RESULTS OF HEPATECTOMY FOR 600 CASES WITH PRIMARY LIVER CANCER

ＲＥＳＵＬＴＳＯＦ　ＨＥＰＡＴＥＣＴＯＭＹＦＯＲ６００ＣＡＳＥＳＷＩＴＨＰＲＩＭＡＲＹＬＩＶＥＲＣＡＮＣＥＲＬｉＧｕｏｈｕｉ李国辉；ＬｉＪｉｎｑｉｎｇ李锦清；Ｚｈａｎｇｙａｑｉ张亚奇；Ｙｕａｎｙｕｎｆｅｉ元云飞；ＣｈｅｎＭｉｎｓｈａｎ陈敏山；ＧｕｏＲ...     

复发性肝癌再次肝切除的效果

在392例次肝癌切除中,19例为复发性肝癌作再次肝切除.第1次至第2次肝切除的间隔时间平均为35月.作第2次肝切除的肿瘤平均5cm.切除术的类型有剔出术4例,1肝段切除8例,2肝段切除7例.复发性肝癌再次术后生存5年以上4例,最长14年健在.已知死亡6例,其生存平均11个月,表明再次肝切除可提高复发性肝癌的生存期.     

原发性肝癌以外科为主的综合治疗(附425例报告)

目的：探讨肝癌以外科为主的综合治疗。方法：以外科为主综合治疗原发性肝癌患者425例，其中直径≤5cm的小肝癌121例。行不规则性肝叶切除134例，局部切除95例，肝叶或肝段切除123例，半肝或半肝以上切除共56例，联合脏器切除17例；切缘注射无水酒精或用渗入无水酒精的明胶海绵包埋于瘤床共39例。结果：总的手术切除率69.8%，小肝癌手术切除率90.3%；手术死亡率1.2%；术后生存5年以上118例，10年以上24例。全组术后3、5、10年生存率分别为57.2%(203/355)、51.3%(118/230)和35.3%(24/68)；其中小肝癌术后3、5、10年生存率分别为74.4%(64/86)、64.6%(42/65)和43.8%(14/32)。结论：以外科为主的综合治疗是目前治疗肝癌最有效的方法。不规则性肝切除、早期发现肝癌、综合治疗大肝癌缩小后二期切除等是提高手术切除率的主要手段；以个体化为原则的术后综合治疗可降低术后复发率，提高肝癌的治疗效果。     

巨大肝癌手术切除治疗的远期疗效

背景与目的：巨大原发性肝癌(直径≥10cm)在临床上占有较大的比例,但关于其手术切除治疗的远期疗效报道较少。本研究探讨手术切除治疗巨大肝癌的远期疗效和预后影响因素。方法：回顾性分析我院1964年至1993年经手术切除的173例巨大肝癌患者的病例资料,根据随访结果计算生存率并作单因素及多因素分析。结果：术后3、5和10年累积生存率分别为31．9％、21．8％和8．3％;生存5年以上37例,生存10年以上8例;单因素分析结果表明预后影响因素为性别、术前肝功能Child-Pugh分级、术中肝硬化程度和是否根治性切除;多因素分析得出影响巨大肝癌切除术后远期疗效的独立预后因素为术中肝硬化程度和是否根治性切除。结论：巨大肝癌应积极争取手术切除治疗,术后能否长期生存取决于肝硬化程度和是否根治性切除。     

Evaluation of partial hepatectomy for primary liver carcinoma

From 1964 to 1985, 120 cases of primary liver carcinoma had undergone hepatectomy in our hospital. Seven of these cases underwent hepatic lobectomy, 28 cases had palliative hepatic resection, and 85 cases had partial hepatectomy. We introduced different surgical modes and compared the mortality, survival rates, and complications between the hepatic lobectomy and partial hepatectomy groups. The mortality rates of these two groups were 14.3 and 3.5%, respectively, and the 1, 3, and 5 year survival rates were 83.3, 33.3, and 16.7 and 68.8, 48.1, and 20%, respectively. In the palliative hepatectomy group (28 cases), ten cases received combined radiotherapy postoperation. Most of these cases died during the first year postoperation. Primary liver cancer in Asia is commonly associated with hepatic cirrhosis. We suggest that partial hepatectomy is suitable for such patients. The results of the present series showed that the outcomes of the hepatic lobectomy and partial hepatectomy groups did not differ, but in partial hepatectomy, the operative mortality and complications were reduced, bleeding minimized, and operation time also shortened.     

巨大肝癌手术切除治疗的临床疗效

目的：通过手术切除巨大肝癌36例,总结手术经验,分析手术疗效和肿瘤复发相关因素。方法：肝门血流阻断16例,半肝血流阻断20例（右半肝阻断14例、左半肝阻断6例）。结果①无手术死亡者;②肝癌复发率为69．44％;③1、2、3年生存率分别为83．33％、44．44％、33．33％。结论巨大肝癌若肿瘤边缘清楚而且患者肝功能正常仍应积极手术切除治疗,半乳治疗,半肝阻断法提高了巨大肝癌的切除率和手术安全性,长了中晚期患者的生存时间,术后经化疗泵化对防治肝癌复发有积极作用。     

"Three-Grade Criteria" of Radical Resection for Primary Liver Cancer

OBJECTIVE The present study was designed to develop the "ThreeGrade Criteria" for radical resection of primary liver cancer (PLC) and to evaluate its clinical significance.METHODS Criteria for radical resection of PLC were summed up to 3 grades based on criterion development. Grade I: complete removal of all gross tumors with no residual tumor at the excision margin. Grade Ⅱ: on or the primary branches of the portal vein, the common hepatic duct or its dition to the above criteria, negative postoperative follow-up result including AFP dropping to a normal level (with positive AFP before surgery)within 2 months after operation, and no residual tumor upon diagnostic imaging.The clinical data from 354 patients with PLC who underwent hepatectomy were reviewed retrospectively. Based on the "Three-Grade Criteria" these patients were divided into 6 groups: Grade Ⅰ radical group,Grade Ⅰ palliative group, Grade Ⅱ radical group, Grade Ⅱ palliative group,Grade Ⅲ radical group, Grade Ⅲ palliative group. The survival rate of each group was calculated by the life-table method and the rates compared among the groups.RESULTS The survival rate of patients receiving radical treatment was better than those receiving palliative treatment (P＜0.01). Survival improved as more criteria were applied. The 5-year survival rate of the patients in Grade Ⅰ, Ⅱ and Ⅲ who underwent radical resection was 43.2%,51.2% and 64.4%, respectively (P＜0.01).CONCLUSION The "Three-Grade Criteria" may be applied for judging the curability of resection therapy for PLC. The stricter the criterion used,the better the survival would be. Adopting high-grade criteria to select cases and guide operations and strengthening postoperative follow-up would improve the results of hepatectomy for PLC.     

脓肿型肝癌诊治分析

目的探讨脓肿型肝癌（表现为肝脓肿的原发性肝癌）诊治规律,以期早期诊断早期治疗。方法回顾分析14例脓肿型肝癌,分析临床表现、既往史、辅助检查、治疗方式及预后。结果男性12例,女性2例,平均年龄为（56．4±12．6）岁。临床表现有发热、上腹痛或上腹不适、肝区叩痛等,合并乙肝6例,AFP、CA19—9升高者各有4例;病灶位于右肝者8例,位于左肝者1例,5例患者左右肝均有病灶。病灶平均直径为（8．9±3．3）cm,边界欠清晰。CT表现方面,边缘强化者2例,内部不规则强化者7例。11例患者接受了抗感染治疗,但效果不明显。10例接受病灶切除手术治疗,4例行活检术。未行手术治疗的4例患者随访时均已死亡;接受手术治疗的患者7例复发,6例已死亡。结论脓肿型肝癌术前难以与细菌性肝脓肿鉴别。是否合并乙肝,是否有AFP、CA19—9检测指标升高对术前诊断脓肿型肝癌有帮助。脓肿型肝癌诊断时病情较晚、预后差,术前抗感染治疗不应延误手术时机,应争取早期接受手术治疗。     

A successful case of preoperative intermittent hepatic arterial infusion of high-dose 5-FU and pharmacokinetic modulating chemotherapy against unresectable liver metastasis of colon cancer

A 46-year-old adult who underwent a sigmoidectomy for sigmoid colon cancer at the age of 44 was found to have a liver tumor 2 years after the first operation. His CEA was elevated to 158.8 ng/ml. An abdominal CT showed a huge mass of 10 x 7 x 7 cm in the anterior segment of right lobe of the liver invading into segment 4 and 7, which compressed the left hepatic vein and the umbilical portion of the portal vein. We diagnosed an unresectable liver metastasis of sigmoid colon cancer. Intermittent hepatic arterial infusion of high-dose 5-FU was started on a weekly schedule and oral UFT was added as pharmacokinetic modulating chemotherapy 4 weeks after the initial chemotherapy. Chemotherapy was continued for 13 weeks and the tumor shrunk up to 64%. An extended right hepatectomy was performed. Pathological examination showed residual cancer cells in the central part of the tumor, but fibrous degeneration and calcification were observed in the surrounding area and considered to be the effect of chemotherapy.     

肝动脉栓塞化疗治疗巨块型肝癌

 目的　探讨肝动脉栓塞化疗对巨块型肝癌的治疗作用。方法　回顾性分析 46例不可切除的巨块型肝癌栓塞化疗的治疗效果。肿瘤直径 1 2～ 1 9cm,平均 1 3.73± 1 .2 7cm。 35例经皮股动脉穿刺插管肝动脉栓塞化疗 ,1 1例不成功者行开腹插管肝动脉栓塞化疗。每例栓塞化疗 1～ 6次(平均 2 .4次 )。结果　 1 8例获二期切除 ;1年、2年、3年及 5年生存率分别为 73.9%、44.4%、42 .9%及 2 3.5%。结论　肝动脉栓塞化疗是不能切除的巨块型肝癌的有效治疗方法。     

肝囊腺癌的诊治(附18例报告)

目的探讨肝囊腺癌的诊治方法,提高对肝囊腺癌的认识。方法对18例在2000年1月至2004年12月在我院进行手术治疗并经病理证实为肝囊腺癌的病例进行回顾性分析,收集其临床表现、影像学及病理等资料。结果肝囊腺癌在男女发病比例为9/9,平均年龄51岁。单结节病变占94.44%(17/18),病灶平均直径约10.08cm(3-17cm),1例病灶为多发。AFP及CEA均为阴性,61.11?19.9阴性(11/18)。超声检查示病灶呈囊实性块状回声伴液化,边缘呈菜花样突起。平扫CT示:肝内低密度占位,边缘结节状突起。增强CT示:病灶结节状突起,周边强化,延迟期消失。66.67%的病灶大于10cm(12/18)。所有病例在术后均得到病理证实。其中12例位于肝左叶,3例位于肝右叶,1例位于中肝叶,1例位于尾状叶,1例肝左右叶内均有病灶。18例中6例行囊腺癌切除;2例行剖腹探察术;1例行TAE 活检;9例行肝叶切除 胆囊切除及T管引流术。其中1例行左肝叶切除 胆囊切除 胃癌根治术 淋巴结清扫。1例于术后20个月复发再次手术行胆肠吻合术,6个月后再次复发仅行PMCT,此病人死于术后胆瘘。7例患者死于复发转移。10例患者目前健在无复发和转移(平均随访时间20个月)。结论肝囊腺癌是一种少见的肿瘤,生长缓慢。该肿瘤临床特征明显。临床医师对其病理及临床特征的认识将有助于该疾病的诊治。根治性手术切除是延长患者生存期的有效方法。     

“Three-Grade Criteria” of Radical Resection for Primary Liver Cancer

OBJECTIVE The present study was designed to develop the “Three- Grade Criteria” for radical resection of primary liver cancer （PLC） and to evaluate its clinical significance. METHODS Criteria for radical resection of PLC were summed up to 3 grades based on criterion development. Grade Ⅰ： complete removal of all gross tumors with no residual tumor at the excision margin. Grade Ⅱ： on the basis of Grade Ⅰ, additional 4 requirements were added： （1） the tumor was not more than two in number; （2） no tumor thrombi in the main trunks or the primary branches of the portal vein, the common hepatic duct or its primary branches, the hepatic veins or the inferior vena cava; （3）no hilar lymph nodes metastases; （4）no extrahepatic metastases. Grade Ⅲ ： in addition to the above criteria, negative postoperative follow-up result including AFP dropping to a normal level （with positive AFP before surgery） within 2 months after operation, and no residual tumor upon diagnostic imaging.The clinical data from 354 patients with PLC who underwent hepatectomy were reviewed retrospectively. Based on the “Three-Grade Criteria” these patients were divided into 6 groups： Grade Ⅰ radical group, Grade Ⅰ palliative group, Grade Ⅱ radical group, Grade Ⅱ palliative group, Grade Ⅲ radical group, Grade Ⅲ palliative group. The survival rate of each group was calculated by the life-table method and the rates compared among the groups. RESULTS The survival rate of patients receiving radical treatment was better than those receiving palliative treatment （P〈0.01）. Survival improved as more criteria were applied. The 5-year survival rate of the patients in Grade Ⅰ, Ⅱ and Ⅲ who underwent radical resection was 43.2%, 51.2% and 64.4%, respectively （P〈0.01）. CONCLUSION The “Three-Grade Criteria” may be applied for judging the curability of resection therapy for PLC. The stricter the criterion used, the better the survival would be. Adopting high-grade criteria to select cases and guide operations and strengthening postoperative follow-up would improve the results of hepatectomy for PLC.     

Localization of small liver tumors.

Thirty-six patients with small liver tumor were diagnosed by alpha-fetoprotein (AFP); sonography, and computed tomography (CT), and underwent hepatectomy. The pathological types included 23 hepatocelluler carcinoma (HCC), 11 hepatic cavernous hemangioma, and 2 secondary liver cancer. In 22 patients, the tumor nodules were located in the right lobe and 14 cases in the left lobe. The diagnostic accuracy rate of CT was 100% for HCC and secondary liver cancer, but for hepatic cavernous hemangioma it was only 72.2%. However, the accuracy rate of sonography was as high as 81.8% for hepatic cavernous hemangioma and only 60.4% for liver malignancies. The positive rate of AFP for the HCC patients of this series was only 66.6%. The method of intraoperative detection of small liver tumor is introduced, if the tumor was invisible grossly or nonpalpable during exploratory laparotomy. In the series, 7 cases in whom the right lobe lesion was too small to be located by routine manual examination during exploratory laparotomy were detected by this method, and all small liver tumors were resected successfully.     

Evaluation of irregular hepatectomy for primary liver carcinoma

From 1964 to 1985, 120 patients with primary liver carcinoma were treated by operation in our hospital. Regular hepatectomy was done in 7 patients, palliative irregular hepatectomy in 28 and radical irregular in 85. The operation mortality was 4.2% in irregular hepatectomy group (113 cases) but 14.3% in regular hepatectomy group (7 cases) (P greater than 0.05). The 1, 3 and 5 year survival rates were 68.8%, 48.1% and 20.0% in radical irregular hepatectomy group but 83.3%, 33.3% and 16.7% in regular hepatectomy group. 10 of 28 patients treated by palliative hepatectomy were added with radiation. Majority of these patients died in 1 year after operation but 2 patients survived for more than 2 years and 1 for more than 7 years. The data show that in Asia, the incidence of primary liver carcinoma concurrent with liver cirrhosis is high and irregular hepatectomy is a suitable treatment. There is no difference between irregular and regular hepatectomy groups in the prognosis. But the former could reduce the operative time, mortality and the possibility of bleeding and complications.     

Roles of hepatectomy for colorectal liver metastases with necrotic foci caused by prior anti-cancer therapies

Recent advances in chemotherapy for colorectal cancer prolonged survival. Tumor necrosis may develop as a side effect of chemotherapeutic agents. Recently, radiofrequency ablation sometimes indicated to patients with colorectal liver metastasis, when hepatectomy cannot be performed due to impaired hepatic functional reserve or general condition. We experienced hepatectomy for colorectal liver metastasis containing necrotic foci which was induced by anti-cancer drugs and radiofrequency ablation. Massive liver necrosis and abscess developed in a patient with initially unresectable large liver metastasis 6 months after induction of mFOLFOX6 and bevacizumab. Chemotherapy was discontinued due to systemic inflammatory responses. Extended right hepatectomy resulted in both resection of the tumor and significant improvement of septic condition. Chemotherapy was re-started after the operation. Bevacizumab targeted to tumor-related vascular endotherial cells might be responsible for the massive tumor necrosis. Another patient with chronic renal dysfunction underwent radiofrequency ablation for colorectal liver metastasis 2 cm in diameter in the segment 7. Three months after ablation, the tumor grew very rapidly to 6 cm in diameter. After extended posterior sectorectomy of the liver, blood CEA levels were normalized. Resected specimen showed a massive tumor growth around the necrotic foci of radiofrequency ablation. Hepatectomy played significant roles in these patients with necrotic foci of the liver. Decision and timing of hepatectomy are very important to save the patient.     

Laparoscopic hepatectomy for liver neoplasms in 15 cases

Objective

The aim of our study was to retrospectively analyze 15 patients’ clinical materials with laparoscopic resection of liver neoplasms.

Methods

From December 2007, a total of 15 patients with liver neoplasms were performed with laparoscopic hepatectomy, and their clinical materials, perioperative dates, postoperative complications, postoperative recovery and short-term curative effects were analyzed and summarized respectively.

Results

Laparoscopic hepatectomy (LH) were performed in 15 patients, including 1 case underwent laparoscopic hepatic left lobectomy, 1 case of left lateral hepatectomy, 13 cases of partial liver resection. Fourteen cases of total laparoscopic liver resections for liver neoplasms, 1 case of hand-assisted laparoscopic liver resection of the tumor, there was no conversion to open approach. Of the 15 patients with liver neoplasms, 13 cases of hepatic neoplasms with the maximum diameter was 8 cm × 8 cm × 9 cm, 9 cases of the borderline micro hepatocellular carcinoma (MHCC) with the diameter not more than 2 cm, 3 cases of hepatic benign tumor. The mean operation time was (120 ± 30) min, and the intraoperative average hemorrhage was 100 mL, beginning to eat and get out of bed following 1–2 days of operation. The average postoperative hospitalization was 8 days, WBC, ALT, AST, albumin, bilirubin returned to normal after one week of operation. There were no postoperative complications such as hemorrhage, bile leakage or air embolism etc. Twelve patients with HCC were confirmed by postoperative pathology, 1 case of liver smooth muscle lipoma, 2 case of hepatic hemangioma. By one year of followed-up in 12 cases of HCC, the longest survival was 38 months, and no recurrence or death, 1 year survival rate was 100%.

Conclusion

Among the choice of cases, the advantages of LH for liver neoplasms compared with open surgery were less trauma, faster recovery and less blood loss. it is safe and effective for choosing a reasonable surgical indication, especially for peripheral micro hepatocellular carcinoma.     

Pedunculated hepatocellular carcinoma and surgical treatment.

To determine the optimal surgical therapy for patients with pedunculated hepatocellular carcinoma (HC), we evaluated findings in ten patients with pedunculated HC among 350 patients with HC who underwent hepatectomy from 1975 to 1991 at Kyushu University Hospital. These patients were classified into three groups: Group I (n = 4) Pedunculated HC with no intrahepatic HC, Group II (n = 2) Pedunculated HC with a single intrahepatic HC, and Group III (n = 4) Pedunculated HC with multiple intrahepatic HC. Patients in group I and II were treated by partial hepatic resections or subsegmentectomies. In two patients there was an intrahepatic recurrence in the same lobe, after radical resection. All patients in group III who underwent palliative resection died within 8 months after surgery. Retrospectively, we favour the view that patients in Groups I or II may have had a better prognosis if lobectomy rather than partial hepatectomies had been done.     

肝部分切除与肝十二指肠韧带骨髂化治疗肝门部胆管癌

Objective To summarize the surgical experience of partial hepatectomy with skeletonization of the hepatoduodenal ligament in the treatment of hilar cholangiocarcinoma.Methods Between Jan.1999 and Dec,2001,67 consecutive patients with hilar cholangiocarcinoma underwent surgical exploration at the Second Military Medical University,Eastern Hepatobiliary Surgery Hospital.The clinical data of these patients were reviewed.Results Of the 67 patients,65(97%) underwent surgical resection.Fourty-nine patients(73%) received curative resection:22 skeletonization resection(SR) and 27 SR combined with partial hepatectomy.In 16 patients(9%) with curative resection the tumor margin was histologically postive and the resection was therefore considered palliative.The tumors were classified according to Bismuth with SR was type Ⅱ(17cases),various types of partial hepatectomy with SR was type Ⅲ and type IV.Right lobectomy with right caudate lobectomy was indicated in type Ⅲ(6cases),left lobectomy with complete caudate lobectomy in type Ⅲb(15cases),right loobectomy with complete caudate lobectomy(3 cases),left lobectomy with complete caudate lobectomy(9 cases) and quadrate lobectomy(2 cases)in type IV.SR and left lobectomy with complete caudate lobectomy was successfully performed in 2 patients(3%) who had undergone palliative biliary resection and cholangiojejunostomy before.Eight patients(12%) had local resecton of the tumor with Roux-en-Y hepaticojejunostomy reconstruction using intrahepatic stents.Two patients(3%) had palliative biliary drainage.Combined portal vein resection was performed in 13 patients(20%) and hepatic artery resection in 27 patients(40%) .Twenty-four atients(36%) had no postoperative complication,23 patients(34%) had minor complications only ,and the remaining 20 patients(30%) had major complications.Of the 20 patients with major complications,14 recovered,the remaining 6 patients died from hepatorenal failure with other organ failures,from myocardial infarction or from intraabdominal or gastrointestianl bleeding 7,12,14,42,57 or 89 days after surgery.The 30-day operative mortality was 4.5%.The mean survival of the patient with curative resecton was 16 months(range 1-32 months);for those undergong palliative resection mean survival was 7 months(range 1-14months).Conlusion Partial hepatectomy with SR for hilar cholangiocarcinoma can be performed with acceptable morbidity and mortality.For curative treatmet of hilar cholangiocarcinoma,caudate lobectomy is always recommended in Bismuth Ⅲ/IV.     

Surgical treatment of hilar bile duct carcinoma

From June, 1986 to June 1989, 24 cases of hilar bile duct carcinoma were explored in the Surgical Department of General Hospital of PLA, 16/24 cases were resected, a resectability rate of 66%. The increase of resectability rate was due to earlier recognition of this condition and the extension of surgery, including major resection of liver as well as radical dissection of the hepato-duodenal ligament and repairative operations on the blood vessels. Among these 16 cases, major hepatic resection was performed in 10 cases, in which, 3 cases of resections of the middle lobe of the liver were done instead of right or extended right lobectomy. No operative mortality in the 30 days’ postoperative period, but the postoperative morbidity rate was still high and most of the complications were related to biliary leakage and infection. Three patients died in the follow up period at 6, 14 and 15 months respectively. All of them died from biliary infection. The remaining 13 patients were still alive, the longest being 40 months and the average living time was 16.1 months. Probably, lowering of the operative mortality rate and morbidity rate are still the most important considerations in the surgical treatment of hilar carcinoma at the present time. Extensive liver resection especially on the right side, carried a high mortality rate in the deeply jaundiced patients. We considered that preoperative PTCD was of much less value than that used in lower bile duct obstruction such as tumors of the periampullary region. Preservation of the superior and posterior portion of the right lobe of the liver may be of advantages as to lowering postoperative hepatic failure and infection of the right subphrenic space as observed in this series of cases.     

Assessment of future remnant liver regeneration after portal vein embolization using three‐dimensional CT and MR volumetric analyses

The purpose of this study is to portray right portal vein embolization (PVE) as a valuable technique that helps in expanding the volume of the left liver lobe and discuss the relevant published work. We describe our experience with four patients who underwent PVE and analyse the value of CT and MRI in the preoperative evaluation of these patients. Four patients with hepatic malignancy (hepatocellular carcinoma) (n = 2) and metastatic liver disease (n = 2) underwent portal vein occlusion. PVE was carried out in three patients using polyvinyl alcohol and stainless steel coils. Portal vein ligation was carried out in the fourth patient. In patients who were candidates for right hepatectomy, CT volumetric analysis was carried out before the surgery to assess the total liver volume and the future remnant liver, which is the residual left hepatic volume (in cases of right hepatectomy) or left lateral segment volume (in cases of right tri‐segmentectomy). Because the left lobe volumes were insufficient, patients were selected to undergo right PVE. Computed tomography volumetry was carried out 2–4 weeks after embolization to assess left hepatic lobe regeneration. Magnetic resonance volumetric analysis was carried out in two patients before and after embolization. All four patients had significant regeneration of the left lobe and tolerated the surgery with uneventful postoperative recovery.