术后肝内复发,提高生存率的有效方法.     

胆囊切除与Mirizzi综合征

目的 探讨胆囊切除术中Mirizzi综合征的诊断、外科治疗,以及预防胆管损伤的经验.方法 :对1800例胆囊切除术中30例经手术证实的Mirizzi综合征进行回顾分析.结果 :30例Mirizzi综合征患者均行外科手术治疗.包括:胆囊切除术、胆囊切除及胆管瘘口修补术、胆囊切除及肝总管Roux-Y吻合术等.术后均未出现胆瘘及胆道狭窄.结论 :Mir-izzi综合征术前诊断困难,应根椐其病理分型行相应的外科手术治疗.     

肝癌肝移植7例体会

目的 探讨原位肝移植在原发性肝癌治疗中的意义. 方法 回顾性分析2001年3月至2004年12月肝癌肝移植7例的临床病例资料. 结果 7例手术全部成功,无围手术期死亡.现4例无瘤生存.1例死于肝癌复发肺转移,2例死于乙肝复发,其中1例存活了42个月. 结论 肝移植术治疗肝癌仍应严格掌握适应证.     

Hepatocellular carcinoma presenting with obstructive jaundice

BACKGROUND: Jaundice occurs in 5-44% of patients with hepatocellular carcinoma (HCC). It is an important clinical presentation as the different aetiological causes of jaundice in HCC determine the therapeutic approach and the prognosis. This article aims to review the classification, management and prognosis of patients with jaundice associated with HCC. METHODS: A Medline search was undertaken to identify articles using the key words 'hepatocellular carcinoma', 'jaundice' and 'tumour thrombus'. Additional articles were identified by a manual search of the references from the key articles. RESULTS: Patients with jaundice due to hepatic parenchymal insufficiency (hepatocellular type) have a very dismal prognosis. For patients with biliary obstruction due to HCC (icteric type), the reported 1-, 3- and 5-year survival rates after curative resection were 57.1-100%, 20-47% and 6.7-45%, respectively. The mean survival after palliative biliary drainage alone was less than 6 months but when biliary drainage was combined with other palliative treatment, the mean survival could be up to 1 year. CONCLUSIONS: It is important to differentiate the hepatocellular type from the icteric type of HCC. For patients with the icteric type of HCC, curative liver resection can achieve a survival comparable to that in patients without jaundice. For patients with unresectable icteric type of HCC, treatment can provide improvement in patient's quality of life and survival.     

Multidisciplinary approach to palliation of obstructive jaundice caused by a central hepatocellular carcinoma

BACKGROUND/AIMS: Obstructive jaundice due to intraductal tumour growth is a rare symptom in association with hepatocellular carcinoma (HCC). METHODS: We report a 65-year-old white male who was admitted to our department with a 2-week history of progressive jaundice. At laparotomy, the liver showed advanced cirrhosis due to long-standing biliary obstruction. Cholangiography confirmed total obstruction of the main bifurcation of the hepatic duct by intraductal tumour growth. Combination treatment with surgical segment III drainage, transcatheter arterial embolization and radioembolization with yttrium-90 resin particles and endoscopic stenting was performed. This form of treatment has never been reported before. RESULTS: With these combined procedures, relief of jaundice and a survival time of 32 months could be achieved. CONCLUSION: The combination of palliative methods may relieve jaundice, ensure a good quality of life and possibly prolong survival in patients with mechanical tumour obstruction of the biliary tree by HCC.     

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目的 探讨不同类型原发性肝癌伴梗阻性黄疸的原因及其治疗方法。方法 分析原发性肝癌伴梗阻性黄疸的病人15例。其中肝癌引起胆管癌栓7例。肝癌压迫或侵犯肝门部胆管8例。其中手术10例，清除肝癌原发灶，解除胆管梗阻，非手术5例，先行减轻黄疸处理，然后行TAE，PEI等综合治疗。结果 手术切除病灶，延长生存期，而非手术处理组也明显改善症状，疗效显著，随访1-24个月（平均9个月）3例死亡，12例仍存活。结论 临床上有必要对原发性肝癌伴梗阻性黄疸进行积极治疗，以改善生活质量，延长生存期。     

Management of hepatocellular carcinoma presenting as obstructive jaundice

Eleven (3%) of 340 patients with hepatocellular carcinoma (HCC) presented with obstructive jaundice. The tumor extensively infiltrated the major bile ducts in eight patients. Jaundice was relieved by endoscopic endoprosthesis in four patients, nasobiliary drainage in two patients, percutaneous transhepatic stenting in one patient, and surgical intubation in one patient. The survival interval of these eight patients (mean +/- SD) was 35 +/- 20 days. Three patients had tumor fragments in the common bile ducts. In two patients, major hepatic resection was done after initial tube decomposition of the biliary system. One patient remained tumor-free on follow-up at 24 months, and the other patient had recurrent tumor detected on follow-up at 17 months after surgery. The tumor was irresectable in the third patient. Multiple surgical and endoscopic procedures kept the bile duct patent for 17 months before the patient died of the disease. Not all patients who present with obstructive jaundice due to HCC are terminally ill. With proper management, good palliation and occasional cure are possible.     

Surgical Treatment for Biliary Carcinoma Arising After Pancreatoduodenectomy

The clinicopathological features and surgical treatment of biliary carcinoma around the major hepatic duct confluence arising after pancreatoduodenectomy (PD) due to initial bile duct carcinoma are described in three patients. Occurrence of biliary carcinoma more than 12 years after initial surgery and a histological finding of cholangiocellular carcinoma mixed with hepatocellular carcinoma suggested metachronous incidence of biliary carcinoma after PD. Extended right hemihepatectomy with complete removal of the residual extrahepatic bile duct and segmental, resection of the jejunal loop were carried out safely without operative death or severe postoperative complications. Two patients died of tumor recurrence 6 months after surgery, and the remaining patient is currently living a normal life without evidence of recurrence 17 months after surgery. These surgical procedures are a therapeutic option in patients with biliary carcinoma around the major hepatic duct confluence arising after PD.     

Surgical Intervention for Obstructive Jaundice Due to Biliary Tumor Thrombus in Hepatocellular Carcinoma

This retrospective study in eight surgically treated patients with obstructive jaundice due to biliary tumor thrombus in a patient with hepatocellular carcinoma (HCC) was performed to evaluate the role of surgical intervention. All biliary tumor thrombi were confirmed preoperatively or intraoperatively. Only two manifested intraluminal biliary obstructions due to a primary tumor that had not been found preoperatively. The operative procedures included hepatectomy with removal of the biliary tumor thrombus (n = 3), hepatectomy combined with extrahepatic bile duct resection (n = 1), thrombectomy through a choledochotomy (n = 3), and piggyback orthotopic liver transplantation (n = 1). The 1- and 3-year survival rates were 62.5% and 37.5%, respectively. Two patients survived more than 5 years. Surgical intervention was effective in patients with obstructive jaundice due to a biliary tumor thrombus in an HCC. Thus surgery for a recurrence can prolong survival, and liver transplantation is a treatment worthy of further investigation.     

肝细胞癌并发梗阻性黄疸的介入治疗

目的评价介入治疗对于肝细胞癌（HCC）并发梗阻性黄疸的疗效。方法对12例HCC伴发梗阻性黄疸接受介入治疗的患者，首先行PTBD，左侧人路3例，右侧2例，双侧人路7例。在PTC显示胆管形态恢复正常后，8例留置内支架（覆膜支架12枚，裸支架2枚）．另4例单纯留置胆道引流管姑息治疗。结果PTBD成功率100％，4例并发胆管内出血。10例行胆管引流术1周后，血清总胆红素下降50％以上，肝功能好转．另2例在引流2周时血清总胆红素下降50％以上。生存时间自首次PTBD时间起3～13个月．平均生存时间6．2个月，6个月生存率41．67％，1年生存率16．67％。留置内支架的病例平均生存时间为6．52个月，仅行引流术而未植入内支架的病例平均生存时间为6．05个月，二者无显著统计学差异（P〉0．05）。7例患者接受经肝动脉化疗栓塞术治疗未发生并发症。结论有效的胆道引流是治疗HCC合并梗阻性黄疸的关键。胆管引流术和胆道内支架留置术都是有效的治疗方法，能够延长生存时间，创造进一步治疗机会。     

Diagnoses and treatments by transcutaneous transhepatic approach in patients with obstructive jaundice

In 298 patients with obstructive jaundice, including 271 (90.9%) with tumoral genesis, endobiliary interventions were performed: transcutaneous transhepatic cholecystectomy--in 76, external cholangiostomy--in 155, external-internal cholangiostomy--in 97, endoprosthesis of biliary ducts (BD)--in 23. Of 155 patients, to whom external drainage of BD was done, recanalization of obstructed portion was performed in 53. Of 102 patients, to whom external drain was adjusted, in 23.1% the complications occurred. Hospital mortality had constituted 22%. The BD perforation was noted in 8 observations. The patients life span, in whom the external-internal BD drainage was done, was 7.8 months, an efficacy of endoprosthesis had constituted 97.3%. The life span of such patients was (9.2 +/- 2.4) months at average.