累及膈肌的第二肝门部肿瘤精准肝切除手术体会

目的:总结累及膈肌的位于第二肝门处肝肿瘤手术切除经验体会。方法:对辽宁省肿瘤医院2012 年1月至2017年2月实施的6例累及膈肌的第二肝门肝肿瘤临床资料和手术方法进行分析、总结。结果:全部病例均取得满意的手术切除和成功的术中止血,手术切除率为100%;术后出现膈下感染1例,胸腔积液3例,经穿刺治疗后痊愈;围手术期死亡率为0。结论:完善的手术前精准评估和科学的手术设计,依赖于手术中的精准操作可以达到对于累及膈肌的第二肝门部肿瘤的安全、整块切除。     

60例第二肝门部肿瘤切除的术后护理经验

目的总结60例第二肝门部肿瘤切除术后的临床护理经验。方法对东莞市人民医院肿瘤外科2005年1月至2010年8月手术切除的60例第二肝门部肿瘤患者的临床资料及护理经验进行回顾性分析。结果全组手术均获成功。术后出现并发症11例,发生率为18.3%,包括术后早期术野大出血2例(3.3%),上消化道出血1例(1.7%),胆汁瘘2例(3.3%),肝功能代偿不全3例(5.0%),右胸积液3例(5.0%)。1例因大出血及肝肾功能不全而于术后4日放弃治疗(按死亡计算),围手术期死亡率1.7%,其余病例经积极术后治疗与护理康复出院。结论经过恰当的术后护理与治疗,第二肝门部肿瘤切除术后可顺利康复出院。护理的主要经验是应针对术后可能出现的专科并发症(术区出血、消化道出血、胆汁瘘、膈下感染、肝功能代偿不全、胸腔积液)进行全方位的预防、观察与处理。     

肝门部胆管癌的诊断及不可切除肝门部胆管癌的治疗研究进展

肝门部胆管癌（hilar cholangiocarcinoma,HCCA）在亚洲的发病率较高,我国是发病率及死亡率最高的国家之一。HCCA早期症状隐匿,临床诊断较为困难,患者就诊时多处于癌症晚期,失去手术机会;对于不可切除HCCA,不同治疗方法的疗效不尽相同。本文基于一些现有的临床试验,对HCCA的诊断及不可切除HCCA的治疗研究进展进行综述,旨在为HCCA的临床诊断及治疗提供参考。     

联合肝叶切除治疗肝门部胆管癌的疗效分析

背景与目的：肝门部胆管癌(hilar cholangiocarcinoma,HC)侵袭途径广泛以及术后缺乏有效辅助治疗,目前患者获得治愈的惟一途径依然是手术根治性切除。术前可切除性评估、术前胆道引流、肝切除的范围及淋巴结清扫范围等问题一直是研究的热点。本文探讨联合肝叶切除治疗HC的临床经验及疗效。方法：回顾性分析昆明医科大学第一附属医院2007年1月—2013年10月行手术治疗的207例HC患者的临床及随访资料。结果：全组207例患者中,125例行根治性切除(R₀切除),R₀切除率为60.4%。联合肝叶切除156例,肝叶切除组获R0切除率70.5%;51例行单纯性切除,单纯性切除组获R₀切除率29.4%,两组比较R₀切除率差异有统计学意义(P<0.01)。2例患者死于围手术期,术后主要并发症包括肝肾功能不全和胆漏。获得随访的172例中,102例行R₀切除的患者中位生存时间为45个月,术后1、3、5年累积生存率分别为96.1%、59.1%、17.2%,70例行R_1-2切除的患者中位生存时间为26个月,术后1、3年累积生存率分别为81.3%、19.2%,无5年存活患者。获得R₀切除患者术后生存率优于姑息性切除(R_1-2切除)患者,差异有统计学意义(χ²=39.121,P<0.01)。在联合肝叶切除组中获R₀切除患者术后1、3、5年生存率为97.8%、63.9%、18.0%,在单纯性切除组中获R₀切除患者术后1、3、5年生存率为83.3%、20.8%、8.3%,两组术后生存率差异有统计学意义(χ²=5.988,P=0.014)。结论：根治性切除是提高HC远期疗效的关键,联合肝叶切除及标准化淋巴结清扫可显著提高HC的根治性切除率及远期疗效。     

肝门部胆管癌的手术治疗体会

目的探讨肝门部胆管癌的手术切除方式及影响手术切除的因素。方法回顾性分析32例肝门胆管癌的生长方式,病理类型,手术方式及影响手术切除的因素。结果32例中大体病理呈乳头状3例,结节型5例,硬化型22例,弥漫性癌2例;侵犯门静脉9例,其中侵犯肝组织2例,肝内转移1例;侵犯肝动脉2例。组织学呈高分化腺癌9例,中分化腺癌16例,低分化腺癌7例。按Bismuth分型:Ⅰ型7例,Ⅱ型9例,Ⅲa型7例、Ⅲb型5例,Ⅳ型4例,切除率分别是85.71%、77.78%、57.14%、100.00%、50.00%。手术切除24例中联合肝叶切除11例,血管切除4例,获根治性切除18例,住院期死亡2例,术后胆漏1例。结论肝门胆管癌以高、中分化腺癌多见,主要沿胆管壁浸润生长,常横向侵犯周围血管及肝组织。影响手术切除的主要因素是肿瘤向近端胆管壁浸润长度、门静脉受累情况及肝功能耐受能力。联合肝段和血管切除可以提高根治性切除率。     

血管切除及重建治疗肝门部胆管癌

目的 分析肝门部胆管癌患者的预后及术后并发症的发生率,探讨血管切除及重建在肝门部胆管癌治疗中的价值.方法 对117例行手术探查的肝门部胆管癌患者病例资料进行回顾性分77析.结果术后病理检查提示,在切除的血管标本中,有82.6%的门静脉血管外膜和50.O%的肝动脉血管外膜被肿瘤侵犯.无血管切除组吻合口瘘和肝功能衰竭的发生率与肝动脉切除组比较,差异有统计学意义(P＜0.05),而与单纯门静脉切除组比较,差异无统计学意义(P＞0.05).无血管切除组患者的1、3、5年生存率分别为59.0%、34.0%和16.0%,与单纯门静脉切除组和肝动脉切除组比较,差异有统计学意义(P＜0.05);非手术切除组患者的1、3、5年生存率分别为13.O%、0和0,与单纯门静脉切除组比较,差异有统计学意义(P＞0.叭),而与肝动脉切除组比较,差异无统计学意义(P＞0.05).结论 联合门静脉切除和肝动脉切除均能提高肝门部胆管癌的根治切除率.门静脉切除及重建,不仅能改善部分患者的预后,也不增加手术风险;而肝动脉切除及重建对患者的预后无明显影响,但增加了手术风险.     

脾静脉应用于肝门部肿瘤切除术中门静脉入肝血流通道重建2例报告

肝门部肿瘤在临床上常指第一肝门部肿瘤[1 ] ,多见于左右肝管及其汇合部等胆管来源肿瘤 ,原发性肝癌常侵犯肝门结构或肝门部发生淋巴结转移癌。由于肝门部结构非常复杂 ,常常使得该处许多手术难以进行 ,影响手术实施的主要原因之一是门静脉受到肿瘤侵犯。有学者报道切取大隐静脉重建门静脉入肝血流通道 ,但此方法需另做切口 ,做 2个血管断端吻合 ,操作费时 ,同时需暂时阻断门静脉入肝血流 ,可能会导致肝脏缺血性损害。我们认为脾静脉为门静脉一粗大分支[2 ] ,可替代门静脉主干或与门静脉左右分支吻合重建门静脉入肝血流通道 ,且不需预先阻断…     

肝门部胆管癌36例治疗体会

我科自１９８５年１月至１９９８年８月共收治的,经手术,病理证实的肝门部胆管细胞癌３６例,占同期胆管癌４９．１％。现报道如下。临床资料一般资料　本组男２３例,女１３例,年龄４５～７８岁,平均５９．９岁。合并胆管结石８例,肝吸虫１１例。临床表现　本组病例黄疸２４例,占总数８１％,其中无痛性黄疸２３例,占黄疸数的８０％;上腹部不适,胀痛,伴畏寒发热７例,搔痒１９例。有１６例误诊为“黄疸型肝炎”治疗２至４周不等。辅助检查　３６例均行Ｂ超检查,显示肝内胆管轻至中度扩张３４例,肝门部软组织肿块１６例。２９例…     

联合肝叶切除的肝门部胆管癌R0级根治术明显延长患者生存期

目的:本文通过分析单个医学中心5年期间所实施的肝门部胆管癌手术治疗病例资料,确定影响患者术后生存的因素。方法:收集并分析西安交通大学医学院第一附属医院肝胆外科2003-2007年实施102例肝门部胆管癌根治术患者的临床资料,通过统计学方法分析影响患者术后生存期的因素。结果:25例(24.5%)患者入院时丧失接受根治性手术机会,仅行PTBD减黄治疗。77例患者接受开腹手术治疗,67例(87.0%)患者接受根治性切除,其中51例(76.1%)患者术后证实达到R0级。接受开腹手术患者术后1月的并发症发生率为20.8%,术后1月无患者死亡。单因素分析发现联合肝叶切除的根治术、R0级根治术、较好的肿瘤分化程度、肿瘤大小和未发生淋巴结肿瘤转移均影响患者术后的生存期。多因素分析证实联合肝叶切除的根治术和R0级根治术是影响患者术后生存的独立因素。结论:达到R0级的联合肝叶切除的肝门部胆管癌根治术明显延长患者术后生存期,可考虑成为肝门部胆管癌外科治疗的金标准。     

联合肝叶切除的肝门部胆管癌R0级根治术明显延长患者生存期

目的：本文通过分析单个医学中心5年期间所实施的肝门部胆管癌手术治疗病例资料,确定影响患者术后生存的因素。方法：收集并分析西安交通大学医学院第一附属医院肝胆外科2003-2007年实施102例肝门部胆管癌根治术患者的临床资料,通过统计学方法分析影响患者术后生存期的因素。结果：25例（24.5%）患者入院时丧失接受根治性手术机会,仅行PTBD减黄治疗。77例患者接受开腹手术治疗,67例（87.0%）患者接受根治性切除,其中51例（76.1%）患者术后证实达到R0级。接受开腹手术患者术后1月的并发症发生率为20.8%,术后1月无患者死亡。单因素分析发现联合肝叶切除的根治术、R0级根治术、较好的肿瘤分化程度、肿瘤大小和未发生淋巴结肿瘤转移均影响患者术后的生存期。多因素分析证实联合肝叶切除的根治术和R0级根治术是影响患者术后生存的独立因素。结论：达到R0级的联合肝叶切除的肝门部胆管癌根治术明显延长患者术后生存期,可考虑成为肝门部胆管癌外科治疗的金标准。     

术中肝动脉合并门静脉插管化疗预防肝癌手术后复发

目的 :研究原发性肝癌根治性切除以后肝动脉和门静脉插管皮下埋置药物泵预防肝癌肝内复发的效果。方法 :回顾性研究 5 4例根治性切除肝癌术后的患者 ,其中切除肿瘤后肝动脉和门静脉插管的患者为 3 1例 ,未做插管的 2 3例。随访 2～ 3年 ,对结果进行比较。结果 :插管组 1、2年以及 3年的复发率均低于未插管组。结论 :原发性肝癌根治性切除手术合并肝动脉和门静脉插管皮下埋置药物泵是预防肝癌复发的有效方法     

肝癌二期切除20例临床分析

目的：探讨不能切除肝癌的二期切除合理治疗方法。方法：自１９８６年１月至１９９８年１月间,收治１４０例不能切除的原发性肝癌病例,经各种不同的治疗后２０例获二期切除。结果：本组二期切除率为１４．２９％。术后１年、３年、５年生存率分别为９５．０％、６３．５％￣３２．９％。其中位生存期为４６．２９人结论：多种综合治疗方式与单一治疗方式进行预治疗的两组病例中,以前者获得较高的二期切除率（２４．１４％）与长期     

Hepatic resection versus transcatheter arterial chemoembolization for the treatment of hepatocellular carcinoma with portal vein tumor thrombus

BACKGROUND:

The long‐term survival outcomes of hepatic resection (HR) compared with transcatheter arterial chemoembolization (TACE) for resectable hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT) are unclear.

MATERIALS AND METHODS:

Between December 2002 and December 2007, 201 consecutive patients diagnosed with resectable HCC with PVTT received HR as an initial treatment in our center. These patients were compared with 402 case‐matched controls selected from a pool of 1798 patients (with a 1:2 ratio) who received TACE as an initial treatment during the study period. PVTT was classified to 4 types: PVTT involving the segmental branches of the portal vein or above (type I), PVTT extending to involve the right/left portal vein (type II), the main portal vein (type III), or the superior mesenteric vein (type IV).

RESULTS:

The 1‐, 3‐, and 5‐year overall survivals for the HR and TACE groups were 42.0%, 14.1%, and 11.1% and 37.8%, 7.3%, and 0.5%, respectively (P < .001). On subgroup analyses, the overall survivals for the HR group were better than the TACE group for type I PVTT, type II PVTT, single tumor, and tumor size >5 cm (P < .001, P = .002, P < .001, P < .001, respectively), but not for type III PVTT, type IV PVTT, multiple tumors, and tumor size <5 cm (P = .541, P = .371, P = .264, P = .338, P = .125, respectively). Multivariate analysis showed the type of PVTT and initial treatment allocation were significant prognostic factors for overall survival.

CONCLUSIONS:

Compared with TACE, HR provided survival benefits for patients with resectable HCC with PVTT, especially for those with a type I PVTT or a type II PVTT. Cancer 2012. © 2012 American Cancer Society.     

Interferon-alpha and 5-fluorouracil combination therapy after palliative hepatic resection in patients with advanced hepatocellular carcinoma, portal venous tumor thrombus in the major trunk, and multiple nodules

BACKGROUND: The authors reported previously the beneficial effects of interferon (IFN)-alpha/5-fluorouracil (5-FU) combination therapy for patients with advanced hepatocellular carcinoma (HCC) who have tumor thrombi in the major portal branches. In this report, the authors describe the results from IFN/5-FU chemotherapy for patients who underwent palliative hepatic resection for advanced HCC with tumor thrombus in the main trunk of the portal vein and multiple nodules in the whole liver. In addition, they evaluated the correlation between the response to such therapy and expression of IFN-alpha type 2 receptor (IFNAR2). METHODS: From October 1999 to December 2004, 30 patients with advanced HCC, tumor thrombi in the main trunk of the portal vein, and multiple nodules in the whole liver (Vp4 and grade 3 intrahepatic metastases) were recruited for this study. They underwent palliative hepatic resection followed by at least 2 courses of IFN/5-FU. IFNAR2 expression levels were determined by immunohistochemistry. RESULTS: No major treatment-related complications were noted. An objective response was noted in 10 patients (33.3%) and included a complete response in 6 patients (20%), a partial response in 4 patients (13.3%), no response in 1 patient (3.3%), and progressive disease in 19 patients (63.4%). IFNAR2 expression was detected in 20 of 30 patients (66.7%). There was a significant difference in overall survival between patients with positive and negative IFNAR2 expression cases (P<.0025), and a significant correlation was observed between IFNAR2 expression and response to IFN/5-FU combination therapy (P=.0199). CONCLUSIONS: Adjunct IFN/5-FU therapy is a promising modality for patients with advanced HCC, tumor thrombi in the major trunk, and multiple nodules after palliative hepatic resection. The results from this study indicated that the response to such therapy seemed to be correlated with IFNAR2 expression.     

原发性肝癌并门静脉癌栓的临床治疗进展

肝癌患者的治疗效果不佳,生存期不长。合并癌栓是进行肝癌临床分期、选择治疗方法、评估预后等方面的重要参考指标。原发性肝癌合并门静脉癌栓的治疗方法众多,主要包括外科手术、介入治疗、放射治疗、分子靶向治疗及系统化疗等。目前多学科治疗（MDT）开展综合治疗是趋势,也是提高疗效的途径及发展方向。最近,国内首个肝癌门静脉癌栓多学科诊治达成中国专家共识,将为肝癌门静脉癌栓患者的诊断治疗提供指导性意见推动我国肝癌诊治水平的不断提高。     

Combined portal vein resection in the treatment of hilar cholangiocarcinoma: A systematic review and meta-analysis

Objective

To analyse the efficacy and safety of portal vein resection for hilar cholangiocarcinoma (HCCA).

Methods

A thorough search of PubMed, the Cochrane Library, Embase, the Chinese BioMedical Literature (CBM), and the Chinese Medical Current Contents (CMCC) databases was performed to identify comparative studies concerning combined portal vein resection (PVR) versus surgery without portal vein resection (Without PVR) and no surgical tumour resection (NR) in the treatment of HCCA.

Results

Thirteen studies with a total of 1921 HCCA cases were included. The results of the meta-analysis revealed that PVR was associated with a poorer overall survival than Without PVR (HR = 1.90; 95%CI 1.59–2.28; P < 0.00001) but was significantly better than NR (HR = 0.33; 95%CI 0.26–0.41; P < 0.00001). The PVR group exhibited significantly higher rates of advanced disease and a higher proportion of lymph node metastasis (OR = 1.50; 95%CI 1.06–2.13; P = 0.02) and perineural invasion (OR = 2.95; 95%CI 1.80–4.84; P < 0.0001), and the PVR group exhibited a lower curative resection rate (OR = 0.65; 95%CI 0.46–0.91; P = 0.01). No significant differences were found between the two groups with respect to postoperative mortality and morbidity.

Conclusions

Combined PVR is safe and feasible in the treatment of HCCA when the portal vein is grossly involved. For advanced HCCA when the portal vein is grossly involved, surgical resection including PVR can benefit the overall survival in certain patients. However, further randomised controlled trials are necessary to determine the prognostic effects of the addition of PVR to the surgical procedure.     

The impact of portal vein resection on outcomes for hilar cholangiocarcinoma: A multi-institutional analysis of 305 cases

BACKGROUND. Surgical strategy for hilar cholangiocarcinoma often includes hepatectomy, but the role of portal vein resection (PVR) remains controversial. In this study, the authors sought to identify factors associated with outcome after surgical management of hilar cholangiocarcinoma and examined the impact of PVR on survival.

METHODS:

Three hundred five patients who underwent curative‐intent surgery for hilar cholangiocarcinoma between 1984 and 2010 were identified from an international, multi‐institutional database. Clinicopathologic data were evaluated using univariate and multivariate analyses.

RESULTS:

Most patients had hilar cholangiocarcinoma with tumors classified as T3/T4 (51.1%) and Bismuth‐Corlette type II/III (60.9%). Resection involved extrahepatic bile duct resection (EHBR) alone (26.6%); or hepatectomy and EHBR without PVR (56.7%); or combined hepatectomy, EHBR, and PVR (16.7%). Negative resection (R0) margin status was higher among the patients who underwent hepatectomy plus EHBR (without PVR, 64.2%; with PVR, 66.7%) versus EHBR alone (54.3%; P < .001). The median number of lymph nodes assessed was higher among the patients who underwent hepatectomy plus EHBR (without PVR, 6 lymph nodes; with PVR, 4 lymph nodes) versus EHBR alone (2 lymph nodes; P < .001). The 90‐day mortality rate was lower for patients who underwent EHBR alone (1.2%) compared with the rate for patients who underwent hepatectomy plus EHBR (without PVR, 10.6%, with PVR, 17.6%; P < .001). The overall 5‐year survival rate was 20.2%. Factors that were associated with an adverse prognosis included lymph node metastasis (hazard ratio [HR], 1.79; P = .002) and R1 margin status (HR, 1.81; P < .001). Microscopic vascular invasion did not influence survival (HR, 1.23; P = .19). Among the patients who underwent hepatectomy plus EHBR, PVR was not associated with a worse long‐term outcome (P = .76).

CONCLUSIONS:

EHBR alone was associated with a greater risk of positive surgical margins and worse lymph node clearance. The current results indicated that hepatectomy should be considered the standard treatment for hilar cholangiocarcinoma, and PVR should be undertaken when necessary to extirpate all disease. Combined hepatectomy, EHBR, and PVR can offer long‐term survival in some patients with advanced hilar cholangiocarcinoma. Cancer 2012. © 2012 American Cancer Society.