肝切除技术的某些新进展

为合并肝功能障碍者施行肝切除,术后残肝的质和量与病人预后关系密切。因此,近年来针对限制性肝切除术的一些环节,许多作者进行了大胆而成功的探索。某些位于第一、二肝门附近的肝肿瘤,常规方法已不能切除。体外肝切除技术(Extracorpoealhepatic resection,ECHR)为这类肝肿瘤的切除提供了新的手段。本文就此对有关的内容综述如下。     

全肝血流阻断无血切肝术切除巨大肝血管瘤一例

全肝血流阻断无血切肝术切除巨大肝血管瘤一例李捷雷，张宏义肝胆外科主题词肝肿瘤，血管癌，肝切除术患者女，４２岁。上腹部肿块４年，肿块占据整个上腹部，隆起于腹壁表面。术前经Ｂ超、ＣＴ、肝血池扫描诊断为：肝海绵状血管瘤。肝功能ＣｈｉｌｄＡ级。１９９６年１月...     

手术切除治疗原发性肝癌的经验

报告了102例手术切除治疗原发性肝癌的经验。提出了手术切除的指征;主张采用肝门间歇阻断法控制出血;提倡以肝癌的局部切除术替代标准的肝叶切除术;认为肝癌的二期切除和复发性肝癌的再次切除是提高长期生存率的重要途径。     

肝巨大占位性病变肝三叶切除23例治疗分析

目的：探讨肝巨大占位性病变的外科治疗,提高肝三叶切除治疗水平。方法：回顾分析肝三叶切除治疗肝巨大占位性病变２３例（肝肿瘤５例,肝包虫病１８例）治疗过程。结果：手术死亡率（１／２３）４．３５％,术后并发症（４／２３）１７．４％,临床治愈率（２２／２３）９５．６５％。临床治愈出院２２例,随访１、３、５年的生存率分别为９０．９５％、８６．４％和８１．８％。肝癌与肝包虫病的临床治愈率相当,５年生存率前者明显低于后者,与癌复发有关。结论：严格手术指征,围手术期处理,注重手术操作技巧,可提高临床治愈率和术后疗效。     

肝动脉化疗栓塞术后并发上消化道出血23例临床分析

目的　探讨肝动脉化疗栓塞 (TACE)后并发上消化道出血原因及治疗方法 ,并为预防出血提供依据。方法　回顾总结分析 2 3例TACE后短期内并发上消化道出血患者的临床资料。结果　出血患者多有肝功能严重损害 ;出血以食道胃底静脉曲张破裂为主 ,其次胃、十二指肠粘膜病变及胆道出血。 73 9%出血发生在TACE术后 15d之内 ,2 6 1%出血发生在术后 16～ 30d ;因出血死亡患者占 13 0 %。结论　及时预防及正确治疗对延长肝癌患者生命和提高生存质量有着重要意义。     

不同血流阻断技术对肝癌切除患者术中出血及术后恢复影响研究

目的比较不同血流阻断技术对肝癌切除患者术中出血及术后恢复的影响。方法选取自2017年5月至2018年5月就诊于北部战区总医院的62例肝癌合并肝硬化的患者为研究对象。根据血流阻断方式将患者分为A、B两组,每组各31例。A组通过全入肝血流阻断法行肝切除;B组通过区域性血流阻断行肝切除。观察并比较两组患者的手术时间、出血量、住院天数,以及术后1、3 d的丙氨酸氨基转移酶(ALT)改善情况。结果两组患者手术时间、住院天数比较,差异无统计学意义(P>0.05)。B组患者的术中出血量低于A组,两组比较,差异有统计学意义(P<0.05)。术后1、3 d,两组患者的ALT水平均较术前升高,两组术后ALT与术前比较,差异有统计学意义(P>0.05),且术后B组ALT水平显著低于A组,差异有统计学意义(P<0.05)。结论不同的血流阻断技术对于肝癌切除患者的术中出血及术后恢复影响的差异较大,其中,区域性血流阻断技术对于肝癌切除患者的术中出血量及术后恢复速度存在较大优势。     

72例肝切除手术体会

报告了72例肝切除术。手术对象为肝肿瘤、肝胆管结石和肝外伤。半肝以上切除24例,多数采用肝门间隙阻断控制出血。常温下无血切除肝右三叶2例。讨论了肝胆管结石切肝的手术指征和操作要点。提出肝癌手术成功的关键是准确判定病变范围、与第一、二肝门的位置关系、肝硬化的程度;主张肝硬化明显者选用肝癌局部切除。对肝外伤病员应尽量采用清创性肝切除,少做规则性肝切除。所有肝脏手术均放置双套管间断负压吸引以预防腹腔感染。     

肝外伤术后大出血3例分析

分析3例肝外伤术后大出血发生的原因,发现均与首次手术质量有关。认为肝脏解剖结构的认识和提高手术操作的技能是减少并发症的必要措施。     

奥美拉唑预防肝动脉化疗栓塞术后急性胃粘膜病变出血

目的观察奥美拉唑预防肝动脉化疗栓基术后急性胃粘膜病变出血的临床效果。方法46例病人术后当日静脉滴注奥美拉唑40mg，每天1次，并设非奥美拉唑对照组，疗程7天。结果奥美拉唑组出血率显著低于非奥美拉唑组（8．7％和27．5％，P〈0．005）。结论奥美拉唑对肝动脉化疗栓塞术后急性胃粘膜病变出血有良好的预防作用。     

肝移植术后不同部位出血的原因分析和预防

目的:探讨肝移植术后不同器官出血的原因和有效的防治措施。方法:回顾性分析本院近6年来原位肝移植术(OLT)后24例出血患者的临床资料。结果:OLT出血并发症的发生率为13.2%(24/181),其中颅内出血4例(2.2%),切口和腹腔出血11例(6.1%),消化道出血9例(5.0%);因出血死亡占出血病人的20.8%(5/24)。结论:OLT术后可出现颅内、腹腔和消化道等不同部位的出血,死亡率高。密切监测术后的凝血功能,合理应用免疫抑制剂,控制腹腔感染可有效的预防肝移植术后的出血。     

Primary benign liver lesions

Benign focal liver lesions can origin from all kind of liver cells: hepatocytes, mesenchymal and cholangiocellular line. Their features at imaging may sometimes pose difficulties in differential diagnosis with malignant primary and secondary lesions. In particular, the use of MDCT and MRI with extracellular and hepatobiliary Contrast Agents may non invasively help in correct interpretation and definition of hepatocellular or mesenchymal and inflammatory nature, allowing to choose the best treatment option. The peculiarities of main benign liver lesions at US, CT and MRI are described, with special attention to differential diagnosis and diagnostic clues.     

Utility of diffusion‐weighted MRI in distinguishing benign and malignant hepatic lesions

Purpose:

To evaluate apparent diffusion coefficient (ADC) values for characterization of a variety of focal liver lesions and specifically for differentiation of solid benign lesions (focal nodular hyperplasia [FNH] and adenomas) from solid malignant neoplasms (metastases and hepatocellular carcinoma [HCC]) in a large case series.

Materials and Methods:

A total of 542 lesions in 382 patients were evaluated. ADC values were measured in 166 hemangiomas, 112 hepatomas, 107 metastases, 95 cysts, 10 abscesses, 43 FNH, and nine adenomas. ADCs of 1.5 and 1.6 (×10^?3 mm²/second) were selected as threshold values to separate benign and malignant lesions. Sensitivity, specificity, positive, and negative predictive values (PPV, NPV) were calculated. Comparisons were carried out with studentized range test.

Results:

There was high interobserver agreement in ADC measurements for all lesion types. The mean ADCs for cysts was 3.40 (×10 ^?3 mm²/second), hemangiomas 2.26, FNH 1.79, adenomas 1.49, abscesses 1.97, HCC 1.53, and metastases 1.50. The mean ADC for benign lesions was 2.50 and for malignant lesions was 1.52. Cysts were easily distinguished from other lesions. There was, however, overlap between solid benign and malignant lesions.

Conclusion:

Benign lesions have higher mean ADC values than malignant lesions. However, ADC values of solid benign lesions (FNH and adenomas) are similar to malignant lesions (metastases, HCC) limiting the value of diffusion weighted imaging (DWI) for differentiating solid liver masses. J. Magn. Reson. Imaging 2010;32:138–147. © 2010 Wiley‐Liss, Inc.

     

Detection and characterization of benign focal liver lesions with multislice CT

MDCT is a rapidly evolving technique that significantly improves CT imaging for several indications including depiction of focal benign lesions. Imaging mainly profits from improved longitudinal spatial resolution allowing high-quality non-axial reformations and 3D reconstructions and CT angiography as well as rapid accurate multiphase imaging with short breath-holding periods. This review provides an overview of the current status of MDCT with respect to liver imaging and the implications for characterizing benign focal liver lesions. MDCT currently allows the acquisition of thin slices in daily routine diagnostics providing an improved detection rate of small liver lesions. Whereas large benign focal liver lesions exhibit typical patterns of morphology, attenuation and perfusion, which also may be assessed with single-slice scanners, small lesions remain challenging even with MDCT, since the specific criteria for confident diagnosis become more ambiguous. Here, MR imaging provides more detailed information about tissue components and the availability of liver-specific contrast agents, adding further impact to this technique. With respect to dose considerations, the number of necessary multiphase scans as well as the application of very thin collimation should be strictly checked for each patient undergoing MDCT based on the individual clinical situation and question.     

ADC值在鉴别肝脏良恶性局灶性病变的应用价值

目的 评价ADC值在鉴别肝脏良恶性局灶性病变(focal liver lesion,FLL)的诊断价值.方法 采用signa 3.0T MR对306例共391个FLL进行屏气DWI成像(b=800s/mm2),包括肝囊肿78灶,成熟肝脓肿23灶,肝血管瘤39灶,FNH\肝腺瘤17灶,原发性肝癌121灶,胆管细胞癌45灶,肝转移癌68灶.DWI图像经GE公司AW4.2工件站后处理得到ADC图,测量以上各类病灶的ADC值,统计分析良恶性性FLL的ADC值及其差异.结果 良恶性FLL的平均ADC值(×10-3 mm2/s)分别为2.63±0.35、1.18士0.41,差异有统计学意义(P=0.007).以ADC≤1.64×10-3 mm2/s诊断恶性FLL的敏感性、特异性和准确率分别为:87％、81％、84％.结论 恶性FLL的ADC值明显低于良性,以ADC值能明显提高对肝脏局灶性病变良恶性的鉴别诊断能力.     

Superparamagnetic iron oxide (SPIO)-enhanced liver MRI with ferucarbotran: efficacy for characterization of focal liver lesions

PURPOSE: To evaluate the efficacy of ferucarbotran in T2-weighted (T2W) fast spin-echo (FSE) and T2*W gradient-echo (GRE) sequences for characterizing focal liver lesions. MATERIALS AND METHODS: In 68 patients, 46 malignant and 22 benign focal liver lesions were evaluated. Precontrast (NCE) T2W FSE images and contrast-enhanced (CE) T2W FSE and T2*W GRE images were obtained on a 1.5T MR system. Based on signal intensity (SI) measurements in focal lesions and liver parenchyma, the signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were calculated for all sequences. The percentage of SI loss (PSIL) in focal lesions after contrast agent (CA) application was calculated for the T2W FSE sequence. Qualitative analyses were performed to assess image quality and lesion conspicuity obtained with the CE-T2W FSE and CE-T2*W GRE sequences. RESULTS: The mean PSIL was higher in solid benign lesions than in malignant lesions (39.6% vs. 3.2%, P<0.05). With a threshold PSIL of 25%, the sensitivity and specificity for characterizing malignant lesions were 97.8% and 92.9%, respectively. The mean CNR of the malignant lesions was higher in the CE-T2*W sequence than in the CE- and NCE-T2W FSE sequences (29.9 vs. 22.7 (P<0.01) vs. 12.8 (P<0.01)). CE-T2*W images showed a superior image quality and lesion conspicuity (P<0.05) compared to the CE-T2W FSE sequence. CONCLUSION: The PSIL can be an accurate tool for characterizing benign and malignant lesions. The addition of a CE-T2*W GRE sequence is helpful for the detection and characterization of malignant lesions.     

颌下腺良恶性病变的CT表现分析

目的 探讨颌下腺良恶性病变的特征性CT表现.方法 回顾性分析经手术病理证实的75例颌下腺良恶性病变的CT表现,其中多形性腺瘤38例,恶性肿瘤22例,慢性炎症11例,肌上皮瘤2例,神经鞘瘤及血管瘤各1例;总结其CT诊断及鉴别诊断要点.结果 (1)38例多形性腺瘤病灶均仅累及患侧颌下腺的一部分,其中35例位于颌下腺边缘,33例边缘光整,30例密度均匀;增强后33例病灶呈轻中度强化;10例病灶呈“靶状”强化.(2)22例恶性肿瘤中3例淋巴瘤边缘光整、密度均匀,位于颌下腺边缘,增强后呈轻中度强化;余19例边缘不光整、密度不均匀,18例边界不清楚,其中2例侵犯大部分颌下腺,16例侵犯整个颌下腺,增强后17例呈明显不均匀强化,其中12例内见增粗迂曲的血管影;9例伴有颈部短径＞1.0 cm的肿大淋巴结.(3)颌下腺慢性炎症11例,均表现为颌下腺弥漫增大,边缘较光整,边界较清楚,增强后多呈较均匀中等强化;其中6例伴有颌下腺导管内结石及导管扩张;11例均伴有颈部短径＜1.0 cm的淋巴结,其中8例短径＜0.5 cm.(4)2例肌上皮瘤具有明显不规则环形强化的CT表现;1例神经鞘瘤伴明显囊变,增强后边缘轻度强化;1例血管瘤内见多个静脉石,增强后呈明显持续强化.结论 颌下腺良恶性病变大多数具有一定的特征性CT表现,但颌下腺淋巴瘤与多形性腺瘤较难鉴别.     

Malignant focal hepatic lesions complicating underlying liver disease: dual-phase contrast-enhanced spiral CT sensitivity and specificity in orthotopic liver transplant patients

The aim of this study was to determine the accuracy of contrast-enhanced biphasic spiral CT as a screening tool in the preoperative evaluation of orthotopic liver transplant (OLT) patients. Spiral-CT examinations were performed before liver transplantation in 53 patients. Scans were retrospectively reviewed and compared with pathologic findings in fresh-sectioned livers. When findings between spiral CT and pathology were discordant, formalized livers were reexamined with lesion-by lesion evaluation. Fresh pathologic evaluation revealed 23 liver lesions (16 HCC, 7 macro-regenerative nodules). Malignancy was identified in 13 of 53 patients (24.5%). Pre-transplantation spiral CT depicted 27 liver lesions (23 HCC, 4 macro-regenerative nodules). Malignancy was suspected in 14 patients (26.4%). In 10 of 53 (18.9%), spiral CT and pathologic evaluation were discordant. Subsequent retrospective pathologic evaluation showed malignancy in 4 additional patients. Spiral CT compared with the retrospective pathologic findings revealed 36 real-negative, 14 real-positive, 0 false-positive, and 3 false-negative patients with malignancy. Sensitivity and specificity of spiral CT in detection of malignancy was 82 and 100%, respectively. Contrast-enhanced biphasic spiral CT is an accurate technique in the evaluation of patients preceding OLT. Routine fresh-sectioned liver pathologic findings are not as sensitive as previously estimated.     

Focal liver lesions: breathhold gradient- and spin-echo T2-weighted imaging for detection and characterization

PURPOSE: To evaluate breathhold gradient- and spin-echo (GRASE) T2-weighted imaging for the detection and characterization of focal liver lesions. MATERIALS AND METHODS: Two GRASE sequences with different echo times (75 and 90 msec, GRASE75 and GRASE90) were compared with respiratory-triggered fast spin-echo (SE) and breathhold fast SE in 64 patients with 103 malignant and 51 benign lesions. Compared with respiratory-triggered and breathhold fast SE, GRASE reduced scan time by 77% to 82% and 21% to 27%, respectively. Two independent readers evaluated image quality and reviewed 504 liver segments on a segment-by-segment basis. Observer performance was evaluated with receiver operating characteristic (ROC) curve analysis. The signal-to-noise ratio (SNR) of liver and spleen, and lesion-to-liver contrast-to-noise ratio (CNR) were also measured. RESULTS: The overall quality of the GRASE images was higher than that of the respiratory-triggered and breathhold fast SE images, although signal inhomogeneities were more frequently observed with GRASE. No significant difference in the values of the area under the ROC curve (Az) for malignant lesion detection was found. The mean SNR and CNR were highest for respiratory-triggered fast SE. CONCLUSION: T2-weighted breathhold GRASE has the potential to provide faster liver imaging.     

MRI measurement of liver regeneration in mice following partial hepatectomy.

Improvements in noninvasive imaging modalities are crucial for preoperative in vivo assessments of liver condition and potential for regeneration after liver resection for removal of liver tumors. To that end, an MRI study of liver regeneration in mice following partial hepatectomy is described and validated. Hepatic volumes were accurately measured from contrast-enhanced, gradient-echo images of the liver. Regeneration curves were constructed for a series of mice (N = 6) from a longitudinal MR study, with images collected 1, 2, 3, 4, 5, and 9 days following surgery. We validated the MR method by correlating serial MR-measured volumes with liver wet weight. The success of this method will enable future studies to better elucidate the factors that affect regeneration, and help to optimize the timing and dosing of chemotherapeutics to minimize their deleterious effects on liver regeneration.