前入路右半肝切除技术探讨（附12例）

目的探讨前入路右半肝切除术在巨块型肝癌中应用的安全性及可行性。方法对12例用常规手术方法难以切除的肝右叶巨块型肝癌用前入路的方法行肝切除,进行回顾性分析。结果本组12例前入路行右半肝切除,手术均获得成功。术中平均出血量850ml,手术至出院时间14d。术后并发胆瘘1例,治愈出院。本组无手术死亡。结论 对于巨块型肝癌施行前入路规则性半肝切除术是安全、可行的。     

ICG-R15联合三维可视化技术用于巨块型肝癌治疗决策22例分析

正巨块型肝癌是指肿瘤直径≥10 cm的一种特殊类型的肝癌,由于瘤体巨大,位置常靠近肝门等重要区域,压迫和侵犯肝内外大血管,造成手术困难;同时,手术切除范围大,术后并发肝功能不全风险较高。因此,如何选择合理的治疗方案,常是肝脏外科医生面临的困境。皖南医学院附属弋矶山医院肝胆外科采用吲哚菁绿15 min滞留率试验(ICG-R15)联合三维可视化技术对巨块型肝癌病人进行可切除性评估,根据评估结果选择个体化治疗方案。现报道如下。     

青年人肝癌24例分析

目的 分析青年人肝癌的临床和病理特点，探讨改善青年人肝癌疗效的途径。方法 将我科１９９３年１月至１９９８年１２月收治的原发性肝癌２５３例划分为年龄≤３５岁和〉３５岁的青年人组及成年人组。从男女性别比、肝癌类型（单结节、多结节、巨块型、弥漫型），ＨＢｓＡｇ阳性率，脾大，腹水，门静脉癌栓，ＡＦＰ≥４００μｇ／ｍｌ，手术切除率及存活率等方面进行对比分析。结果 青年人组男女性别比为２３：１，成年组为７．２     

肝动脉化疗栓塞加深冷冻治疗原发性巨块型肝癌

采用肝动脉化疗栓塞（ＴＡＣＥ）加深冷冻治疗８例原发性巨块型肝癌（瘤体最小１２ｃｍ，最大１８ｃｍ）。治疗后瘤体均明显缩小，ＡＦＰ下降，且无严重并发症。生存最短１１个月，最长已２年零２个月。认为该方法是目前治疗不能手术切除的中晚期巨块型肝癌的有效方法。     

巨块型肝癌病人行氩超冷刀手术的护理

对26例行氩超冷刀手术的巨块型肝癌病人的临床资料进行回顾性总结.提出术前重点做好心理护理及营养支持,术后重点做好并发症的观察及护理.     

原发性肝癌自发性破裂出血诊治分析(附40例报告)

原发性肝癌自发性破裂出血是原发性肝癌的一种严重并发症。我院自１９８８年至１９９８年共收治４０例,现报告如下。 临床资料 本组４０例中男３６例,女４例,年龄１５～７４岁,平均５４岁。术前确诊２７例,误诊为其他疾病者１３例。３５例行手术治疗,术中快速病理检查均诊断为原发性肝癌,术后病理诊断为原发性肝癌自发性破裂,其中术中见肝癌呈巨块型１９例,呈结节融合型１３例,呈弥漫型３例。肿瘤直径４．５～１８ｃｍ。４０例病人均以不同程度的急腹症入院,其中合并腹水２２例（５５％）,休克１９例（４７．５％）,ＡＦＰ阳性…     

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目的探讨虚拟肝脏手术规划对中央型肝癌切除术的指导价值。方法应用虚拟肝脏手术规划系统软件Liv1.0对福建医科大学附属第一医院2007年6月至2012年6月49例病人进行虚拟中央型肝癌切除手术规划,将虚拟手术规划结果与手术中所见进行对比。结果 49例病人虚拟肝脏手术规划所测预切除肝脏体积为(543±225)mL,实际切除肝脏体积为(573±212)mL,平均误差(29±66)mL,两者间高度正相关(相关系数r=0.983,P<0.01)。结论针对中央型肝癌切除术,应用虚拟肝脏手术规划进行手术模拟,有利于评估肿瘤的可切除性并指导手术切除方式的选择。     

肝动脉栓塞化疗联合经皮乙酸消融双介入治疗巨块型肝癌的护理

目的探讨肝动脉栓塞化疗（TACE）联合经皮乙酸消融（PAI）双介入治疗巨块型肝癌的护理方法。方法对38例巨块型肝癌患者首次行常规TACE治疗后1周复查,根据碘油的填充情况,对碘油稀疏和缺损区域进行PAI治疗,间隔30～45d重复小剂量TACE治疗。结果治疗后38例患者肿块均缩小,肝动脉造影示肿瘤血管消失20例（52.63%）,甲胎蛋白恢复正常31例（81.58%）。发生不良反应27例（71.05%）。1、2、3年生存率分别为97.37%、84.21%、34.21%。结论TACE联合PAI双介入治疗巨块型肝癌的疗效较好。术前细致的心理护理和周密的术前准备,术中准确配合、密切观察患者反应并及时配合医生作出相应处理,术后加强不良反应的观察和护理是保证治疗效果的主要措施。     

巨块型肝癌自发性破裂出血72例的急救护理

目的总结巨块型肝癌自发性破裂出血的急救处理及护理经验,以提高患者的抢救成功率。方法回顾和分析72例原发性肝癌破裂出血患者的急救治疗和护理措施。结果47例患者入院时已伴有失血性休克,47例患者行手术止血,治愈出院40例,死亡2例,放弃治疗5例。25例行非手术治疗,好转7例,放弃治疗12例,死亡6例。结论有效的抗休克处理,及时纠正失血性休克,为手术治疗创造条件,赢得宝贵时间,是提高巨块型肝癌破裂出血患者的抢救成功率及治疗效果的关键。     

经胸单切口肝癌并肺转移癌切除术的探讨(18例分析)

目的分析我院1993-2003年间收治的18例巨块型原发性肝癌,经肝动脉的联合介入化疗栓塞(TACE)治疗后出现肺转移的病人。总结经胸单切口同期切除肝癌并肺转移癌的体会。方法及结果选择18例均为巨块型肝癌病人,经TACE治疗,出现同侧孤立性肺转移病灶,其中右肝癌并右肺转移11例,左肝癌左肺转移7例。经右侧开胸一切口行肝癌及肺转移瘤同期切除11例,经左侧开胸行肝癌及肺转移瘤同期切除7例。全组手术经胸切口一次完成,无需分期手术,过程顺利,无重大并发症,无手术死亡。结论该术式可同期一次完成胸腹部病灶的切除,无需分期经胸腹部两切口手术,无需改变体位,手术快捷、安全、出血少、创伤小,可减轻病人经济及心理负担,值得临床推广。     

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??Recent advances and difficulties in techniques of the complex and extended liver resection CHEN Xiao-ping, HE Song-qing. Hepatic Surgery Center??Tongji Hospital??Tongji Medical College??Huazhong University of Science and Technology??Wuhan430030, China
Abstract Advances in liver surgery have increased the safety of all types of liver resections and have made complex and extended hepatectomy performed successfully with low operative mortality. The progresses achieved are attributable to an improved understanding of hepatic anatomy using computer-aided reconstruction of the tumor zones,vascular and biliary anatomy, intraoperative ultrasound and other new imaging technologies and a better method of vascular clamping, vascular reconstruction and better techniques and instruments to achieve more precise liver transection with a good haemostasis on the cut surface. Preoperative manipulation of the liver volume with hypertrophy of the future liver remnant (portal vein embolization) has made complex and extended hepatectomies feasible. Control bleeding during hepatic resection using low CVP anesthesia with selective vascular inflow and outflow control before parenchymal transection is a safe, reliable and effective approach. Complex combinations of surgery, chemotherapy and local ablation are used in advanced disease, extended the limits of resectability for liver tumors. Hepatic laparoscopic surgery is gaining popularity due to the useful for staging purposes and the availability of new laparoscopic instruments for liver transection. Advances in laparoscopic equipment and techniques and telerobotic surgery will undoubtedly expand the use of the techniques and become the next frontier in hepatic complex resectional surgery.     

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??Basic principles and clinical application of the different surgical techniques of liver resection for liver cancer LAU WY??LAI ECH. Faculty of Medicine??the Chinese University of Hong Kong??Sha- tin??New Territories??Hongkong SAR??China
Corresponding author??LAU WY??E-mail: josephlau@cuhk.edu.hk
Abstract Curative liver resection for liver cancer aims to resect the tumor with an adequate safety margin??while at the same time preserve enough volume and function of the remnant liver. Recent developments in liver surgery have allowed different techniques in liver resection to evolve. All the different techniques involve the combination of five surgical steps??although the 5 steps can differ in their order of execution. The 5 steps are mobilization of liver by division of ligaments??interruption of the vasculo-biliary inflow??liver parenchymal transection??interruption of venous outflow from the short hepatic veins and the main hepatic veins. Obviously??adequate haemostasis is required before closure of the abdomen. Liver resection can be divided into anatomical and non-anatomical liver resections. Theoretically??anatomical liver resection has many advantages over non-anatomical resection and the latter should only be carried out for lesions situated at the junction of several liver segments??or at the peripheral edges of the liver. Anatomical liver resection is based on the intrahepatic anatomy of the liver which divides the liver into hemilivers??sections (or sectors) and segments. Liver resection carried out through anatomical planes results in less blood loss and better preserved liver remnant function. The surgery can be well-planned pre- and intra-operatively??and the operation follows oncological surgical principles.Anatomical liver resection can be carried out based on the following methods: (1) based on liver surface anatomy and intraoperative ultrasound guidance??(2) preliminary control of Glissonian pedicle of the liver segment(s) to be resected??(3) ultrasound guided puncture of portal vein branch and injection of dye??and (4) selective portal venous occlusion using a balloon catheter through a branch of the superior mesenteric vein.The recent development of 3D computed tomographic visualization system has made preoperative planning ofanatomical liver resection even better.     

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??Surgical treatment of liver cancer with insufficient future liver remnant: controversy and consensus ZHOU Jian,PENG Yuan-fei, WANG Zheng. Department of Liver Surgery, Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai 200032, China
Correspongding author: ZHOU Jian, E-mail: zhou.jian@
zs-hospital.sh.cn
Abstract Hepatic resection is the main optimal curative treatment for primary or metastatic liver cancer. The tremendous advance in liver surgery has overcome the complexity of liver anatomy and operative manipulation, but is often halted by the insufficient future liver remnant (FLR) after extensive hepatectomies. Thus far, the artificial liver support system has not been well developed. The main strategies of resection for patients with insufficient FLR are two-stage hepatectomy (resection of tumor after induction of FLR hypertrophy) and downstaging/conversion therapy of prirmary or metastatic liver cancer. The conventional two-stage hepatectomy includes portal vein embolization (PVE) and portal vein ligation (PVL). In hepatocellular carcinoma patients, PVE combined with transarterial chemoembolization can further improve the outcomes. The associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) can significantly increase the resectability by achieving a rapid and an effective hypertrophy of the FLR, but the postoperative complication rate and mortality rate is higher??the safety and oncological results are still controversial. The downstaging/conversion therapy of primary or metastatic liver cancer have also been remarkably improved with the progression of non-surgical treatments, which has enabled more and more patients to benefit from surgery.     

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结直肠精细外科需要有丰富的解剖学知识。已经建立的直肠癌全直肠系膜切除(TME)就是很好的实例。近5年来,完整结肠系膜切除(CME)和低位直肠癌肛提肌外腹会阴联合切除术(ELAPE)的开展逐渐普及。与TME一样,CME和ELAPE均以精细解剖为基础。在结直肠外科中,相关的系膜、筋膜和间隙起着重要作用,而其命名在临床和解剖学尚有差异。本文试图清楚描述结直肠外科相关的腹盆腔系膜、筋膜和间隙,并讨论其外科意义。     

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在过去20年,肝转移灶切除术逐渐成为改善转移性结肠癌病人预后的一种颇有前景的手段,在部分病例中,还提供了长期治愈的可能。为了使转移病灶切除术的安全性和疗效最大化,适宜的术前影像学检查必不可少。CT、MRI以及PET的发展不仅改善了对隐匿病灶的检出能力,同时也优化了解剖结构的定位。MRI在发现小于厘米级大小的肝转移病灶上更有优势。CT可作为一种筛检手段或在做术前计划中比较有用,例如估算残余肝脏容积或在术前为肝动脉灌注泵的安置确定动脉解剖位置。     

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??Metastatic pattern of lymph node in differentiated thyroid cancer and regional applied anatomy of lateral lymph node dissection JIANG Jun??LI Shi-chao.Breast Disease Center, Southwest Hospital, the Third Military Medical University, Chongqing 400038, China
Corresponding author??JIANG Jun??E-mail: jcbd@medmail.com.cn
Abstract Differentiated thyroid cancer (DTC) which includes papillary and follicular thyroid cancer is the most common form of thyroid carcinoma. Most patients are low malignant types and get a better prognosis with a long survival after surgery and postoperative adjunctive treatment. Neck node dissection should be performed on patients with lymph node metastases. However, on account of special biological behavior of DTC and complicated neck dissection as well as relatively high surgical risk and accidental injury or complications, neck node dissection in patients with DTC remains controversy.     

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??Surgical treatment of liver metastases of colorectal cancer: agreement and controversy XU Jian-min??ZHONG Yun-shi. Zhongshan Hospital, Fudan University; Endocopic Research Institute, Fudan University, Shanghai 200032, China
Corresponding author: XU Jian-min, E-mail: xujmin@yahoo.com.cn
Abstract Surgery is the best treatment for liver metastases of colorectal cancer, but there are some controversy, such as: neoadjuvant chemotherapy for resectable cases, treatment of colorecal cancer for unresectale liver metastases cases, liver metastases of rectal cancer, microinvasive surgery and extra-hepatic metastases. The focus of the controversy is the hope that more liver metastases of colorectal cancer can be cured.     

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??Clinical characteristics and surgical treatment for breast cancer patients with liver metastases JIANG Jun, CHAI Fan. Breast Disease Center, Southwest Hospital, the Third Military Medical University, Chongqing 400038?? China
Corresponding author??JIANG Jun, E-mail??jcbd@medmail.com.cn
Abstract Liver is one of the common metastatic sites for breast cancer. Breast cancer patients with liver metastases (BCLM) are often insensitive to traditional therapy and have poor prognosis. Liver resection is generally adopted if the lesion is localized, which has made BCLM obtain a better outcome. However, it still need to be supported by more large-scale clinical data and evidence, especially for standard operation indication, method and combined modality therapy. Minimally invasive surgery, such as radio frequency ablation (RFA) and laser-induced interstitial thermotherapy (LITT), could provide extra options for BCLM with small tumors, but both have some clinical limitations and still need further clinical study to confirm the curative effects. Surgical treatments for BCLM with comparatively large or multiple tumors are still under exploration. Systemic treatment combined with proper surgical process can improve BCLM prognosis.     

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??The best timing of preoperative chemotherapy for liver metastases of colorectal cancer XING Bao-cai, WANG Hong-wei. Department of Hepato-bilio-pancreatic Surgery I, Peking University School of Oncology??Beijing Cancer Hospital??Beijing 100142, China
Corresponding author??XING Bao-cai, E-mail??xingbaocai88@sina.com
Abstract The combination of surgery and chemotherapy has become the standard treatment for patients with liver metastases of colorectal cancer. There is controversy that preoperative chemotherapy should be considered in patients with resectable liver metastases of colorectal cancer. The patients with prognostic factor of poor survival should be received preoperative chemotherapy. Surgery should be performed after a maximum of 6 cycles of preoperative chemotherapy. In patients with unresectable liver metastases, there is no question regarding the indication of chemotherapy. They should be carefully monitored and performed surgery as soon as the metastases become resectable. Surgery can be performed after 4 weeks from the last cycle of chemotherapy, and 6-8 weeks following chemotherapy plus bevacizumab.     

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??Totally laparoscopic ALPPS for primary liver cancer complicated with cirrhosis----application of round-the-liver ligation to replace parenchymal transection CAI Xiu-Jun*??PENG Shu-You??YU Hong??et al. *Sir Run Run Shaw Hospital??Zhejiang University??Hangzhou310016??China
Corresponding author??CAI Xiu-Jun??E-mail??cxjzu@hotmail.com
Abstract Objective To study the feasibility??effectiveness and safety of totally laparoscopic ALPPS in treating primary liver cancer complicated with cirrhosis and to introduce the experience of using round-the-liver ligation to replace parenchymal transection.Methods Retrospectively analyze the clinical data of a patient with a left-lobe liver cancer who underwent totally laparoscopic ALPPS in the Sir Run Run Shaw Hospital in May 2014.The first-stage surgery was laparoscopic ligation of the left branch of portal vein and execution of round-the-liver ligature.11 days later laparoscopic left lobectomy was carried out as the second-stage surgery.The perioperative indicators were then analyzed.Results The operation time was 290 minutes for the first-stage surgery and 160 minutes for the second-stage surgery.Liver function returned to normal 3 days after the first-stage surgery and right lobe volume increased 94.8% compared to the preoperative volume.The second-stage laparoscopic left lobectomy was then performed uneventfully and liver function gradually returned to normal after the second-stage surgery.Conclusion Both two stage operations can be safely performed laprarscopically.ALPPS also can Results in a marked and rapid hypertrophy of future remnant even in liver cancer complicated with cirrhosis.Round-the-liver ligature can replace liver parenchymal transection to reduce complications with similar therapeutic results.