解剖第3肝门切除巨大肝海绵状血管瘤

Objective:To estabhsh a novel and safe operation technique for the resection of giant hepatic cavernous hemangiomas involving the retro-hepatic vena cava.Methods:After ligating the hepatic artery of affected lobe, the short hepatic veins at the third porta hepatis were dissected and ligated individually to separate the tumor from the retrohepatic vena cava, followed by the resection of the tumor under intermittent interruption of the porta hepatis.Results:A total of 62 giant hepatic cavernous hemangiomas were successfully resected without hepatic vascular exclusion. Right and caudate lobectomies were done in 27 cases, right hemihepatectornies in 5 cases, right upper segnentectomies in 7 cases, right posterior lobectomies in 7 cases, extended left and caudate lobectomies in 10 cases, and caudate lobectomies in 6 cases. The blood transfusion requirement during operation was 1 400 ml on average. All did well postoperatively during a follow up of 4 - 84 months.Conclusion:It is safe and feasible to resect giant hepatic cavernous hemangioma following dissection of the third porta hepatis. Duringoperation the key step is dissection of the short hepatic veins.     

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.     

Principles of surgical resection in hilar cholangiocarcinoma

The aim of this article is to describe the surgical techniques for the treatment of hilar cholangiocarcinoma(HC).Resection with microscopically negative margin(R0) is the only way to cure patients with HC.Today,resection of the caudate lobe and part of segment Ⅳ,combined with a right or left hepatectomy,bile duct resection,lymphadenectomy of the hepatic hilum and sometimes vascular resection,is the standard surgical procedure for HC.Intraoperative frozen-section examination of proximal and distal biliary margins is necessary to confirm the suitability of resection.Although lymphadenectomy probably has little direct effect on survival,inaccurate staging information may influence post resection treatment recommendations.Aggressive venous and arterial resections should be undertaken in selected cases to achieve a R0 resection.The concept of "no-touch proposed" in 1999 by Neuhaus et al combine an extended right hepatectomy with systematic portal vein resection and caudate lobectomy avoiding hilar dissection and possible intraoperative microscopic dissemination of cancer cells.More recently minor liver resections have been proposed for treatment of HC.As the hilar bifurcation of the bile ducts is near to liver segments Ⅳ,Ⅴ and Ⅰ,adequate liver resection of these segments together with the bile ducts can result in cure.     

Major hepatic resection under total vascular exclusion

The major complications associated with liver resection are bleeding, hepatic decompensation and iatrogenic injury to the bile ducts and structures in the porta hepatis during its dissection. Operative blood loss and the amount of intraoperative blood transfusion has been shown repeatedly to be the single most important factor affecting the immediate prognosis of patients undergoing hepatic resection. Massive blood loss associated with the standard techniques of liver resection is frequently c…     

肝癌原位肝移植术后肿瘤复发的多层螺旋CT和MRI影像学诊断

Objective To investigate the manifestation and diagnostic value of multislice spiral CT (MSCT)and MRI imaging in detection of tumor recurrence after liver transplantation for bepatocellular carcinoma(HCC).Methods The clinical data of 161 consecutive HCC patients who underwent orthotopic liver transplantation were retrospectively reviewed.Twenty-nine HCC patients were classified by pTNM according to the "Pittsburgh criteria".MSCT and MRI findings of tumor recurrence after liver transplantation were evaluated retrospectively in 29 stage Ⅱ-Ⅳ b HCC patients.The recurrence site and relapse interval between liver transplantation and recurrence were analyzed.Results Lung tumor recurrence were found in 21 cases,presented as cotton-like lesions in a diameter of 2-3 cm,with a clear margin and homogeneous density.Pleural tumor recurrence was detected in 4 cases.Liver tumor recurrence were found in 9 cases,which can be divided into four subtypes:multinodular in 4 cases,diffuse lesion in 2 cases,huge mass in 2 cases,and uninodular in 1 case.Two cases showed tumor thrombus in the inferior vena cava and portal vein.Lymph node tumor recurrence was found in 9 cases,presented as multiple nodules at hepatic hilum,lesser peritoneal sac,posterior mediastinum,retroperitoneum,or around pancreatic head,and accompanied with merging and necrosis in one case.Bone tumor recurrence were found as osteolytie destruction in 4 cases,and accompanied with adjacent soft-tissue mass in 2 cases.The recurrence sites of the 29 cases were as following:lung(21 cases,72.4%),liver(9 cases,31.0%),lymph nodes(9 cases,31.0%),bone (4 cases,13.8%)and other sites(3 cases,10.3%).Lung tumor recurrence was found in all the 10 stage Ⅳb patients with tumor recurrence after liver transplantation,significantly more frequent than that in stage Ⅳ a patients(P = 0.023).After liver transplantation,all 25 patients with stage Ⅲ～Ⅳ b HCC developed recurrence within one year,but in the 4 cases with stage Ⅱ HCC at one year later(P = 0.009).Conclusion The results of our study show that in hepatoceUular carcinoma patients after liver transplantation,the lung and pleura are the most fequent site of recurrence,followed by liver,lymph node and bone as the second and third sites.The Stage Ⅳ b hapatocellular carcinoma should be regarded as a contradiction for liver transplantation due to rapid recurrence.Tumor recurrence occurs later in stage Ⅱ HCC than in stage Ⅲ～Ⅳb patients.MSCT and MRI are of significant importance in diagnosis and formulating operation plan in HCC patients with recurrence after liver transplantation.     

Primary hepatic leiomyosarcoma: Case report and literature review

Primary hepatic leiomyosarcoma are rare tumors with less than 30 cases reported in the English literature.Non specific presentations and often diagnosis delayed until they reach a large size,is the norm with therapy leading to an often dismal prognosis.A 67-year-old man presented complaining of abdominal pain and a palpable abdominal mass since Jan 2010.Abdominal ultrasonography and abdominal computed tomography revealed a large tumor in the left lobe of the liver.Surgical exploration was undertaken and an extended left hepatectomy with extension onto the dorsal part of segment 8 preserving the MHV with partial resection of segment 6 was undertaken.The weight of the resected specimen was 1300 g of the left lobectomy specimen and 8 g of the segment 6 partial resection specimen.The pathology report confirmed the diagnosis of leiomyosarcoma.On immunohistochemistry,the tumor cells were positive for smooth muscle actin stain.The patient is on regular follow up and is currently 9 mo post resection with no evidence of recurrence.We report the case of a resected primary hepatic leiomyosarcoma and emphasize the need for a global database for these rare tumors to promote a better and broader understanding of this less understood subject.     

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 bein     

Clinical outcomes of gastrointestinal stromal tumor in southern Thailand

AIM: To review a single institutional experience in clinical management of gastrointestinal stromal tumors (GIST) and analyze for factors determining treatment outcome. METHODS: Clinicopathological data of patients with a diagnosis of GIST who were treated at our institute during November 2004 to September 2009 were retrospectively reviewed. RESULTS: Ninety-nine cases were included in the analysis. Primary tumor sites were at the stomach in and small bowel in 44% and 33%, respectively. Thirty-one cases already had metastasis at presentation and the most common metastatic site was the liver. Sixty-four cases (65%) were in the high-risk category. Surgical treatment was performed in 77 cases (78%), 3 of whomreceived upfront targeted therapy. Complete resection was achieved in 56 cases (73% of operative cases) and of whom 27 developed local recurrence or distant metastasis at a median duration of 2 years. Imatinib was given as a primary therapy in unresectable cases (25 cases) and as an adjuvant in cases with residual tumor (21 cases). Targeted therapy gave partial response in 7 cases (15%), stable disease in 27 cases (57%) and progressive disease in 13 cases (28%). Four-year overall survival was 74% (95% CI: 61%-83%). Univariate survival analysis found that low-risk tumor, gastric site, complete resection and response to imatinib were associated with better survival. CONCLUSION: The overall outcomes of GIST can be predicted by risk-categorization. Surgery alone may not be a curative treatment for GIST. Response to targeted therapy is a crucial survival determinant in these patients.     

CONVERSION OF SURGICALLY VERIFIED UNRESECTABLE TO RESECTABLE HEPATOCELLULAR CARCINOMA(A REPORT OF 26 PATIENTS WITH SUBSEQUENT RESECTION)

During the period 1978-1987, 255 patients with pathologically proven hepatocellular carcinoma (HCC) were determined by laparotomy to be un-resectable, 155 (60.8%) out of them had their tumor mainly confined in right or left lobe and considered to be potentially resectable if remarkable tumor shrinkage appears after treatment. Second look operation was performed in 26 (16.8%) out of the 155 patients after marked reduction of tumor size, resection was done in all of these 26 patients. Triple or quadruple combination treatment with hepatic artery ligation (HAL), hepatic artery infusion (HAI) with chemotherapy, radiotherapy using linear accelerator, and radioimmunotherapy using 131-I antihu-man HCC ferritin antibody yielded the highest conversion rate (29.8%, 14/47) as compared to double combination treatment with HAL HAI, or cryosur-gery HAL (16.9%, 12/71) and single treatment with HAL or HAI or HAE (embolization) (0%, 0/37). The median tumor size of these 26 patients was reduced from 9.5 cm to 5.0 cm afte     

Clinical Analysis of 45 Patients with Thymic Carcinoma

OBJECTIVE To retrospectively evaluate the prognostic factors for advanced thymic carcinoma.METHODS The data from 45 patients with advanced thymic carcinoma were retrospectively analyzed according to Masaoka stage criteria. There were 29 Stage Ⅲ patients and 16 Stage Ⅳ patients (13 Stage IVA patients and 3 Stage IVB patients).According to the World Heath Organization Histological Criteria (2004), 25 cases were identified as low-grade and 20 cases were identified as high-grade. All diagnoses were confirmed by biopsy. Five patients underwent gross total resection, 21patients underwent subtotal resection and 19 patients underwent biopsy alone. Forty-two patients received radiotherapy with a median dose of 60 Gy, and 37 patients underwent conventional radiotherapy, including local irradiation and expanded irradiation.Local irradiation volume covered the primary tumor bed and approximately 1-2 cm2 surrounding the tumor (according to preoperative imaging). Expanded irradiation volume covered the full mediastinal and pericardium areas (with or without prophylactic irradiation in the supraclavicular area). Five cases received stereotactic radiotherapy. Thirty-one patients were also treated with chemotherapeutics, including Cisplatin, VP-16,Endoxan, 5-FU and taxol.RESULTS The median follow-up period was 59 months. The overall 3-year survival rate was 57.8%, and the median survival was 45 months. Univariate statistical analysis showed that the histological subtype and Masaoka stage were prognostic factors.The 3-year survival rate was 61.9% in patients treated with gross total resection and 55.0% in those who underwent biopsy only. The 3-year survival rate was 59.5% in patients treated with conventional radiotherapy and 80% in those treated with stereotactic radiotherapy. The 3-year survival rate was 64.5% in patients treated with simultaneous chemotherapy and 42.9%in patients treated without simultaneous chemotherapy (P >0.05). Chemotherapy in combination with radiation treatment and surgery achieved better outcomes for Stage Ⅳ patients than radiation treatment and surgery without chemotherapy (P < 0.05).CONCLUSION For patients with Stage Ⅲ and Ⅳ thymic carcinoma, complete resection and postoperative radiotherapy or fractionated stereotactic radiotherapy constitute the best treatment solution. Chemotherapy can also be used in combination to improve prognosis. For patients with Stage Ⅳ thymic carcinoma,chemotherapy is necessary.     

肝尾状叶肿瘤的切除(附5例报道)

目的:探讨肝尾状叶肿瘤的手术切除经验.方法:对我院2001年11月～2002年6月收治的5例累及肝脏尾状叶肿瘤的手术方式作回顾性分析.结果:本组5例均采用右侧路径切断尾状静脉,2例其中游离部分腔静脉,切断尾状静脉4～5支,2例血管瘤和1例肝转移癌患者游离全部肝段下腔静脉,切断全部尾状静脉.5例患者均好转出院.结论:尾状静脉的离断是手术安全的保障.另外解剖肝门板,离断尾状叶的动、静脉分支可以减少手术中的出血量.     

The caudate lobe of the liver: implications of embryology and anatomy for surgery

The anatomy of the caudate lobe has technical and possibly oncologic implications for surgeons. The complex anatomy of the lobe is clarified by embryologic and anatomic analysis. This posterior sector is embryonically and anatomically independent of the right and left liver and the main portal fissure. The caudate lobe represents the only part of the liver that is in contact with the vena cava, except at the entrance of the main hepatic veins into the vena cava, and provides an anastomosis between the hepatic veins and vena cava. The entire caudate lobe is a single anatomic segment that is defined by the presence of portal venous and hepatic arterial branches, which supply the lobe, draining biliary ducts, and hepatic veins. Because no separate veins, arteries, or ducts can be defined for the right paracaval portion of the posterior liver and because pedicles cross the proposed division between the right and left caudate, the concept of segment IX is abandoned. The significance of caudate anatomy is reflected in the increase in the frequency and safety of major hepatic resection for primary and metastatic tumors in the liver. Right hepatic lobectomy routinely involves resection of the right portion of the caudate lobe (C. Couinaud, unpublished data, 1999). In the case of hilar bile duct cancer, which may extend into the dorsal ducts (especially the right lateral duct), partial or total caudate lobectomy is often necessary for complete extirpation of the tumor. Isolated caudate lobectomy can be performed for hepatocellular carcinoma that arises in the caudate lobe or for other tumors that arise in the lobe. The caudate lobe can be resected as part of the donor liver in preparation for a living related donor transplantation. Knowledge of the surgical anatomy of the caudate lobe is an essential part of the repertoire for surgeons who perform liver transplants or treat hepatobiliary cancer.     

Selective hepatic vascular exclusion and Pringle maneuver: A comparative study in liver resection

Objective

Most liver resections require champing of the hepatic pedicle (Pringle maneuver) to avoid excessive blood loss. But Pringle maneuver cannot control backflow bleeding of the hepatic vein. Resection of liver tumors involving hepatic veins may cause massive hemorrhage or air embolism from injuries of the hepatic vein. Although total hepatic vascular exclusion (THVE) can prevent bleeding of the hepatic vein effectively, it also may result in systemic hemodynamic disturbance because of the clamped inferior vena cava (IVC). SHVE, a new technique, can control the inflow and outflow of the liver without clamping the vena cava. We compared the effects of selective hepatic vascular exclusion (SHVE) and Pringle maneuver in resection of liver tumors involving the junction of the hepatic vein.

Methods

From January 2000 to October 2005, 2100 patients with liver tumors had undergone liver resections in our department. Among them, tumors of 235 cases adhered to or were close to the junction of one or more hepatic veins. Both SHVE and Pringle maneuver were used to control blood loss during hepatectomy. These 235 cases were divided into two groups: Pringle maneuver group (110) from January 2000 to December 2002 and SHVE group (125) from January 2003 to October 2005. Data were analyzed regarding the intraoperative and postoperative courses of the patients. In the SHVE group, total SHVE (clamping the porta hepatis and all major hepatic veins) was used in 69 cases and partial SHVE (clamping the porta hepatic and one or two hepatic veins) in 56 cases. There were three methods in hepatic veins occlusion: ligating with suture, encircling and occluding with tourniquets and clamping with Satinsky clamps.

Results

There was no difference between the two groups regarding the age, gender, tumor size, cirrhosis and HBsAg rate, ischemia time and operating time. Intraoperative blood loss and transfusion requirements were significantly decreased in the SHVE group. Hepatic veins rupture with massive blood loss occurred in 14 and air embolism in three during the tumor resection, but there was no massive blood loss and air embolism in the SHVE group due to hepatic vein occlusion. Postoperative bleeding, reoperation, liver failure and mortality rate were higher, and ICU stay and hospital stay were longer in the Pringle group than those in the SHVE group.

Conclusion

SHVE is much more effective than Pringle maneuver in controlling intraoperative bleeding. It can prevent massive blood loss and air embolism from hepatic veins rupture and can reduce the postoperative complication rate and mortality rate. Clamping the hepatic veins with Satinsky clamps is much safer and easier than ligating with suture and occluding with tourniquets.     

Hepatic resection for a single hepatocellular carcinoma in the caudate lobe

INTRODUCTION: Treatments of hepatocellular carcinoma (HCC) located in the caudate lobe have been difficult because of the unique anatomical location. Our objective was to evaluate the surgical outcomes of hepatic resection for a single HCC located in the caudate lobe. METHODS: Between January 1999 and December 2005, 97 patients with a single HCC underwent hepatic resection at our department. Seven (7.2%) of the 97 patients had a single HCC located in the caudate lobe. The caudate lobe HCC was located in the spiegel lobe in 2 patients, the paracaval portion in 2, caudate process in 2 and a total caudate lobe in 1. The influence of the tumor location (caudate lobe origin) on the surgical outcomes was analyzed in comparison with the other site tumors. RESULTS: The morbidity rate after hepatic resection for a single HCC in caudate lobe and the other lobes were 57% and 20%, respectively. The morbidity rate was significantly higher in the caudate lobe group (p < 0.05). The 3- and 5-year cumulative survival rates of the patients with a single caudate lobe HCC and the other lobes were 83.3%, 83.3%, 89% and 85.4%, respectively. Similarly, the 3- and 5-year cumulative disease free survival rates were 51.4%, 51.4%, 59.4% and 45.5%, respectively. There was no significant difference in both the cumulative survival rate and cumulative disease free survival rate. CONCLUSIONS: Hepatic resection for a single HCC located in the caudate lobe was an effective treatment, being equal clinical outcomes to a single HCC in the other sites of the liver.     

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。     

Laparoscopic liver resection of the Spiegel lobe by a left-sided approach preserving an accessory left hepatic artery

BackgroundCaudate lobe of the liver can be divided in three portions: Spiegel lobe, paracaval portion and caudate process [1]. The anatomy of the caudate lobe and its proximity to major vascular structures makes this operation a difficult resection, especially for laparoscopic liver surgery [2]. For that reason the Iwate criteria proposed to classify this surgery at the “2nd International Consensus Conference on Laparoscopic Liver Resection” as intermediate or advanced difficulty depending on the type of resection, and the size of the tumor [3]. For tumors located in the Spiegel lobe, the left side approach is preferred [4].MethodsWe present a 69-year-old woman with liver metastasis from previously resected sternal condrosarcoma on 30/05/2017. A unique recurrence in the caudate lobe was found on computed tomography and magnetic resonance imaging on April 2019.ResultsA Spiegel lobe resection with left side approach preserving an accessory left hepatic artery was performed. A resection of the artery was planned if the preservation was not possible. The operative time was 180 min and the total Pringle time was 30 min. Patient was discharged at the 4 postoperative day and there were no postoperative complicationsConclusionsLaparoscopic liver resection of the caudate lobe for condrosarcoma liver metastasis is feasible and safe. Left approach seems the best option for Spiegel lobe resections even in patients with accessory left hepatic artery.     

Feasibility study of ambulatory continuous infusion of 5-fluorouracil followed by cisplatin through hepatic artery for metastatic colorectal cancer

Purpose: A great synergy has been reported in a number of preclinical studies when 5-fluorouracil (5-FU) precedes cisplatin (CDDP). The objective of this study was to determine the feasibility of ambulatory continuous infusion of 5-FU followed by CDDP through hepatic artery for metastatic colorectal cancer. Patients and methods: Seventeen patients with unresectable liver metastases, who underwent primary tumor resection, were treated with 5-FU (450 mg/m²/day) for seven consecutive days followed by CDDP (100 mg/body/week) for seven consecutive days, each administered continuously by using a balloon pump via Infuse-A-Port catheter inserted into common hepatic artery. The doses of drugs were reduced 20% in patients older than 70 years. The treatment was repeated every 4–6 weeks until disease progression. Results: Of 17 assessable patients, nine patients showed PR (53%; 95% CI, 29.3–76.7%) and eight patients had SD (47%; 95% CI, 23.3–70.7%), with disease control rate of 100%. The median overall survival was 26 months (95% CI: 17.5–41 months) and TTP 14 months (95% CI: 11–20.3 months). Two patients (11.8%), who showed progression due to collateral feeding arteries, responded to HAI again after occlusion. Grade 3 toxicity included leukopenia (12%) and anemia (24%). Grade 4 toxicity was absent. Four patients (23.5%) progressed at extrahepatic sites. Conclusions: This sequential combination of 5-FU followed by CDDP through hepatic artery is active and safe in an outpatient setting, and warrants further multi-institutional study, although prevention of micrometastasis would be mandatory to further prolong overall survival.     

ALPPS术在尾状叶肝癌中的应用(附1例报道)

目的:报道ALPPS成功治疗尾状叶肝癌1例,分析ALPPS对于尾状叶肝癌的可行性及安全性。方法:患者,男,58岁,66 kg,因“体检发现肝占位20天”入院,肝脏超声示肝右叶占位性病变,初步诊断:尾状叶肝癌。患者尾状叶肝癌累及门静脉右支、肝中静脉、肝右静脉、下腔静脉肝后段,需行右半肝及尾状叶切除。经术前评估患者剩余肝脏体积不能满足切除要求,遂行ALPPS手术。结果:第一步手术时间210 min,术中出血量200 ml,术中未输血,术后无严重并发症。术后第7天左半肝体积增长至547 ml,占标准肝脏体积的46.3%,术后第14天行第二步手术。第二步手术时间180 min,术中出血量400 ml,输注红细胞3 U,血浆800 ml。Clavien-Dino并发症分级Ⅱ级,主要并发症为胆漏,予以充分引流后好转。患者术后康复良好,随访13个月,肿瘤无复发。结论:ALPPS为尾状叶肝癌患者提供了新的手术方案参考。     

The impact of caudate lobe involvement after hepatic resection for colorectal metastases

Background

Hepatic resections involving the caudate lobe are technically challenging with results from some centers indicating inferior outcomes. We assessed outcomes following hepatic resection for colorectal metastases involving the caudate lobe in a tertiary care center.

Methods

Operative and oncological data from a prospectively maintained database were analyzed on 687 patients undergoing hepatic resection for colorectal metastases between 1993 and 2006. Patients were analyzed as those with caudate lobe metastases (CLM) and compared with those without caudate lobe involvement (NCLM).

Results

Fifty-two of 687 patients had metastases involving the caudate lobe (8%). Patients with caudate lobe involvement were more likely to require an extended hepatic resection (75% vs 27%, P = 0.001), perioperative blood transfusion (29% vs 14%, P = 0.002), have a positive resection margin (57% vs 32%, P = 0.001) and stay longer in hospital (12 vs 8 days, P = 0.001). There was no difference in the complication rates (37% vs 29%) or 30-day mortality between the two groups (2% vs 1%). The median disease free (20 months vs 21 months), and cancer specific survival (42 months vs 59 months) were also similar in the CLM and NCLM groups.

Conclusions

Although caudate lobe involvement adds to the technical complexity of hepatic resection, these patients can be offered long term survival, similar to other patients with hepatic metastases from colorectal cancer.