选择性门静脉栓塞在肝叶切除术中的临床应用

手术切除肝脏巨大肿瘤或多发性转移瘤的安全性已大为提高,但半肝或肝三叶切除术后残余肝脏的功能不全仍困扰着外科医师。1986年,日本学者Kinoshita等提出选择性门静脉栓塞（portal vein embolization,PVE）作为扩大肝切除术前准备,并应用于肝癌的治疗。PVE使栓塞侧肝叶萎缩,而非栓塞侧肝叶代偿性增生,     

Benefit of percutaneous transhepatic portal vein embolization for extended hepatectomy

Severely locally advanced biliary cancer requires extended hepatectomy in many cases. Percutaneous transhepatic portal vein embolization (PTPE) is effective to expand the residual liver volume and to avoid postoperative hepatic failure. The ratios of increase in the expected residual liver volume after PTPE are about 10% in cases with right lobar or right trisegment embolization and about 7% in cases with left trisegment embolization. After the introduction of the PTPE technique in our department, the morbidity rate from hepatic failure and mortality rate decreased from 33.3% to 23.8% and from 21.9% to 9.5%, respectively. The technique of PTPE has contributed to an improved survival rate for patients with severely advanced biliary cancer.     

Preoperative portal vein embolization for hepatocellular carcinoma

As a countermeasure to portal tumor thrombi, which are a serious danger in liver cancer, we did portal vein embolization (PVE) during percutaneous transhepatic portography. Our 21 patients later underwent hepatic resection. After PVE, portal pressure increased and there was slight liver function damage, but this procedure was safer than transarterial embolization (TAE). We examined the pathologic specimens to view the state of occlusion achieved and also for histological findings, and found that Lipiodol ® mixed with fibrin was most effective. PVE done before hepatic resection strengthened the anticancer effect of TAE, prevented intrahepatic metastases, and caused permanent hypertrophy of the liver that may be useful as a kind of preparation for surgery.

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Resumen En el Japón en años recientes se diagnostica con mayor frecuencia la presencia de pequeños carcinomas hepatocelulares. Sinembargo pequeños tumores comunmente dan lugar a trombos tumorales en la vena porta, complicación que empeora el pronóstico. Aún la embolización transarterial (ETA), que es efectiva contra el cáncer hepático, tiene casi ningún efecto contra los trombos tumorales. Como una medida contraria ante los trombos tumorales de la vena porta, los cuales significan tan alto riesgo en el cáncer del hígado, nos propusimos realizar embolización de la vena porta (EVP) en el curso de la portografía percutánea transhepática. Nuestros 21 pacientes fueron posteriormente sometidos a resección hepática. Después de EVP, la presión en la vena porta ascendió y se observó leve alteración de la función hepática, pero el procedimiento résultó más seguro que la ETA. Se hizo exámen de los especímenes patológicos para determinar el grado de oclusión obtenido y los hallazgos histológicos y se encontró que el Lipiodol ® mezclado con fibrina fue el material más efectivo. La EVP realizada con anterioridad a la resección hepática incrementa el efecto anticancerígeno de la ETA, previene el desarrollo de metástasis intrahepáticas y causa hipertrofia del hígado, o sea regeneración del hígado del tipo que se produciría con la resección, efecto que puede ser beneficioso como preparación del paciente para cirugía.

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Résumé Pour prévenir les dangers inhérents à la thrombose tumorale portale qui représente un danger sérieux en cas de cancer du foie, les auteurs procèdent à l'embolisation veineuse portale au cours de la portographie percutanée transhépatique. Les 21 malades traités par cette méthode subirent ensuite une résection hépatique. Après l'embolisation portale veineuse la pression portale augmente et les fonctions hépatiques sont légèrement altérées mais la méthode est moins dangereuse que l'embolisation artérielle. Les spécimens prélevés ont été examinés pour juger de l'efficacité de l'obstruction veineuse et aussi pour apprécier l'état histologique. Il a été constaté que l'association Lipiodol ®-fibrine pour réaliser l'embolisation veineuse était l'agent embolisant le plus efficace. La méthode pratiquée avant la résection hépatique dépasse l'effet anticancéreux de l'embolisation artérielle, prévient la dissémination des métastases hépatiques et provoque l'hypertrophie du foie restant fait qui peut être considéré comme utile avant d'avoir recours à l'exérèse du parenchyme hépatique.

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Presented at the Société Internationale de Chirurgie in Paris, September 1985.

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Supported in part by a Grant-in-Aid for Cancer Research (59-6) from the Ministry of Health and Welfare.     

Preoperative percutaneous transhepatic portal vein embolization to extend the indications for hepatectomy and to increase the safety of extended hepatectomy for hepatocellular carcinoma]

The usefulness of preoperative percutaneous transhepatic portal vein embolization (PTPE) in extending the indications for hepatectomy and increasing the safety of extended hepatectomy for hepatocellular carcinoma was studied in 21 patients who underwent right hepatic lobectomy with PTPE of the right first portal branch (group E), in 15 such patients but without PTPE (group N), and in seven such patients who underwent PTPE at this location but could not undergo surgery (group U). The mean volume of the left lobe increased but the results of a 15-minute indocyanine green retention test were worsened 2 weeks after PTPE and again 4 weeks after hepatectomy, but these changes after hepatectomy were almost the same in groups E and N. The worsening of liver function and coagulation test results was less in group E than in group N. The mean prognosis score was better in group E two weeks after PTPE than before, but not in group U. The four patients in group E with high portal vein pressure (> or = 30 cmH2O) or a high prognosis score (> or = 50 points) after PTPE developed hepatic failure after surgery. Preoperative PTPE was useful in extending the indications for hepatectomy and increasing the safety of extended hepatectomy. Evaluation of the clinical course after PTPE was also useful when decisions about the operative method to be used were being made.     

Preoperative portal embolization increases safety of hepatectomy

Postoperative liver failure following major hepatectomy is a frightened complication. In order to increase safety of major hepatectomy, a study evaluating preoperative portal embolization (PE) was performed. Between 1983 and 1990, PE was performed in 71 patients (41 with hepatocellular carcinoma (HCC), 8 with other liver tumors, and 22 with biliary carcinoma), in 63 cases to the main branch, prior to hepatectomy. Out of these 63 patients 42 (extended) hemihepatectomies were performed. For comparison 77 patients with the same extent of hepatectomy, but without PE, were studied. Liver volume was evaluated by CT examination. Portal venous pressure was elevated by 73 mmH2O just after embolization of the main portal branch. However, no complications were associated to the PE procedure except for temporary elevation of transaminases. Volume of the unembolized lobe increased by 8.8% in average following PE. Prominent volume gain was observed in the patients with prior arterial embolization and long observation period. In patients with PE prior to major hepatectomy, postoperative bilirubin values were significantly lower (p less than 0.01). In the group with PE, no fulminant liver failure was seen and no operative mortality was encountered, as compared to 11.7% (9/77) in the control group. Preoperatively performed PE was a safe procedure decreasing postoperative liver failure and mortality.     

Preoperative portal vein embolization for hepatocellular carcinoma]

We performed preoperative portal vein embolization (PVE) for 71 patients with hepatocellular carcinoma (HCC), 59 of whom underwent hepatectomy about two weeks after PVE. The purpose of the PVE was usually to embolize the portal vein supplying the area to be resected. After PVE, the non-embolized part of the liver became hypertrophic and the embolized part of the liver became atrophic. Of the 22 patients who underwent right lobectomy after PVE of the right first branch of the portal vein, the mean results of a test of 15-minute indocyanine green retention after PVE increased significantly less than the mean for six patients who could not undergo right lobectomy after PVE of their right first branch. The extent of this increase and the liver volume of the left lobe 4 weeks after right lobectomy were higher in another 15 patients who did not undergo PVE than 22 patients who underwent PVE. PVE is useful as one preparation for hepatectomy of patients with HCC, because the embolized part of the liver was damaged by PVE, but mean liver function was compensated by the part of the liver that was not embolized and regenerated.     

门静脉栓塞术在二期精准肝切除中的应用

目的: 探讨门静脉栓塞术在二期精准肝切除的应用。方法: 分析7例在超声扫描及X线数字减影血管造影引导下,经皮经肝穿刺门静脉栓塞术后,行二期精准肝切除术的肝癌病人临床资料。分成肝硬化组3例和无肝硬化组4例,分别检测门静脉栓塞术前和术后肝功能指标及肝体积变化,总结二期手术切除。结果: 7例病人均成功实施经皮经肝穿刺门静脉栓塞术,其中6例病人达到肝脏体积代偿增大的预期效果,顺利完成二期精准肝切除术。1例结肠直肠癌肝转移病人在门静脉栓塞8周后,未栓塞肝脏代偿性增大体积未达到精准肝切除的条件,转外院顺利行拯救性联合肝脏离断和门静脉结扎的二步肝切除术。两组经皮经肝穿刺门静脉栓塞术后1 d,肝功能指标较术前升高（P<0.05）,予护肝治疗3~7 d后降至术前水平。未发生严重并发症。结论: 门静脉栓塞技术成功率高、安全可行。剩余肝脏代偿性增大明显,可显著提高二期精准肝切除手术率。     

Preoperative selective portal vein embolization before hepatectomy for liver metastases: long-term results and impact on survival

BACKGROUND: Some patients cannot undergo curative surgical procedures for liver metastases because of the risk of severe postoperative hepatic failure, which stems from a too-small future remaining liver (FRL). Preoperative portal vein embolization (PVE) is an effective means of creating hypertrophy of the FRL, thus permitting safe hepatic resection. The aim of this retrospective study was to investigate the long-term results of this technique. METHODS: Sixty-eight patients underwent PVE. Of those, 60 (88%) subsequently underwent hepatic resection. Indication for PVE was an estimated FRL ratio (assessed by volumetric computed tomography) of less than 30%. However, if the patient had undergone multiple courses of chemotherapy, the threshold was 40%. The origin of the primary neoplasm was colorectal in 41 patients (68%); in the remaining 19 (32%), the primary neoplasms originated at other sites. RESULTS: Mean growth of the estimated FRL measured by computed tomography 1 month after PVE was 13%. Major complications after hepatectomy occurred in 27% of the patients, and the operative mortality rate was 3%. For the 60 patients who underwent PVE followed by hepatic resection, the 5-year overall survival rate and the disease-free survival rate were 34% and 24%, respectively. The 5-year overall survival rate and the disease-free survival rate of patients with colorectal metastases only were 37% and 21%, respectively. CONCLUSIONS: The long-term survival rate after PVE followed by resection is comparable with the survival rate obtained after resection without preoperative PVE. The 5-year survival rate of patients undergoing PVE followed by hepatectomy justifies the use of this technique. This technique thus increases the suitability of resection as a treatment choice for patients with liver metastases. PVE should number among the therapeutic options available to every hepatic surgeon.     

门静脉栓塞术后右肝切除术的初步体会

为提高大体积肝切除手术的安全性,我们对8例右半肝或扩大右半肝切除病人进行了手术前门静脉栓塞,现将我们的体会介绍如下.资料和方法1.病例资料:8例病人中男7例,女1例.年龄:36～65岁,平均48.5岁.其中原发性右肝癌6例,病灶直径9～20 cm,平均15 cm.4例有肝炎后肝硬化.Bismoth Ⅲa型肝门部胆管癌1例,在经皮经肝胆管造影引流至血清总胆红素明显下降后行门静脉栓塞术.结肠癌右肝转移癌病人1例,曾经过6个疗程的连续化疗.8例病人术前肝功能状态均为Child A级.     

Preoperative portal vein embolization improves prognosis after right hepatectomy for hepatocellular carcinoma in patients with impaired hepatic function

BACKGROUND: Percutaneous transhepatic portal vein embolization (PTPE) increases the safety of subsequent major hepatectomy. The aim of this study was to determine the effect of PTPE on long-term prognosis after hepatectomy in patients with hepatocellular carcinoma (HCC). METHODS: Seventy-one patients with HCC underwent right hepatectomy between 1984 and 1998. Preoperative PTPE was performed in 33 patients (group 1) and was not used in 38 patients (group 2). Outcome after operation was compared between the groups. The patients were further divided according to the median tumour diameter (cut-off 6 cm) and indocyanine green retention rate at 15 min (ICGR15) (cut-off 13 per cent). RESULTS: The cumulative survival rate was significantly higher in group 1 than in group 2 in patients with an ICGR15 of at least 13 per cent. Tumour-free survival rates were similar in both groups. Of patients with tumour recurrence after right hepatectomy, those in group 1 were more frequently subjected to further treatment. CONCLUSION: Preoperative PTPE improves the prognosis after right hepatectomy for HCC in patients with impaired hepatic function, although it does not prevent tumour recurrence.     

Preoperative portal vein embolization for major liver resection: a meta-analysis

INTRODUCTION: Preoperative portal vein embolization (PVE) is used clinically to prevent postoperative liver insufficiency. The current study examined the impact of portal vein embolization on liver resection. METHOD: A comprehensive Medline search to identify all registered literature in the English language on portal vein embolization. Meta-analysis was performed to assess the result of PVE and its impact on major liver resection. RESULT: A total of 75 publications met the search criteria but only 37 provided data sufficiently enough for analysis involving 1088 patients. The overall morbidity rate for PVE was 2.2% without mortality. Four weeks following PVE, 85% patients underwent the planned hepatectomy (n = 930). Twenty-three patients had transient liver failure following resection after PVE (2.5%) but 7 patients developed acute liver failure and died (0.8%).The reason for nonresection following PVE (n = 158, 15%) included inadequate hypertrophy of remnant liver (n = 18), severe progression of liver metastasis (n = 43), extrahepatic spread (n = 35), refusal to surgery (n = 1), poor general condition (n = 1), altered treatment to transcatheter artery embolization or chemotherapy (n = 24), complete remission after treatment with 3 cycles of fluoracil and interferon alpha in a patient with hepatocellular carcinoma (n = 1), incomplete pre- or postembolization scanning (n = 8). Of those who underwent laparotomy without resection, (n = 27) reasons included intraoperative finding of peritoneal dissemination (n = 15), portal node metastasis (n = 2), severe invasion of the tumor to the hepatic artery and portal vein (n = 1), and gross tumoral extension precluding curative resection (n = 9).Two techniques were used for portal vein embolization: percutaneous transhepatic portal embolization, (PTPE) and transileocolic portal embolization, (TIPE). The increase in remnant liver volume was much greater in PTPE than TIPE group (11.9% vs. 9.7%; P = 0.00001). However, the proportion of patients who underwent resection following PVE was 97% in TIPE and 88% PTPE, respectively (P = <0.00001). Although there was no significant difference in patients who had major complications post-PVE, the rate for minor complications was significantly higher among patients who had PTPE (53.6% vs. 0%, P = <0.0001). CONCLUSION: PVE is a safe and effective procedure in inducing liver hypertrophy to prevent postresection liver failure due to insufficient liver remnant.     

门静脉栓塞术在肝脏肿瘤二期切除中的应用

目的 探讨门静脉栓塞术在肝脏肿瘤二期切除过程中的作用与安全性。方法 分析总结5例难以一期切除肝脏肿瘤,先行门静脉栓塞术后再行二期肿瘤切除患者的临床资料。所有患者均采用B超及DSA引导下经皮肝门静脉左支穿刺法对门静脉右支进行栓塞。检测门静脉栓塞术后肝功能及肝叶体积变化,总结门静脉栓塞与肿瘤二期切除手术成功率。结果 5例患者均成功实施PVE术,术后出现一过性的肝功能减退,经保肝治疗短期恢复,未栓塞侧肝脏体积代偿性增大明显,达到预期效果;所有病例均顺利完成二期肝叶切除术,术后肝功能良好。结论 门静脉栓塞术成功率高、安全可行,对侧肝脏代偿性增大明显,达到预期目的,使得难以一期切除的肝脏肿瘤可以切除,从而提高肝脏肿瘤的切除率。     

肝脏肿瘤肝切除术前选择性门静脉栓塞的临床应用

目的 探讨选择性门静脉栓塞技术细节及其在残余肝容积不足患者肝切除术前应用的临床意义.方法 2008年1月至2012年7月,6例肝脏肿瘤因残余肝容积不足,二期肝切除术前行选择性门静脉栓塞术.结果 6例选择性门静脉栓塞术均成功.无手术并发症,栓塞对肝功能影响轻微.术前,6例残余肝容积平均(474.33 ±89.19) cm3,术后6周,平均(722.67±151.51) cm3,术前术后残余肝容积比较差异有统计学意义(t=-5.587,P=0.003).术前6例肝脏肿瘤负荷(瘤体总体积)平均(134±181) cm3,栓塞术后6周,肿瘤负荷平均为(270±346) cm3,栓塞前后肿瘤负荷比较差异无统计学意义(t=-1.64,P=0.16).5例二期肝切除术顺利.1例未行肝切除术.随访中位时间为37个月,4例存活(2例无瘤生存),1例死亡.结论 门静脉选择性栓塞是肝切除前增加残余肝容积的有效技术手段;经同侧(患侧)人路并选择弹簧圈作为栓塞材料简单易行、安全、有效.门静脉栓塞前,应以化疗或选择性肝动脉化疗栓塞等手段有效控制肿瘤生长.     

Beneficial effects of arterialization of the portal vein on extended hepatectomy

BACKGROUND: Extended hepatectomy may result in postoperative liver failure. The aim of this study was to evaluate the effects of arterialization of the portal vein on oxygen supply, hepatic energy metabolism and liver regeneration after extended hepatectomy. METHODS: Portal haemodynamics were evaluated 0 or 10 days after arterialization of the portal vein in three experimental groups: 85 per cent partial hepatectomy, 85 per cent partial hepatectomy 10 days after arterialization of the portal vein and 85 per cent partial hepatectomy 10 days after ligation of the hepatic artery. Survival rates, weight of the regenerating liver, levels of adenine nucleotides and hepatic energy charge were assessed. RESULTS: Arterialization of the portal vein caused a significant increase in partial pressure of oxygen and oxygen saturation. Portal blood flow 10 days after arterialization was significantly increased. Survival rate and weight of the regenerating liver in the group with arterialization of the portal vein were significantly higher than those in the other two groups. The group with arterialization of the portal vein showed the highest levels of adenosine 5'-triphosphate. CONCLUSION: The increase in portal blood flow and oxygen supply produced by arterialization of the portal vein has beneficial effects on hepatic energy metabolism and liver regeneration, and leads to improved survival after experimental extended hepatectomy.     

扩大肝部分切除术后入肝门静脉动脉化对大鼠血流动力学的影响

目的对大鼠行扩大肝部分切除术后利用右肾动脉行入肝门静脉动脉化加门腔分流术,研究该术式对大鼠门静脉血流动力学的影响。方法 Sprague-Dawley大鼠130只,分为A组(动脉化组)47只,行70%扩大肝部分切除术后,用右肾动脉行门静脉动脉化加门腔分流术;B组(肝切组)43只,行70%扩大肝部分切除及右肾切除,阻断门静脉10min;C组(对照组)40只,仅行右肾切除及门静脉主干游离。分别于术后第2、7、14、28天检测门静脉压力、内径和血流量。结果 A组及B组手术成功率分别为85.1%和93.0%,差异无统计学意义,C组手术成功率100%。术后各时间点A组与B、C组比较,入肝门静脉压力、门静脉内径、血流速度和入肝血流量变化均较后两组更明显(P0.01);A组入肝门静脉压力随时间推移有下降趋势,于术后第14天(12.7±0.7)cmH2O达到稳态,与术后第28天(12.4±0.6)cmH2O比较,差异无统计学意义;而A组门静脉内径、血流速度和入肝血流量在术后各时间点间相比差异无统计学意义。B组术后门静脉血流速度均较C组增快(P0.05),门静脉血流量在术后14～28d较C组增加(P0.05)。结论大鼠扩大肝部分切除术后行入肝门静脉动脉化模型稳定可靠,手术成功率理想,动脉化术后门静脉压力明显升高,门静脉内径出现扩张以适应压力变化,入肝血流量明显增加。门静脉血流动力学指标在术后早期即发生改变并取得稳态。     

肝切除术前门静脉栓塞疗效的荟萃分析

目的 探讨肝切除术(右半肝、扩大半肝切除术)前应用门静脉栓塞(portal veinembolization,PVE)的临床价值.方法 通过电子检索Pubmed、Medline、Ovid数据库,对1986至2008年有关右半肝或扩大半肝切除术前行PVE的病例对照研究资料进行meta分析.结果 共纳入文献9篇,494例患者.荟萃分析结果 显示,PVE手术组较单纯手术组术后肝功能衰竭的发生率降低(P=0.02),但两者术后手术死亡的差异无统计学意义(P>0.05);亚组分析肝细胞癌和结直肠癌肝转移PVE手术组较单纯手术组1、3、5年生存率差异无统计学意义(P>0.05);1篇文献报道结肠癌肝转移发生率PVE手术组术后肝内复发转移发生较单纯手术组降低(P=0.001),而其他远处转移发生率相对增高(P=0.004).结论 术前行PVE能够有效降低术后肝功能衰竭的发生,但临床医师应当谨慎把握行术前PVE的指征.     

术前选择性门静脉栓塞在肝癌二期切除中的应用

目的 探讨术前选择性门静脉栓塞(POSPVE)后不能手术切除的原发性肝癌(HCC)二期切除的可能性。方法 采用B超引导下经皮经肝细针门静脉分支穿刺栓塞法对26例不能手术切除的HCC病人行POSPVE，栓塞剂由无水乙醇、碘油按1：2比例配制，以0．4ml/kg为标准，平均用量26．5ml。观察手术成功率及术后不良反应、肝功能改变、各肝叶体积及肝切除率的动态变化、二期手术切除率等指标。结果 POSPVE成功24例(92．3％)，右侧门静脉支栓塞的21例栓塞后，右肝体积逐步减小，栓塞前、栓塞后1，2，3周体积分别为683．7，657．4，621．3，604．1cm^3，左肝体积逐步增大，栓塞前、栓塞后1，2，3周体积分别为332．2，343．7，375．1，392．8cm^3。肝切除率逐步下降，栓塞前、栓塞后1，2，3周分别为66．3％、65．4％、62．7％、59．2％。POSPVE后出现不同程度的肝区隐痛、恶心呕吐、低热和以肝酶、胆红素升高为主的肝功能减退。POSPVE后2—3周，12例(46．2％)完成了肝切除术。结论 POSPVE扩大肝癌肝切除手术的适应证，提高手术的安全性，具有确定的临床实用价值。     

Preoperative hepatic venous embolization for partial hepatectomy combined with segmental resection of major hepatic vein

BACKGROUND: Liver resection of segments VII and/or VIII sometimes requires segmental resection of the right hepatic vein in patients with liver tumours invading or located close to the hepatic vein. In this situation, hepatic vein reconstruction is thought to have an important role in the postoperative function of segment VI. This study investigated whether preoperative embolization of the major hepatic vein could obviate the need for hepatic vein reconstruction after cranial partial resection of the liver including the major hepatic vein trunk in a preclinical model. METHODS: Sixteen beagles were divided into two groups of eight: control group (hepatectomy alone) and hepatic venous embolization (HVE) group (hepatectomy after HVE). HVE was performed 2 weeks before hepatectomy. All dogs underwent resection of the cranial third of the left lateral liver lobe together with the major trunk of the left hepatic vein. Following hepatectomy, survival, histological features, portal venous pressure and serum aspartate aminotransferase (AST) levels were determined. RESULTS: Six control animals and seven in the HVE group were alive 1 week after hepatectomy. Immediately after hepatectomy, portal venous pressure was significantly higher in the control group compared with the HVE group (mean(s.d.) 14.0(1.1) versus 8.1(1.0) mmHg; P < 0.01). Histological examination of the remnant left lateral lobe demonstrated patchy parenchymal haemorrhage in the control group and normal parenchymal architecture in the HVE group. Peak AST levels were observed on day 1 in both groups and were significantly higher in the control group (mean(s.d.) 182(42) versus 67(40) units/l; P < 0.01). CONCLUSION: In this model, preoperative HVE facilitated interlobar venous collateral formation and minimized the untoward effects of segmental hepatic vein resection. This procedure may obviate the need for hepatic vein reconstruction after cranial partial liver resection including the major hepatic vein.