晚期肝癌肝脏内外侧支供血及临床意义

目的：探讨肝癌肝脏内、外侧支供血的产生机理。方法：收集TAE治疗资料完整的中晚期肝癌340例，对其血管造影表现进行分析。结果：肝内侧支供血227例：叶间侧支207例，叶内侧支20例；肝外侧支供血78例：胃左肝在动脉共干21例、网膜动脉29例、右IPA13例、左IPA5例、结肠中动脉9例、右肾动脉1例；肝内合并肝外侧支同时供血35例。结论：侧支供血形成的机制与肝脏的解剖及肿瘤生长部位有关。认为了解肿瘤侧支供血的造影表现，对肝癌TAE及手术治疗有重要的临床意义。     

原发性肝癌肝外动脉供血在介入治疗中的意义

目的 探讨原发性肝癌的肝外动脉供血情况,提高肝癌介入治疗的疗效.方法 本组52例原发性肝癌患者行常规腹腔动脉造影及肝外动脉探查,并对其行超选择性插管和化疗栓塞治疗.结果 52例患者共见57条肝外动脉,其中膈下动脉16条,肠系膜上动脉13条,右肾上腺动脉及右肾动脉10条,胃左动脉7条,胃十二指肠动脉5条,胃网膜动脉2条,...     

肠细膜上动脉供血型肝癌的血管造影分析及介入治疗

目的 研究肠细膜上动脉供血型(即变异肝动脉起源于肠细膜上动脉)肝癌的血管造影表现及插管技术。 方法 回顾分析41例肠细膜上动脉供血型肝癌的DSA及介入治疗资料,统计血管解剖变异的发生率,对其起源、走行、分支、分布等解剖学特征及其与血管插管的关系进行描述和分析。 结果 350例肝癌中,肠细膜上动脉供血型41例(11.9％),其中副肝右动脉15例(36.5％),替代肝右动脉16例(39.0％),肝总动脉8例(19.5％),腹腔动脉干起源于肠细膜上动脉2例(5％)。31例肠细膜上动脉发出替代或副肝右动脉者,29例(94.0％)腹腔动脉造影表现为肝右动脉细小或缺如,肝右叶出现无血管区。RH导管超选择性插管成功25例(61％),未成功者改用Cobra、Simmon导管以及结合微导管技术后获得成功。 结论 肠系膜上动脉供血型肝癌是一种比较常见的肝动脉变异性供血,熟悉其血管变异的特点对肝动脉化疗栓塞术具有重要的意义。     

肝动脉变异在肝门淋巴结廓清中的临床意义

目的:探讨肝动脉变异在肝门淋巴结廓清中的识别与预防损伤策略。方法:回顾性分析2013年1 月至2014年7 月蚌埠医学院第一附属医院肝胆外科62例肝门淋巴结廓清中12例肝动脉变异患者术中处理情况。结果:12例肝动脉变异类型分为:MichelsⅢ型3 例（25.0%）,MichelsⅥ型2 例（16.7%）,MichelsⅨ型1 例（8.3%）,Hiatt6 型1 例（8.3%）,肝右动脉与肝总管空间位置变异2 例（16.7%）,肝左右动脉共同起源于肝总动脉2 例（16.7%）,以及肝右动脉起自胃十二指肠动脉1 例（8.3%）。 12例患者无肝动脉损伤;2 例发生术后并发症,其中1 例胰漏,另1 例切口感染;无术后出血、胆漏及肝脓肿等并发症发生。整体恢复良好。结论:在熟知各种肝动脉解剖变异类型的前提下,术前完善的影像学检查与评估,加以术中谨慎且精细的操作,将使肝动脉损伤明显减少。      

Case of gastric perforation after TAI (trancatheter arterial infusion) of SMANCS with special reference to accessory left gastric artery

In 1993, a 55-year-old-man was diagnosed with chronic active hepatitis (HCV). In January 1999, a solitary hepatocellular carcinoma (HCC) was discovered in his liver S8, and a sub-segmental hepatectomy was performed. In July 1999, multiple recurrences in the liver were noticed, and on August 6, 1999, the first SMANCS-TAE was performed. After that, PEIT was added, and then on July 18, 2000 and November 9, 2000, a second and third SMANCS-TAE were carried out, respectively. This time multiple HCCs in the bilateral lobes were discovered, and the 4 th SMANCS-TAE was undergone on April 12, 2001. On a celiac angiogram, the right hepatic artery was shown to have been obliterated by the last TAE. In addition, accessory left gastric artery (accessory LGA) originating in the left hepatic artery (LHA) proximal to the umbilical point (UP) could be seen. So we advanced a microcatheter to the LHA distal to the accessory LGA and injected SMANCS (0.8 mg) into the left hepatic artery. On April 24, he was admitted to hospital by ambulance due to severe upper abdominal pain. The muscular defense was noticed, and an air pocket under the diaphragm was indicated on an X-ray. An emergency total gastrectomy and R-Y re-construction were performed under the diagnosis of gastric perforation. A hole of approximately 10 cm in diameter was found in the anterior wall between the cardia and the upper body, and the accessory left gastric artery (LGA) was obliterated. The principal known side effects of SMANCS are fever, nausea and vomiting. However, as far as this writer has investigated, gastric perforation has never been reported. SMANCS presumably can flow into the stomach wall through the accessory LGA, triggering necrosis of the gastric wall due to circulatory damage. Although arterial infusion of SMANCS is an effective treatment, it causes considerable vascular damage, so intensive follow-up treatment is necessary.     

原发性肝癌的动脉供血特点

目的　探讨供血动脉分型与肝癌的生物学特性的关系及其对临床治疗选择的意义。　方法　分析和统计了419例巨块型原发性肝癌(>10cm)患者的动脉造影资料及临床资料。　结果　根据供血动脉数量的多少及形态,把原发性肝癌的供血动脉分为中央型、外周型、混合型和少供血型四种。前三型为多供血型,占7184%,少供血型占2816%。中央型根据血管的分支形态分为穿透型、树枝型、团状型三种亚型,分别占中央型的4063%、5260%、677%。外周型根据供血动脉的数量分为单枝型和多枝型两种亚型,分别占外周型的3043%和6957%。外周型肝癌患者的1年和2年生存率较中央型和混合型高,而少供血型肝癌较多供血型低。　结论　肝癌的供血动脉分型对肿瘤生物学特性的了解、临床治疗的选择及预后的判断具有重要的意义     

原发性肝癌患者手术前后入肝血流量的观察

作者用Ｂ超多普勒复合装置测定了６２例肝癌患者手术前后的入肝血流量。结果：①无门脉主干癌栓的肝癌患者术前肝固有动脉血流量和门静脉血流量均大于对照组；②肝固有动脉结扎加栓塞术后，门静脉血流量增加；③右半肝切除术后肝固有动脉血流量的减少较肝右动脉结扎加栓塞术后更为明显；④门静脉主干癌栓经治疗（肝动脉和门静脉灌注化疗）缩小后，门静脉血流量增加，肝固有动脉血流量减少；⑤门静脉血流增加的量与肝固有动脉血流量减     

Characterization of extrahepatic distribution of Tc-99m macroaggregated albumin in hepatic perfusion imaging studies prior to yttrium-90 microsphere therapy

Tc-99m macroaggregated albumin (MAA) hepatic perfusion study and hepatic angiography are routinely performed prior to yttrium-90 (Y-90) microsphere therapy for patients with hepatocellular carcinoma (HCC) or metastatic cancers to the liver. The purpose of this study was to examine the incidence of altered Tc-99m MAA distribution in these patients and to identify factors that are associated with these changes. A total of 176 Tc-99m MAA hepatic perfusion studies in 159 patients performed in preparation for Y-90 microsphere therapy were retrospectively reviewed. Abnormal findings were identified and correlated with diagnosis, infusion site, tumor volume, and tumor uptake by using bivariate statistical analysis. Abnormal Tc-99m MAA distribution on the hepatic perfusion imaging studies include excessive hepatopulmonary shunting with an elevated shunting fraction (>10%; n=23, 13%) and abnormal intra-abdominal visceral deposition in the GI tract, pancreas, spleen, and umbilical vein (n=19; 11%). Patients with a diagnosis of HCC showed higher incidence of abnormal hepatopulmonary shunting compared with other types of tumors (p<0.05). The incidence of abnormal intra-abdominal visceral deposition is higher with infusion into the left hepatic artery or proper hepatic artery/common hepatic artery compared with infusion into right hepatic artery (p<0.001). In 9 of 12 cases with abnormal deposition in the stomach, duodenum, or pancreas, the cause was identified upon reviewing angiography retrospectively and was subsequently corrected. In conclusion, the hepatic perfusion imaging study is an important imaging modality in preparation and guidance of Y-90 microsphere treatment.     

原发性肝癌的介入综合治疗及其预后影响因素

目的评价原发性肝细胞肝癌肝动脉化疗栓塞（TACE）为主的综合治疗,分析、筛选与预后相关的因素。方法141例原发性肝细胞肝癌分别采用TACE治疗、TACE＋手术切除、TACE＋PEI治疗和TAI治疗。根据多因素回归模型,对患者年龄、性别、血清AFP、ALT、HBsAg、肝功能Child分级、治疗方式、肿瘤大小及数目、血清白蛋白水平、门静脉癌栓、肿瘤病理类型和血清HBeAg进行预后分析。结果本组患者的总体中位生存时间为19个月,平均生存23,59个月。1、2、3、5年生存率分别为63．9％、44．5％、25．8％和7．4％。多因素分析显示,患者年龄、肝功能Child分级、治疗方式、门静脉癌栓和肿瘤病理类型与TACE综合治疗预后有关（X^2=45．993,P=0．0001）。结论原发性肝细胞肝癌介入综合治疗安全、有效。患者年龄、肝功能Child分级、门静脉癌栓和肿瘤病理类型是影响介入综合治疗预后的危险因素,治疗方式是影响预后的保护性因素。     

留置肝动脉导管化学治疗胃癌肝转移23例

目的观察肝动脉序贯化疗治疗胃癌肝转移的临床效果.方法观察组23例留置从左锁骨下动脉置入的导管,固定于肝固有动脉,应用EFP方案序贯化疗4个周期,进行疗效评价,跟踪随访.对照组26例,采用EFP方案静脉化疗.结果观察组近期有效率100%,1,2,3年生存率分别为100.0%、73.9%和39.1%,毒副反应轻微.对照组近期有效率23.1%,1,2,3年生存率分别为57.7%、30.8%和11.5%,毒副反应较重.两组比较差异有显著性(P＜0.05).结论留置肝动脉导管化疗是治疗胃癌肝转移的有效方法,不良反应轻,值得进一步研究.     

56例肝癌自发性破裂出血的外科治疗

目的：探讨外科手术治疗肝癌自发性破裂出血的效果。方法：５６例肝细胞性肝癌（肝癌）自发性破裂出血患者，其中６例行填塞术，１３例行单纯缝合术，８例行肝固有动脉或造反性肝动脉结扎术，１８例行肝动脉化学栓塞术，１１例行肝切除术。结果：１）手术止血率：平均为９３．０％（５２／５６），其中填塞术为６６．７％（４／６），缝合术为７４．６％（１１／１３），肝动脉结扎术为１００％（８／８），肝动脉化学栓塞术为９４．     

肝动脉解剖变异在肝癌介入治疗中的临床价值

 目的 探讨肝动脉解剖变异在肝癌介入治疗中的临床价值。方法 本文收集2003年1月～2004年6月在同济医院放射科做肝动脉化疗栓塞术（TACE）和肝动脉栓塞（TAE）的中晚期肝癌150例，将每例病人的肝动脉造影所见与临床资料及随访结果一起进行分析。结果 150例中，有肝动脉变异者23例，占全部病例的15．3％。结论 表明肝动脉变异发生率较高。同时发现有些病例虽然肝动脉及其分支无变异，但肝动脉走行位置变异，对选择性肝动脉插管有较大影响。作者对肝动脉变异的类型、肝动脉走行位置异常、以及它们在肝癌介入治疗中的意义进行了讨论。     

Hepatic arterial catheterization combining interventional radiological and laparotomic approaches

BACKGROUND AND OBJECTIVES: This report describes a modified method of implanting a catheter-port system for hepatic arterial infusion chemotherapy (HAIC) that combines interventional radiological (IVR) and laparotomic approaches. METHODS AND RESULTS: In patients, scheduled for HAIC and laparotomic surgery, we now employ a modified method of implanting the catheter-port system. In our method, an IVR approach is used to implant the catheter-port, and arterial occlusions are primarily carried out using a laparotomic approach. Following celiac and superior mesenteric arteriographies, a tapered microcatheter with a side hole is inserted by a catheter exchange method. The catheter tip is advanced far into the gastroepiploic artery via the gastroduodenal artery (GDA). The side hole is located at the orifice of the proper hepatic artery, and its location is confirmed by injection of contrast media. The microcatheter is connected to the port, and the port is buried in the subcutaneous pocket. During the laparotomy stage, the GDA lumen and the catheter lumen are clipped, and the right gastric artery (RGA) and all small branches supplying the stomach, duodenum, and pancreas are ligated. Among the 13 patients successfully implanted with a port-catheter system using our combined approach, no patients had hepatic artery occlusion or occlusion of the catheter system. CONCLUSIONS: Initial results from a study of a new method of implanting a microcatheter-port system in the hepatic artery using combined IVR and laparotomic approaches suggest that this method may enable operators to avoid complicated selective coiling and may lower the incidence of hepatic artery occlusion in patients receiving long-term HAIC.     

Advanced gastric cancer with a duplicated hepatic artery: preoperative diagnostic value of multidetector-row computed tomography for surgical resection

A 63-year-old woman with appetite loss and general fatigue underwent gastrointestinal fiberscopy, which revealed type 2 advanced gastric cancer. Multidetector-row computed tomography revealed a massive gastric cancer invading the left hepatic lobe, pancreatic head, and common hepatic artery, as well as revealing a duplicated hepatic artery in which the right hepatic artery branched directly from the celiac axis, and ran behind the splenic vein. On the other hand, the common hepatic artery ran anterior to the splenic vein. We were able to perform pancreaticoduodenectomy with common hepatic artery resection and left lobectomy as curative surgery because her duplicated hepatic artery enabled us to ligate the common hepatic artery. Her postoperative clinical course was uneventful, and she is in good health 3 years after the surgery, without recurrence. We consider that multidetector-row computed tomography is very useful for the diagnosis of vascular anomaly, preoperative staging and decision making on the appropriate surgical strategy.     

经药盒系统对晚期肿瘤行化疗栓塞的临床研究

目的：采用介入技术经锁骨下动脉入路皮下植入药盒系统。研究经药盒系统对晚期肿瘤行化疗栓塞的临床疗效。方法：随机分成A、B两组。A组选择化疗栓塞的给药方案，B组选择单纯灌注化疗的给药方案，各20例。结果：两组有效率（CR＋PR）A组为45％，B组为20％（P＜0．05）。1年生存率A组为50％，B组为30％（P＜0．05）。结论：晚期肝癌患者，采用介入技术经锁骨下动脉入路皮下植入药盒系统行化疗栓塞是有效、可行的。     

A simplified surgical technical procedure for intra-arterial chemotherapy in secondary liver cancer. Experience in 50 patients

The purpose of this study was to prove that only one intra-arterial catheter for hepatic chemotherapy can perfuse the whole liver in all anatomic cases, including cases with aberrant or accessory hepatic arteries. The ligations of various hepatic arteries induce the immediate aperture of intra hepatic arterial shunts and a total revascularization of the whole liver by the only remaining hepatic artery. Based on the experience from 50 consecutive cases of surgical implantation of intra-arterial catheters for local chemotherapy, the simplified technique is analysed principally as a function of anatomical variations of the hepatic artery. The usual procedure (catheter implanted into the gastro-duodenal artery) was performed in 58% of the cases, while in 28% of the cases this was possible only after section of a right and/or a left aberrant or accessory hepatic artery. Unusual implantations were necessary in 14% of the cases to ensure complete perfusion of liver. The evaluation was based on three criteria: intra-operative perfusion of fluorescein, post-operative scan with 99mTc macro-aggregated albumin and objective clinical responses after intra-arterial chemotherapy. The perfusion of the whole liver was good in all cases except one. Unusual procedures gave the same clinical objective responses after intra-arterial chemotherapy (61%) as usual procedures (48%) (chi-square: P = 0.40).     

Long-term regional chemotherapy for colorectal liver metastasis: significance of hepatic arterial anatomy in the surgical placement of the implantable infusion device

The range and frequency of aberrant hepatic arterial anatomies and their significance for placement of implantable hepatic arterial infusion devices have been studied. The angiographs of 1439 patients treated at the Institute's Clinic (1985-2002) were used. The following 6 types of aberrant hepatic arterial anatomy were identified (J. Hiatt et al). Normal anatomy (type 1) was the most frequent (67.6%). The abnormal variants included: the aberrant left hepatic artery (LHA) running from the left gastric artery (LGA) (type 2)--9.9%; the aberrant right hepatic artery (RHA)--from the superior mesenteric artery (SMA) (type 3)--9.2%; the aberrant LHA from LGA with the aberrant RHA from SMA (type 4)--3.8%); the common hepatic artery running from SMA (type 5)--1.5%: other variants (type 6)--8.0%. Aberrant hepatic arterial anatomy occurred in every third patient. It was responsible for failed perfusion, frequent thrombosis of both hepatic arteries and infusion devices, suspension of regional chemotherapy and affecting its effectiveness. Proper identification of aberrant hepatic artery anatomy is vital for placement of implantable infusion systems.     

A clinical study of hepatic arterial infusion chemotherapy with low-dose CDDP and 5-FU for liver metastases

We followed patients who underwent hepatic arterial infusion chemotherapy with low-dose CDDP+5-FU for liver metastases from colorectal cancer in the outpatient setting. A catheter was inserted from the femoral artery into the proper hepatic artery using the interventional technique. Two complete response (CR) and seven partial response (PR) were achieved, but later 2 of these patients had lung metastases. We conclude that this therapy may be effective, but control of extrahepatic lesions is necessary for life prolongation.     

A hepatocellular carcinoma showing sarcomatous features and an extensive metastasis]

A 47-year-old female was admitted for a right hypochondrial pain and was diagnosed as having a hepatic tumor with a cystic lesion. After a right and a caudal lobectomy, she died of hepatic failure due to a tumoral recurrence. At autopsy, a cystic tumoral nodule, 15 x 7 cm in size, and numerous other nodules were revealed in the liver. Metastases were seen in both lungs, the left kidney, the colon, the mesenterium, the peritoneum, the diaphragm, and the para-pancreatic lymph nodes. The hepatic tumors consisted of four types of tumor cells: spindle, round, mixed (spindle and round cells), and cells with pseudoalveolar features. All tumor cells showed a positive immunohistochemical reaction to polyclonal keratin, low molecular monoclonal keratin, alpha 1 anti-trypsin, vimentin and to actin in their cytoplasms. This is considered a very rare case.     

肝癌的肝外动脉供血及其介入治疗

目的 探讨肝癌的肝外动脉供血规律、插管技术及介入治疗。方法 分析62例肝癌患者78条肝外动脉供血特征,对肝外动脉供血支行超选择插管,并同时进行肝动脉系统及肝外动脉供血支的双动脉化疗栓塞术。结果 肝外动脉供血占肝癌患者的43．1％,肝外动脉供血与肿瘤部位、大小密切相关;RH、Cobra、SP管配合使用,肝外动脉供血支插管成功率为71．8％。治疗后1个月复查,CT显示肿瘤缩小,碘油沉积致密完全。结论 肝癌有丰富的肝外动脉供血,对具有肝外动脉供血的肝癌患者采取双动脉内化疗栓塞是可行、必要和有效的。