肝段切除术治疗原发性肝癌

前言原发性肝癌(以下简称肝癌)是我国常见恶性肿瘤之一,其死亡率次于胃癌,位居我国第2位[1,2]。目前治疗方法多样,肝切除是肝癌治疗的首选方法[3,4]。肝癌的发生与复发同乙型肝炎和(或)丙型肝炎病毒所致的肝硬化有密切关系[5]。保留正常的肝组织是预防术后肝功能衰竭的重要措施。根据Couinaud的现代肝脏解剖学概念,完整的肝段切除可以使肝功能损害降至最低,这也符合肿瘤微创外科的治疗原则,即彻底清除病灶,缓解疼痛,又减少了病人机体和心理创伤。1解剖基础Couinaud最初把肝脏分为8段[6],每个段可视为功能和解剖上是一个独立单位,由于每个段可独立或和相连的段一起切除,这对肝脏手术的改进产生了重大影响,从而也提高了肝脏手术的安全性[7]。后来Couinaud对肝内解剖又作了进一步的研究,并在1989年发表了肝脏9段的报告[8],这在解剖和临床应用上都有重要的意义[9]。肝脏由主肝和肝背扇区2部分组成,主肝由II段至VIII段组成,肝背扇区由I和IX段组成。主肝部分为半肝、区和段3级。①正中裂将肝分为左右半肝,直接分开相邻的左内叶(IV段)与右前叶(V段和VIII段),正中裂在肝膈面为下腔静脉左壁至胆囊切迹中...     

原发性肝癌外科治疗新进展

切除术是肝癌首选的治疗方法。肝钳、肝梳、生物胶、激光刀、超声刀、低温无血切肝等新技术减少了术中出血量,规则性肝段切除术和超声导向下肝亚段切除术减少了肝切除量,体外肝手术和自体部分肝原位移植术解决了肝门区肿瘤的切除。     

肝门区肝癌姑息性切除术──附6例报告

肝门区肝癌是指发生在Ⅰ、Ⅳ、Ⅴ和Ⅷ肝段的癌肿，由于其紧靠门静脉或其主要分支，或肝静脉汇入下腔静脉附近，亦或骑跨下腔静脉，手术切除的难度和危险性大，切除率低，预后差。本文作者报告６例肝门区肝癌，采用肿瘤姑息性切除，并配合肝脏灌注化疗（一例加腹腔化疗），取得了满意疗效，除一例术后１０月因上消化道出血死亡外上其余５例随访６月、１１月、１２月、１５月、３０月均健在。作者认为，对于肝门区肝癌，只有采取积极综合治疗原则，采用姑息性切除结合肝脏灌注化疗的方法，才可望提高其疗效。     

包括腔静脉旁部的肝右尾叶及全尾叶切除

目的 探讨并总结包括腔静脉旁部肝尾叶切除的方法和经验。方法 分别采用右后途径和左侧途径行右尾叶和全尾叶切除；前者附加部分右后叶切除，后者可为单独全尾叶切除或附加左外叶或左半肝切除。结果 成功施行包括腔静脉旁部的肝尾叶切除13例，其中右尾叶切除7例，全尾叶切除6例；全组无手术死亡，术中、术后均无严重病发症发生；术后平均失血量为896.15ml，平均肝门阻断时间为25.40min，术后平均住院12.38天。结论 虽然解剖关系复杂，切除包括腔静脉旁部的肝尾叶安全可行。     

吲哚靛青绿储留率判断切肝量及其与肝癌术后肝功能不全的关系

背景与目的:肝癌术前正确评估肝脏储备功能、术中合理掌握切肝量是避免肝功能衰竭的重要措施。近年来,吲哚靛青绿储留率(indocyaninegreenretentionrateat15min,ICGR15)已被认为是反映肝脏储备功能的灵敏指标。如何根据肝脏储备功能特别是ICGR15来决定所能切除的最大肝脏体积,目前未有定论。本研究旨在探讨术前ICGR15与术中切除肝体积对术后肝功能不全的影响。方法:对225例手术切除的肝细胞肝癌患者进行研究。观察指标包括术前ICGR15的测定,术中切除的肝段数以及术后患者出现肝功能不全的情况。结果:ICGR15<10%时,切除A组(切除肝段数相当于一个肝段以内)、B组(切除肝段数大于一个肝段,但在两个肝段以内)、C组(切除肝段数大于两个肝段)肝段的腹水产生率分别为21.2%、14.3%、15.4%(P>0.05);黄疸率分别为3.0%、7.1%、15.4%(P>0.05)。ICGR15介于10%～20%时,腹水产生率分别为26.8%、38.9%、50.0%(P>0.05);黄疸率分别为0、27.8%、20.0%,(P<0.01);其中2例死亡,均切除两个或以上肝段。ICGR15>20%时,6例切除A组肝段的患者中有2人出现腹水;而仅有2例切除B组肝段的患者均出现腹水和黄疸,其中1例死亡。结论:可根据ICGR15值粗略决定肝脏切除量。ICGR15<10%时,可切除两个或更多的肝段;ICGR15介于10%～20%时,切除一个肝     

全肝血流隔离技术在肝外科手术中运用的系列研究

中山医科大学附一院黄洁夫教授改进了常温下和低温灌注下全肝血流隔离的无血切肝技术，在动物实验和临床研究的基础上改进了不同时期阻断腹主动脉和不必开胸的常温下全肝血流隔离技术以切除巨大肝肿瘤和累及肝脏大血管损伤的肝外伤的处理。为了切除侵犯第二肝门血管的巨大肝肿瘤和修复血管，研究者提出仅作健侧半肝的门静脉单源性的原位低温灌注，从上下腔静脉的肝静脉置管作灌注液出口，切肝后，肝动脉先恢复灌注，全肝血流恢复．肝脏复温后再作门静脉的修复或整形吻合。改进后的低温灌注下的全肝血流隔离手术，可以缩短肝缺血时间。该技术…     

肝门区肝癌姑息性切除术：附6例报告

肝门区肝癌是指发生在Ⅰ、Ⅳ、Ⅴ和Ⅷ肝段的癌肿，由于其紧靠门静脉或其主要分支，或肝静脉汇入下腔静脉附近，亦或骑跨下腔静脉，手术切除的难度和危险性大，切除率低，预后差。本文作者报行６例肝门区肝癌，采用肿瘤姑息性切除，并配合肝脏灌注化 例加腹腔化疗）。取得了满意疗效，除一例术后１０月因上消化道出血死亡餐，其余５例随访６月、１１月、１２月、１５月、３０月均健在。作者认为，对于肝门区肝癌，只有采取积极综合治     

肝切除手术中,术后防治出血的体会

笔者单位在１８个月内共地肝切除手术５８例，文中重点讨论肝切除手术中，术后出血的原因及防治措施，５８例中肝局部切除６例，肝段切除１０例，左外叶切除１１例，左半肝切除４例，右前叶切除３例，右后叶切除８全地肝切除１０例，中肝叶切除１例，尾状叶切除１例，左三叶切除１例，肝血管瘤捆扎术３例。     

肝尾叶切除

肝尾叶即Couinaud肝段解剖中的Ⅰ段，有独立的管道系统，为独立于左右叶的单元，有人称之为副肝[1]，因位置深，周围毗邻复杂，切除风险大，常被视为手术禁区。随着肝脏外科技术的发展，近年来肝尾叶切除已有了零星报导。本文就肝尾叶的临床解剖、影像学特征、切除指征及手术方法作一综述。一。肝尾叶毗邻与分界。肝尾叶以形态变异的几部分构成［2］：56.7％有腔静脉后突，这一突起可能包绕下腔静脉，而不是与血段相接，而在一些病例则通过含有肝细胞的纤维组织与之相连。在此处，左、右侧常有尾叶向下极的两个突起，称为尾状突和乳头突，…     

选择性出入肝血流阻断在肝切除手术中的应用

目的进一步改进无血切肝技术,提高肝脏巨大肿瘤患者的切除率和手术耐受性。方法回顾分析16例肝脏巨大肿瘤切除术,讨论选择性出入肝血流阻断方式在肝切除中的应用。结果巨大肝脏肿瘤在肝切除手术中,应用选择性出入肝血流阻断术,术中出血少,患者耐受性好,提高了肝脏手术的切除率。结论应用选择性出入肝血流阻断术可以提高肝脏巨大肿瘤的切除率和手术耐受性,为肝脏手术提供了一个合理安全的术式。     

逆行肝切除治疗难切性肝癌244例报道

目的　逆行肝切除是治疗难切性肝癌的有效方法 ,本文报道了 2 44例临床经验。方法　常规肝切除方法切除困难的 2 44例巨大、显露困难或下腔静脉受累的肝癌采用逆行切肝法结合血管外科技术予以切除 (A组 ) ,同期临床特征类似的 31例肝癌采用常规切肝法切除 ,作为对照 (B组 )。结果　两组均无手术死亡 ,A组与B组相比 ,术中出血量较少 ( 12 90± 998ml比 2 2 86± 136 3ml)、术后胸水发生率 ( 2 6 /2 44比 10 /31)、腹水发生率 ( 72 /2 44比 19/31)、中度到重度黄疸率 ( 14 /2 44比 5 /31)、手术区积液率 ( 17/2 44比 7/31)、膈下感染率 ( 3/2 44比 1/31)、胆漏发生率 ( 2 /2 44比 1/31)、切口感染率 ( 3/2 44比 1/31)以及ALT恢复时间 ( 13.8± 5 .1天比 18.9± 8.9天 )均较低 ,差别具有统计学意义 (P <0 .0 1)。结论　对于难切性肝癌而言 ,逆行肝切除是安全有效的手术方法。     

微波外科在肝肿瘤中的应用价值

从1989年10月至1990年应用微波外科治疗肝肿瘤116例,其中95例,在游离肝叶后,顺着预定的肝切除线逐点作肝组织凝固,然后沿着凝固线作肝切除术。另21例中因肿瘤较大或侵及主要肝内管道而不能切除17例,因合并重度肝硬化而不宜作肝切除术4例。作根治性肝切除的52例AFP阳性中,术后AFP降至正常者28例,明显下降但未降至正常18例,其余6例术后AFP再度上升。原发灶切除而卫星灶作微波凝固术的14例中AFP阳性9例,术后AFP均降至正常。17例单纯作微波固化术,AFP降至正常4例。微波外科在肝肿瘤手术中未见明显术后并发症。     

The possible role of sorafenib as a part of the multimodal treatment for hepatocellular carcinoma

The role of sorafenib is unclear in multimodal treatment for hepatocellular carcinoma (HCC). We analyzed patients who underwent multimodal treatment including surgical operation for advanced HCC after administration of sorafenib. A 79- year-old man underwent extended right hepatectomy for Stage III huge HCC. Three years later, multiple recurrences observed in the liver, and an extrahepatic tumor was diagnosed. Peritoneal seeding was suspected, thus we decided to start a sorafenib administration. After 11 months, new intrahepatic lesions were detected, but extrahepatic tumor was unchanged. We considered the extrahepatic tumor was solitary and resectable, and new lesions in the liver were still treatable, then we attempted a surgical treatment with partial hepatectomy and ablation therapy. The tumor was successfully resected, and residual viable tumors were treated by radiofrequency ablation. The patient remains alive without recurrence at 7 months. We could perform a surgical treatment for another 2 patients with sorafenib treatment. These results suggested that there are cases of advance HCC in which multimodality treatment including surgical treatment can be achieved after sorafenib administration.     

Central hepatectomy: The golden mean for treating central liver tumors?

The treatment of patients with central liver tumors involving segments 4, 5 and 8 is a difficult clinical problem. These tumors often straddle Cantlie's line and involve parts of both lobes of the liver. The traditional management of such tumors is to perform either an extended right or an extended left hepatectomy. However, extended hepatectomies are associated with greater morbidity and mortality, mainly due to increased risk of postoperative liver failure. Central hepatectomy (or mesohepatectomy) may be superior to extended hepatectomy, because it conserves more liver parenchyma. However, the operation can be tedious and may result in increased blood loss, and was therefore infrequently used. Recommendations for its application for centrally located tumors are not clear. The aim of our study is to evaluate the evidence supporting central hepatectomy as a safe procedure for the management of central hepatic tumors, and to describe the effectiveness of central hepatectomy compared to extended hepatectomy. We present herein two patients who underwent central hepatectomy and systematically review the English literature until December 2006. We found 13 studies of multisegmental (> or = 2 segments) central liver resection that included at least four patients. Only three retrospective non-randomized studies have looked at central hepatectomy in comparison to lobar or extended hepatectomy, and no clear consensus emerges. To date, there is insufficient evidence to categorically state that central hepatectomy is superior to extended hepatectomy, thus the use of all approaches can be justified. However, if central hepatectomy can be performed without excessive blood loss, then it should be preferred, as it is less extensive and results in greater functional remnant liver. Additionally, it would clearly be superior in patients with cirrhosis.     

Clinical analysis of renal cell carcinoma with extension into the inferior vena cava

We performed clinical analysis of 12 patients with renal cell carcinomas associated with tumor thrombosis in the inferior vena cava. Eleven cases were men, and one was a woman; their ages range from 48 to 76 years old with a mean of 58 years. Nine tumors were observed on the right side, the other 3 tumors were observed on the left side. In five cases, the distant metastases of the disease were noticed at the first visiting to our hospital. Lung metastases were found in five and bone or liver in each one. Chief complaints were macroscopic hematuria in 8 cases (67%), and were weight loss or general fatigue. The symptoms of obstruction of the inferior vena cava, such as venous dilatation of abdominal wall, edema of lower extremities and varicocele of the testes, were seen in 6 cases. The level of the tumor thrombosis was preoperatively determined by CT, echography, cavography or MRI. The level was near the right atrium in one, near the hepatic vein in 8 and near the renal vein in 3, although there was no case extending into the right atrium. Transperitoneal nephrectomy and thrombectomy in the inferior vena cava were performed in 9 cases. Surgery could not be performed in the other 3 patients of their poor general condition or severe heart disease. One patient died because of massive hemorrhage during the operation. The other complications were transient renal failure in 3 cases and postoperative bleeding in one case. In 4 patients without distant metastases or regional lymph nodes metastasis, two died of multiple metastasis of renal cell carcinomas and diabetic coma. The other two cases are alive without disease for 4 and 40 months after operation. For renal cell carcinoma extending into the inferior vena cava without metastasis, nephrectomy and thrombectomy should be performed using the extracorporeal circulation.     

累及第2肝门区巨大肝癌55例手术切除体会

Objective To investigate the possibility and surgical procedures for huge liver cancer involving the second porta hepatis.Methods 55 cases of huge liver cancer, with the diameter of 8-28 cm(mean 12.7 cm) were studied. Right subcostal or “rooftop” incision was made, the liver ligments were divided, good exposure of the tumor and access to retrohepatic inferior vena cava were achieved.Hepatectomies were completed under intermittent interruption of first porta hepatis. Occluding tape around vena cava was applied before liver resection if necessary.Results All tumors were successfully resected without death during operation.The longest survival time was now 4 years in one case. The 1-4 year postoperative survival rates were 63%,50%,50% and 30% respectively.Conclusion Young patients with solitary large liver tumor, which grows slowly over a long period on basis of non-cirrhotic or mild cirrhotic liver, should undergo an exploration in an attempt of resection irrespective of the image contraindication, provided that there is no extra-hepatic metastasis.     

Amelioration of radiation-induced liver damage in partially hepatectomized rats by hepatocyte transplantation

Hepatic tumors often recur in the liver after surgical resection. Postoperative radiotherapy (RT) could improve survival, but curative RT may induce delayed life-threatening radiation-induced liver damage. Because RT inhibits liver regeneration, we hypothesized that unirradiated, transplanted hepatocytes would proliferate preferentially in a partially resected and irradiated liver, providing metabolic support. We subjected F344 rats to hepatic RT and partial hepatectomy with/without a single intrasplenic, syngeneic hepatocyte transplantation. Hepatocyte transplantation ameliorated radiation-induced liver damage and improved survival of rats receiving RT after partial hepatectomy. We further demonstrated that transplanted hepatocytes extensively repopulate and function in a heavily irradiated rat liver.     

Effect of loss of heterozygosity of the c-kit gene on prognosis after hepatectomy for metastatic liver gastrointestinal stromal tumors

The authors have previously reported that loss of heterozygosity (LOH) of the c-kit gene could be responsible for the gain in high proliferative activity in some gastrointestinal stromal tumors (GIST), resulting in enhanced metastatic potential. In the present study, an attempt was made to identify the factors that might predict the postoperative prognosis of patients with metastatic liver GIST. The clinicopathologic or genetic features of resected liver GIST in 14 patients who had undergone a hepatectomy for metachronous liver metastases and who had not received adjuvant imatinib treatment were examined. LOH of the c-kit gene was observed in seven of 12 metastatic liver GIST (58.3%), of which DNA suitable for testing could be extracted. Ten patients had recurrence after hepatectomy and four had none. The median post-recurrent disease-free survival (PRDFS) after hepatectomy was 27.5 months (range 8–104). The tumor-specific PRDFS was examined using clinicopathologic features, c-kit mutation and LOH of the c-kit gene. No single clinicopathologic or genetic finding was significantly associated with PRDFS. However, patients with 'Ki67 labeling index <5% and LOH(–)' had a significantly longer PRDFS than those with 'Ki67 ≥5% or LOH(+)' ( P =  0.032), and there was no correlation between the presence of LOH of the c-kit gene and the Ki67 labeling index. LOH of the c-kit gene in metastatic liver seems to be a common event, and LOH of the c-kit gene in resected liver GIST may be a helpful factor in the prediction of the post-recurrent prognosis of patients with liver metastasis. ( Cancer Sci 2007; 98: 1734–1739)     

A case of the 5-year survivor of ascending colon cancer associated with synchronous multiple liver metastasis and peritoneal dissemination successfully treated with combination therapy of systemic and hepatic arterial infusion chemotherapy

A 67-year-old woman was diagnosed by a series of examinations as having ascending colon cancer with synchronous multiple liver metastasis. She underwent an operation after the PTPE (percutaneous transhepatic portal vein embolization) to the right lobe of the liver, as we considered that the metastatic liver tumors were all resectable. In the surgery, we identified seven peritoneal tumors and a lymph node swelling. We then pathologically diagnosed them as being peritoneal dissemination (p3) and lymph node metastasis (n2(+)). Therefore, hepatectomy was not performed, but the right hemicolectomy (D2) and insertion of an arterial infusion catheter into the hepatic artery were performed. In addition, all seven peritoneal tumors were resected. After being discharged from hospital, she was treated as an outpatient with the combination chemotherapy of systemic intravenous administration (5-fluorouracil or 5-FU, 2,500 mg/month) and hepatic arterial infusion (5-FU, 1,500 mg/week) for 16 months. Then, she continued to take tegafur uracil (300 mg/day) by mouth for 39 months. The metastatic liver tumors were gradually reduced and resulted in complete response (CR) for 20 months after the operation. She has been in remission for the past 5 years without recurrence. During the treatment, we noticed a complete atrophy that was sustained in the right lobe of the liver to which PTPE was performed. As far as hepatic arterial infusion chemotherapy is concerned, our case study was interesting and effective.     

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...