不阻断肝血流状态下左半肝切除术的临床前瞻性研究

目的前瞻性分析研究不阻断肝血流状态下行左半肝切除术的临床可行性。方法 32例左半肝切除术患者随机分成AB两组:A组(n=16肝切除时阻断入肝血流);B组(n=16肝切除时不阻断入肝血流)。比较两组患者的相关临床及手术资料。结果两组患者在术中出血量、手术时间、并发症、术后住院天数等临床资料的差异无统计学意义;但不阻断肝血流组患者术后1、3天ALT、AST水平明显低于阻断肝血流组,有统计学差异。结论不阻断肝血流的左半肝切除术是一种安全、有效、可行的手术切除方法,但其总体疗效并不优于阻断肝血流。     

Rupture of the hepatic artery after left hemihepatectomy for hilar bile duct carcinoma

Hilar bile duct carcinoma has a poor prognosis, but this has been improved in recent years by an aggressive surgical approach. We treated a 73-year-old woman who had obstructive jaundice due to bile duct carcinoma at the hepatic hilum. The jaundice decreased after percutaneous transhepatic biliary drainage. The tumor was resected with the left and caudate lobe of the liver and a part of portal vein. The right hepatic artery was located behind the common hepatic duct, and was suspected to be invaded by the tumor. We dissected the tumor from the arterial wall without carrying out combined resection of the hepatic artery. On the 6th postoperative day, the hepatic artery ruptured and the patient suffered hypovolemic shock. Resection of the hepatic artery and reconstruction were done, but the patient died 2 days later. Histological examination of the resected artery showed that the tumor had been curatively removed by dissection and that no tumor remained at the arterial wall. The rupture of the right hepatic artery was thought to have been caused by damage to the wall during the dissection procedure.     

腹腔镜与开腹左半肝切除术治疗肝脏恶性肿瘤的疗效对比

目的:探讨腹腔镜左半肝切除术治疗肝脏恶性肿瘤的安全性、可行性及其相较开腹手术的临床优势。方法:回顾分析2015年1月至2017年12月行左半肝切除术的147例恶性肿瘤患者的临床资料,其中腹腔镜左半肝切除术42例(腔镜组),开腹左半肝切除术105例(开腹组)。对比分析两组术中、围手术期及术后随访资料。结果:两组患者性别、年龄、肿瘤直径、各项血生化指标、合并疾病等临床资料差异无统计学意义(P>0.05)。腔镜组手术时间[(196.3±48.6)min vs.(225.7±69.1)min]、术中出血量[(232.6±68.3)mL vs.(302.7±108.4)mL]、术后排气时间[(3.4±0.8)d vs.(4.9±1.3)d]及术后住院时间[(6.8±2.1)d vs.(9.4±2.6)d]均低于开腹组,差异有统计学意义(P<0.05);术后第1天、第3天、第7天,腔镜组转氨酶水平、血清白蛋白水平均优于开腹组,差异有统计学意义(P<0.05)。在术后并发症方面,开腹组术后总并发症发生率为37.1%,高于腔镜组的9.5%(P=0.002);其中开腹组术后切口液化发生率高于腔镜组(P=0.030),但两组胆漏、顽固性腹水、腹腔出血及切口感染等并发症发生率差异无统计学意义(P>0.05)。腔镜组术后1年、2年及3年生存率分别为93.6%、84.6%与66.9%,开腹组为94.5%、81.4%与68.5%,两组各时点生存率差异无统计学意义(P=0.708)。结论:腹腔镜左半肝切除术治疗肝脏恶性肿瘤是安全、可行的,腹腔镜手术的术中及术后恢复情况优于开腹手术。     

Techniques of Inflow Occlusion for Liver Resection

Limited resection can be a therapeutic approach in patients with cirrhosis with very low remnant hepatic function after resection. In this study, two hilar vascular clamping methods (hilar selective clamping [n=13] and hilar lobar clamping method [n=8]), which were used for resection ofhepatocellular carcinoma in patients with cirrhosis, were compared based on cardiovascular stability during clamping, intraoperative bleeding, operative time and postoperative course. In the past, the Pringle method had been used (n=19) and those instances were included for comparison. The mean operation time of the lobar clamping group was 209 ± 44 minutes, which was significantly less than that of the selective clamping group (259 ± 44 minutes, p < 0.05). Furthermore, the mean intraoperative blood loss of the lobar clamping group was 920 ± 400 milliliters, which was significantly less than that of the selective clamping group (1,640 ± 590 milliliters, p < 0.01). The postoperative total bilirubin and glutamine-oxaloacetic transaminase levels tended to be high in the Pringle group, but there was no significant difference between the groups. Although the blood pressure during clamping significantly decreased in all groups, the decrease was profound in the Pringle group as compared with those in the other two groups. Thus, as a method for controlling afferent bloodflow during hepatic resection in patients with cirrhosis, we recommend the lobar clamping method as a simple, safe and effective way to minimize bleeding and maintain cardiovascular stability.     

Right-sided hemihepatectomy in the closed hepatic trauma (clinical observation and review of the literature)

A case observation of a severe closed hepatic injury, treated using right-sided hemihepatectomy after primary suturing with tamponade performance and angiographic embolization of right hepatic artery, is presented. The literature review for this problem is presented with special attention to modern approaches in the treatment of the injured persons, suffering hepatic trauma. Various methods of treatment of hepatic injuries are analyzed as well as indications for their usage and efficacy. The tactics of conservative treatment in trauma of IV-V severity grade in the injured persons in conditions of a stable hemodynamics state presence was elaborated. The interventional radiology methods are more widely used in the patients, to whom conservative therapy is conducted or while their stable state is achieved, using a tamponade performance. While unstable state presence during the surgical treatment conduction a tendency is observed to use a "damage control" tactics.     

Prospective analysis of valvular replacement without venting the left ventricle.

The present study is a prospective analysis of a series of consecutive valve replacement and combined (valvular plus coronary artery) operations performed without left ventricular decompression. Results indicate that left ventricular venting (direct or indirect) is unnecessary provided that cardioplegic arrest is used, that the venous line is positioned in the right atrium, and that left-sided pressures are monitored. Left ventricular distention, as measured by left ventricular pressure recording, did not occur; air embolism, as determined clinically and by electroencephalographic (EEG) monitoring, was not encountered. The routine use of a left ventricular vent has been abandoned in most intracardiac operations at our center.     

保留左肝管主干的前入路左半肝切除术在预防胆漏中的应用

目的探讨保留左肝管主干的前入路左半肝切除术在治疗左肝内胆管结石预防胆漏中的应用价值。方法回顾性分析泰州市人民医院2008年1月至2016年9月行左半肝切除术治疗的左肝内胆管结石患者75例,其中行保留左肝管主干的前入路左半肝切除术37例(前入路组),传统入路左半肝切除术38例(传统组),比较两组手术时间、术中失血量、住院天数及术后胆漏并发症的差异。结果所有病例均顺利完成手术。两组的性别、年龄、肝功能Child-Pugh分级的比较无统计学差异,前入路组较传统组手术时间短[(153.27±19.55)min vs(184.26±22.41)min,t=-6.38,P0.01],术中出血量少[(109.78±18.41)m L vs(317.71±28.14)m L,t=-37.76,P0.01],住院时间短[(10.16±0.65)d vs(15.39±1.03)d,t=-26.32,P0.01],术后胆漏并发症例数少(1 vs 13,χ~2=12.26,P0.01)。结论保留左肝管主干的前入路左半肝切除术可减少手术时间、术中失血量和住院时间,并显著减少术后胆漏发生率,在左半肝切除治疗左肝内胆管结石中值得推广。     

腹腔镜规则性左半肝切除术治疗左肝内胆管结石

目的 探讨完全腹腔镜规则性左半肝切除术治疗左肝内胆管结石的可行性及安全性.方法 2007年1月至2011年6月,区域性控制左半肝入肝血流情况下,运用多种器械对8例左肝内胆管结石患者行完全腹腔镜规则性左半肝切除术.结果 所有患者均成功完成手术,手术时间100~255min(平均173min),术中出血量为100~500mL(平均225mL),术后第1天自行下地活动,术后1~2d拔除胃肠减压管、进食,术后1周左右(平均7.1d)出院,术后无严重并发症发生,术后无结石残留、复发.结论 腹腔镜规则性左半肝切除术治疗左肝内胆管结石是安全和可行的,同时具有微创的优势,是治疗左肝内胆管结石的一种较好选择.     

腹腔镜左半肝切除术治疗肝胆管结石的应用研究

目的:探讨完全腹腔镜左半肝切除术治疗左肝胆管结石病的临床应用价值。方法:回顾分析2013年6月至2015年9月为33例左肝胆管结石患者行腹腔镜左半肝切除术的临床资料。在腹腔镜下行左半肝切除、胆道检查并放置T管。术后6周行超声、CT、胆道镜检查或T管造影了解有无结石残留等并发症。患者均得到随访。结果:31例患者顺利完成腹腔镜手术,2例中转开腹,术中生命体征平稳,手术时间平均(177±56)min,术中出血量平均(317±57)ml,术后胃肠功能恢复时间24~48 h,平均(29.0±15.3)h,术后48~72 h拔除腹腔引流管。术后1例发生胆漏,经引流后痊愈;1例出现切口感染,经加强换药、调整血糖后痊愈,1例患者出现膈下积液,行穿刺引流治愈。平均住院(8.7±1.7)d。术后随访1~24个月,均恢复良好,无胆道狭窄、结石复发等并发症发生。结论:由经验丰富的腹腔镜医师开展腹腔镜左半肝切除术治疗左肝胆管结石是安全、可行的,值得临床推广应用。     

Left hemihepatectomy with microsurgical reconstruction of the right-sided hepatic vasculature

BACKGROUND: Right hemihepatectomy (RH) for proximal bile duct cancer occasionally results in liver failure. We report the feasibility of left hemihepatectomy (LH) with vascular reconstruction (VR) of the right-sided hilar vessels to preserve hepatic reserve. METHODS: Among 110 patients with proximal bile duct cancer (PBC) treated between January 1980 and December 1998, 11 patients underwent LH with VR of eight portal veins and nine hepatic arteries, and 14 underwent RH with VR of four portal veins and one hepatic artery. Microsurgical techniques were used in 80% (8/10) of the hepatic arterial reconstructions. RESULTS: Although operation time was significantly longer in the LH group, hospital mortality, blood loss and incidence of histologically cancer positive margin at the bilioenteric anastomotic site were similar in the two groups. Peak serum liver enzyme concentration was significantly higher in the LH group with longer inflow occlusion time, whereas peak serum total bilirubin concentration was significantly higher in the RH group, which had smaller liver remnant. No liver abscess occurred in any patients who underwent microvascular reconstructions. The cumulative survival of the LH group was worse than that of the RH group, in which the proportion of vascular invasion was lower, but not significantly. CONCLUSION: LH with right-sided microvascular reconstruction is technically possible and a feasible option when RH is likely to result in postoperative liver failure.     

不同肝血流阻断方法在肝切除术中的效果比较

目的比较Pringle法（Pringle组）、选择性门脉血流阻断法（selective portal venous exclusion,SPVE,SPVE组）及Glisson鞘选择性入肝血流阻断法（selective Glisson sheath exclusion,SGSE,SGSE组）在肝脏切除手术中的效果及临床意义。方法回顾性分析2006年8月至2012年3月期间于中南大学湘雅医院采用上述3种肝脏血流阻断方法行肝脏切除手术患者的临床资料,比较3组患者的手术时间、血流阻断时间、失血量、输血率、术后肝功能、并发症发生率及住院时间指标。结果 3组患者的术前情况、手术时间、血流阻断时间、肿瘤特征、术后血常规及肝功能、住院时间及ICU时间的差异均无统计学意义（P〉0.05）;SGSE组患者的术中出血量及输血者比率均明显少或低于Pringle组和SPVE组（P〈0.05）;SPVE组和SGSE组术后各时间（除术后第1天外）的AST及ALT较Pringle组改善明显（P〈0.05）,TBIL在第3、5天较Pringle组显著改善（P〈0.05）;SPVE组和SGSE组的并发症发生率低于Pringle组（P〈0.05）。结论 SGSE法能够在相似的手术时间和血流阻断时间内,能更好地控制患者的术中出血量与输血率,有利于术后肝功能的恢复,并降低了术后并发症的发生,具有一定的优越性。但手术时仍要根据实际情况选择阻断方式。     

常规腹腔镜及腹腔镜超声下左半肝切除术治疗 原发性肝癌的临床疗效比较

目的:对比分析常规腹腔镜与腹腔镜超声(LUS)下左半肝切除术围手术期相关指标、并发症情况及预后,为临床术式选择提供可借鉴依据。方法:选择2013年3月至2016年3月140例行左半肝切除术的原发性肝癌患者作为研究对象,按手术方法将患者分为观察组与对照组,每组70例。观察组在LUS下行左半肝切除术,对照组行常规腹腔镜左半肝切除术。对比两组围手术期指标、术后并发症及术后3年生存情况。结果:观察组术中出血量[(311.21±59.43)mL vs.(415.81±88.42)mL,t=8.215,P0.001]少于对照组,术中肝中静脉损伤发生率(0 vs.14.29%,χ~2=8.723,P=0.003)低于对照组。两组手术时间、病灶切缘距离、术后肛门首次排气时间、引流管拔管时间及术后并发症发生率差异均无统计学意义(P0.05)。两组术后3年无进展生存率(45.71%vs.38.57%,χ~2=0.732,P=0.392)、总生存率(64.29%vs.58.57%,χ~2=0.482,P=0.487)差异均无统计学意义。结论:LUS与常规腹腔镜左半肝切除术治疗原发性肝癌的术后并发症、预后相近,但LUS有助于减少术中肝中静脉损伤及术中出血量。     

Occlusion of left internal mammary artery with intra-aortic balloon: clinical implications

Obstruction of the left internal mammary artery by a malpositioned intra-aortic balloon in patients undergoing coronary bypass grafting may erroneously preclude its use during the procedure or may cause a potentially fatal reduction in coronary flow postoperatively in patients with left internal mammary grafts.     

保留尾状叶左半肝切除治疗左肝内胆管结石

目的 分析左肝内胆管结石行左肝外叶切除术后结石复发的危险因素及对策.方法 回顾性分析湖南省浏阳市人民医院1998年4月-2008年8月263例因左肝内胆管结石行左肝外叶切除病例的临床资料,对出现术后结石复发患者各影响因素进行x2检验,并分析结石复发的独立危险因素.并回顾性分析2008年9月-2013年6月,对高危险因素的左肝内胆管结石患者行保留尾状叶左半肝切除后,与左肝外叶切除术后胆道镜次数进行x2检验.结果 单因素分析显示:肝脏Ⅳ段有萎缩、左肝管开口处狭窄、肝脏Ⅳ段有结石及肝脏Ⅳ段有纤维化与左肝内胆管结石行左肝外叶切除术后结石复发有关联(P =0.000);对结石复发的高危险因素病例行保留尾状叶左半肝切除,比较两种手术方式术后胆道镜次数,发现保留尾状叶左半肝切除的手术方式能显著减少术后胆道镜次数(P=0.000).多因素非条件Logistic回归分析结果显示:肝脏Ⅳ段萎缩、左肝管开口处狭窄和肝脏Ⅳ段结石是左肝内结石行左肝外叶切除术后,结石复发的独立危险因素(P＜0.05).结论 肝脏Ⅳ段萎缩、左肝管开口处狭窄和肝脏Ⅳ段结石是左肝内结石行左肝外叶切除术后,结石复发的独立危险因素;保留尾状叶左半肝切除是处理这种危险因素的理想治疗方法.     

腹腔镜与开腹左肝内胆管结石左半肝切除术疗效对比

目的探讨腹腔镜与开腹左半肝切除术治疗左肝内胆管结石的临床疗效与安全性。 方法回顾性分析2010年1月至2013年12月收治的左肝内胆管结石患者73例,分为腹腔镜组(35例)和开腹组(38例)。采用SPSS17.0软件对数据进行统计学分析,两组患者术中术后等计量资料以( ±s)表示,采用独立t检验;术中输血率、止痛药使用率、术后结石清除率、结石复发率及并发症发生率等计数资料组间比较采用χ²检验,以P<0.05差异有统计学意义。 结果腹腔镜组患者手术时间长于开腹组,术中出血量、术中输血率、止痛药使用率、肛门排气时间、下床活动时间、恢复饮食时间以及平均住院时间均明显短(低)于与开腹组(P<0.05);两组患者术后结石清除率、结石复发率及并发症发生率比较差异无统计学意义(P>0.05)。 结论腹腔镜左半肝切除术治疗左肝内胆管结石是安全可行的,具有局部创伤小、术后恢复快等优势。     

Duodenal ulcer penetration into the liver at the previous left hemihepatectomy site

INTRODUCTIONDuodenal ulcer penetration into the liver is a rare, but serious complication. Its frequency was thought to have decreased owing to advances in therapies for peptic ulcers. However, we encountered a case in which the duodenal ulcer had penetrated into a previous hemihepatectomy site.PRESENTATION OF CASEA 69-year-old man with a history of left hemihepatectomy 20 months previously presented to the emergency room with sudden-onset abdominal pain and nausea. An upper gastrointestinal examination with a fiberscope revealed a giant ulcer in the duodenal bulb. In addition, a foreign body was detected at the ulcer floor and was strongly suspected of being a ligature from previous hemihepatectomy.DISCUSSIONThe presence of a gas-filled liver mass and bowel wall thickening with inflammatory changes are important imaging findings for prompt diagnosis of such a condition, but in this case, none of these were reported. Further, no definite abscess was found. Thus, the patient was treated conservatively with a proton pump inhibitor.CONCLUSIONThis case demonstrates the importance of using absorbable suture materials, adequate lavage in the postoperative peritoneal space and gastroduodenal mucosal protection postoperatively.     

A Prospective Randomized Controlled Trial to Compare Pringle Manoeuvre with Hemi-hepatic Vascular Inflow Occlusion in Liver Resection for Hepatocellular Carcinoma with Cirrhosis

Background

The duration of hepatic vascular inflow occlusion and the amount of intraoperative blood loss have significant negative impacts on postoperative morbidity, mortality and long-term survival outcomes of patients who receive partial hepatectomy for hepatocellular carcinoma (HCC) with cirrhosis.

Aim

This study aimed to compare the perioperative outcomes of partial hepatectomy for HCC superimposed on hepatitis B-related cirrhosis using two different occlusion techniques.

Methods

A randomized controlled trial was carried out to evaluate the impact of two different vascular inflow occlusion techniques. The postoperative short-term results were compared.

Results

During the study period, 252 patients received partial hepatectomy for HCC with cirrhosis. Of these patients, 120 were randomized equally into two groups: the Pringle manoeuvre group (n?=?60) and the hemi-hepatic vascular inflow occlusion group (n?=?60). The number of patients who had poor liver function on postoperative day 5 with ISLGS grade B or worse was 24 and 13, respectively (P?=?0.030). The postoperative complication rate was significantly higher in the Pringle manoeuvre group (40 versus 22 %, P?=?0.030). However, the Pringle manoeuvre group had significantly shorter operating time (116 versus 136 min, P?=?0.012) although there was no significant difference in intraoperative blood loss between the two groups [200 ml (range 10–5,000 ml) versus 300 ml (range 100–1,000 ml); P?=?0.511]. There was no perioperative mortality.

Conclusions

The results indicated that for patients with HCC with cirrhosis, hemi-hepatic vascular inflow occlusion was a better inflow occlusion method than Pringle manoeuvre.     

Laparoscopic left hemihepatectomy a consideration for acceptance as standard of care

Introduction

Since the inception of laparoscopic liver surgery, the left-lateral sectionectomy has become the standard of care for resection of lesions located in segments II and III. However, few centers employee laparoscopic left hemihepatectomy on a routine basis. This study evaluated the safety and efficacy of the laparoscopic left hemihepatectomy as a standard of care.

Methods

An international database of 1,620 laparoscopic liver resections was established and outcomes analyzed comparing the laparoscopic left lateral sectionectomy (L lat) to laparoscopic left hemihepatectomy (LH). All data are presented as mean ± standard deviation.

Results

A total of 222 laparoscopic L lat and 82 LH were identified. The L lat group compared with LH group had a higher incidence of cirrhosis (27 vs. 21 %; p = 0.003) and cancer (48 vs. 35 %; p = 0.043). Tumors were larger in the LH group (7.09 ± 4.2 vs. 4.89 ± 3.1 cm; p = 0.001). Operating time for LH was longer than L lat (3.9 ± 2.3 vs. 2.9 ± 1.4 h; p < 0.001). Operative blood loss was higher in LH (306 vs. 198 cc; p = 0.003). Patient morbidity (20 vs. 18 %; p = 0.765) was equivalent with a longer length of stay (7.1 ± 5.1 vs. 2.5 ± 2.3 days; p < 0.001) for LH. Patient mortality and tumor recurrence were equivalent.

Conclusions

Laparoscopic left hemihepatectomy is a more technically challenging and often time-consuming procedure than a left-lateral sectionectomy. This international multi-institutional confirmed that intraoperative blood loss, complications, and conversions are more than acceptable for laparoscopic left hemihepatectomy in expert hands. Postoperative morbidity and mortality rates together with adequate surgical margins and long-term recurrence are not compromised by the laparoscopic approach.