肝中叶切除术治疗中央区大肝癌25例临床分析

目的 探讨肝中叶切除术治疗中央区大肝癌的手术安全性和近远期疗效,总结该术式的技术要点和经验.方法 回顾性分析2005年8月至2011年12月于安徽医科大学第一附属医院器官移植中心接受肝中叶切除术治疗且病理诊断为原发性肝细胞癌(肿瘤直径＞5 cm)的25例患者的临床资料及随访结果.其中男性24例,女性1例;年龄33～ 67岁,中位年龄48.8岁.应用Kaplan-Meier法计算本组患者无瘤及总体生存率.结果 25例均为原发性肝细胞癌,肿瘤直径5.0～15.0 cm,中位直径为8.1 cm;其中有7例瘤体直径超过10.0 cm,最大者为15 cm.HBsAg阳性22例,AFP升高者(≥20 μg/L) 16例.全组患者为Child-Pugh A级.术中第一肝门阻断23例,半肝血流阻断1例,未阻断肝门1例.肝门阻断时间12～ 70 min,平均30.3 min.手术失血量50～600 ml,平均为266.8 ml.手术时间135 ～358 min,平均为191.3 min.输血14例,住院时间9～37 d,平均20.2d.术中行门静脉癌栓取出术2例,术后并发症发生率为44％(11/25),无围手术期死亡病例.随访时间3 ～78个月,平均28个月,全组1、3年无瘤生存率分别为63.7％、26.7％,1、3年总体生存率分别为86.4％、38.7％.结论 肝中叶切除术用来治疗中央区大肝癌是安全可行的.该术式是中央区大肝癌,尤其是伴有肝硬化或者慢性肝炎背景的患者一种有效的外科治疗手段.     

中肝叶切除治疗中央型大肝癌

目的 评估中肝叶切除治疗中央型大肝癌的临床结果.方法 回顾性分析我院2001-2007年采用中肝叶切除治疗的136例直径＞5 cm的中肝叶大肝癌病例资料,并对所有手术患者均进行临床随访.结果 中肝叶切除术的肝门阻断时间、手术时间、术中出血量、术中输血量及住院时间分别为(13.3±9.1) min、(173.1±41.1) min、(548.7±320.5)ml、(511.4±231.7) ml和(18.6±8.8)d.11例患者术中未输血.全组无手术死亡,仅4例(2.9％)患者发生主要并发症.中肝叶切除术术后患者1、3、5年总生存率分别为71％、46％、29％,1、3、5年无瘤生存率分别为65％、40％、24％.结论 中肝叶切除术治疗中央型大肝癌安全可行,能最大限度地保留有功能的肝实质,可作为首选术式.     

中央型肝癌的手术切除

目的探讨中央型肝癌手术切除的方法和疗效。方法回顾分析1988—2005年在我所行手术切除的257例中央型肝癌的临床资料及随访结果。按手术切除的方式将患者分为半肝切除（包括扩大半肝，n=19）和肝中叶切除（包括部分及扩大肝中叶，n=238）两组，比较手术情况及预后的差异。结果257例中央型肝癌患者术后1、3、5年生存率及无瘤生存率分别为73．4％、55．6％、41．2％和83．8％、73．8％、63．4％。Cox多因素分析提示，肿瘤大小、包膜及微血管侵犯是影响患者预后的相关因素。两种手术方式对手术时间、术后并发症、围手术期死亡、生存率及无瘤生存率的影响差异无统计学意义（P〉0．05）。结论手术切除是治疗中央型肝癌的有效手段，而对于合并有肝硬化的中央型肝癌，肝中叶切除术（包括部分及扩大肝中叶）则是首选的治疗方法。     

���������滮�������͸ΰ��г�Ӧ�ü�ֵ�о�

目的探讨虚拟肝脏手术规划对中央型肝癌切除术的指导价值。方法应用虚拟肝脏手术规划系统软件Liv1.0对福建医科大学附属第一医院2007年6月至2012年6月49例病人进行虚拟中央型肝癌切除手术规划,将虚拟手术规划结果与手术中所见进行对比。结果 49例病人虚拟肝脏手术规划所测预切除肝脏体积为(543±225)mL,实际切除肝脏体积为(573±212)mL,平均误差(29±66)mL,两者间高度正相关(相关系数r=0.983,P<0.01)。结论针对中央型肝癌切除术,应用虚拟肝脏手术规划进行手术模拟,有利于评估肿瘤的可切除性并指导手术切除方式的选择。     

中央型肝癌手术切除联合放疗的临床研究

目的 探讨中央型肝癌切除联合放疗的安全性及治疗效果.方法 本研究为前瞻性研究.2007年至2010年于我院行手术治疗的34例中央型肝癌患者入选.所有患者术前均通过影像学评估手术的可切除性.术中采用区域性肝血流阻断配合超声乳化吸引刀技术切肝.瘤床放置金属标记、术后进行适形调强放射治疗,并予定期随访.结果 术后病理证实34例均为肝细胞癌,5例见脉管瘤栓,1例有门静脉瘤栓,30例(88.2％)伴有肝硬化.术后5例出现并发症,肺部感染、右侧胸腔积液、腹腔感染、急性肾功能衰竭、房颤各1例.3例患者未完成放疗疗程,31例完成术后放疗.除3例出现Ⅲ°骨髓抑制外,其余均为Ⅰ°或Ⅱ°副反应.34例均获随访,随访率100％,中位随访时间19个月.1年、3年无瘤生存率分别为69.5％、64.2％;1年、3年总生存率分别为97.0％、86.2％.结论 中央型肝癌手术切除联合放疗安全,疗效较好.     

Treatment of centrally located hepatocellular carcinoma with central hepatectomy

BACKGROUND: For treatment of centrally located hepatocellular carcinoma (HCC), central hepatectomy (including central trisegmentectomy [Couinaud's segments 4, 5, and 8] and anterior segmentectomy [Couinaud's segments 5 and 8]) may have an important advantage (ie, preservation of nontumorous parenchyma) over conventional lobectomy or extended lobectomy. For determination of the efficacy of this technique, we compared the outcomes of patients with HCC who underwent treatment with the central and conventional methods. PATIENTS AND METHODS: In our institute, 52 patients with HCC underwent treatment with central hepatectomy (group 1) and 63 patients with comparable tumor size underwent treatment with conventional major hepatectomy (group 2) from November 1993 to April 1999. Overall patient survival and disease-free survival rates were calculated and analyzed. The possible prognostic risk factors for patient and disease-free survival in group 1 were analyzed. RESULTS: Group 1 had comparable overall patient and disease-free survival rates with those of group 2. Vascular invasion, higher pathology grading, and resection margin less than 1 cm appeared to be the prognostic factors for overall patient survival, and vascular invasion was the only risk factor for disease-free survival. CONCLUSION: Central hepatectomy is a safe and effective operative procedure for the treatment of centrally located HCC. The patient and disease-free survival rates were the same as those of conventional major hepatectomy. Although it is technically more demanding, central hepatectomy preserves more nontumor liver parenchyma, which is important for the survival of those patients with liver cirrhosis.     

中肝叶切除术治疗中央型肝肿瘤:九例报告并系统综述

目的 评价中肝叶切除术治疗中央型肝肿瘤的安全性和疗效.方法 9例报告并系统性综述中肝叶切除术治疗中央型肝肿瘤的中英文文献.结果 9例病人围手术期病死率和并发症的发生率分别为0%和66.6%,在3～38个月的随访期间,8例病人存活.系统性综述共纳入20项临床试验,其中4项为比较中肝叶切除术与肝叶切除或扩大半肝切除术的回顾性非随机对照研究.中肝叶切除术外科病死率为0%～7.4%,常见的并发症有:胆漏(0.4%～18.5%)、胸腔积液(5.7%～23.5%)、腹水(1.9%～11.6%)和肺炎(1.7%～2.5%).4项非随机研究结果均显示中肝叶切除术组与肝叶切除或扩大的半肝切除术组之间围手术期病死率和早期术后并发症无显著差异.其中2项研究显示两组间肝细胞癌病人的平均生存期和无瘤生存率相似.结论 中肝叶切除术治疗中央型肝肿瘤安全、有效.     

腹腔镜解剖性肝切除治疗位于中央部位肝癌单中心经验

目的探讨腹腔镜解剖性肝切除治疗中央部位肝细胞癌的安全性和可行性。方法2015年1月至2019年12月,12例肿瘤位于肝中央部位的肝细胞癌患者在佛山市第一人民医院肝脏外科实施了腹腔镜肝切除;其中男9例、女3例,平均年龄(55.5±6.8)岁,平均肿瘤直径(3.7±2.5)cm,术前肝脏储备功能ICG-R15(3.9±2.82)%,肝功能Child-Pugh分级A级。实施肝Ⅳ~Ⅷ段切除5例、肝Ⅴ~Ⅷ段切除6例、肝Ⅳ段切除1例。统计分析手术时间、手术切缘、术中出血量、术后并发症及住院时间等。结果12例患者均在腹腔镜下完成手术,无中转开腹,平均手术时间(398.8±115.4)min,平均术中出血量(420.8±279.2)ml,有1例输血,术后平均住院时间(9.1±2.2)d,无围手术期死亡病例,术后并发症包括肝断面出血1例、胆漏1例、膈下包裹性积液1例,平均手术切缘(1.2±0.6)cm。结论对位于肝中央部位的肝细胞癌,行解剖性肝Ⅳ~Ⅷ段切除、肝Ⅴ~Ⅷ段切除以及肝Ⅳ段切除是安全、可行的。采取肝内Glissonian鞘外的方法预先控制肝蒂有利于掌握断肝平面,术前精准的评估,术中有效的控制出血以及娴熟的腔镜外科技术能有效帮助术者安全实施手术。     

Total laparoscopic limited anatomical resection for centrally located hepatocellular carcinoma in cirrhotic liver

Background

Limited anatomical liver resection for hepatocellular carcinoma (HCC) is complicated in cirrhotic patients with centrally located HCC and limited liver reserve. We present a case of total laparoscopic left medial and right ventroanterior sectionectomy performed using the intrahepatic Glissonian approach in a cirrhotic liver for curative resection of HCC.

Methods

The patient was a 69-year-old man with a 6.5-cm-diameter HCC located at segments 4, 5, and 8 and which was compressing the middle hepatic vein (MHV). Child–Pugh class A liver cirrhosis was noted, and the 15-min retention rate for indocyanine green was 14 %. Preoperative surgical planning suggested the feasibility of limited anatomical subsegmental resection. The patient was placed in the supine position and 5 trocars were used for the procedure. The operation began with cholecystectomy, division of liver ligaments, and exposure of the right hepatic vein root and the umbilical Glissonian pedicles to the left medial segment. Parenchymal transection was performed using a laparoscopic harmonic scalpel and Cavitron Ultrasonic Surgical Aspirator until the MHV was reached. After exposing the ventral branches of the right anterior Glissonian pedicle and dividing them, resection was continued along the demarcation line. Fissure veins draining to the MHV root were identified and divided. The MHV root was closed using an automatic stapler.

Results

The operation time was 565 min and estimated blood loss was 665 ml; blood transfusion was not required. Pathological examination confirmed a moderately differentiated HCC with all resected margins free of malignancy. Postoperative recovery was uneventful and the patient was discharged on the postoperative day 7. There was no tumor recurrence 18 months after the operation.

Conclusions

Total laparoscopic left medial and right ventroanterior sectionectomy via the intrahepatic Glissonian approach is feasible for HCC in a cirrhotic liver with limited liver reserve. Preoperative planning is essential in order to compute successful hepatic function. Standardization of surgical techniques may aid in safely performing this procedure.     

New procedure to remove a centrally located bone bar

A centrally located bone bar of the lower tibia was removed after epiphyseolysis with an Ilizarov device. The bone bridge attached to the metaphysis was easy to remove, and methylmethacrylate was used as an interpositional material. Varus deformity was corrected at the level of the epiphyseolysis. At the 2-year follow-up, there was evidence of further growth and correction of the varus was maintained.     

Role of mesohepatectomy with or without transcatheter arterial chemoembolization for large centrally located hepatocellular carcinoma

BACKGROUND: The role of preoperative transcatheter arterial chemoembolization (TACE) for resectable hepatocellular carcinoma (HCC) was controversial. METHODS: 246 patients with large centrally located HCC underwent mesohepatectomy (MH) and were divided into two groups: group A, 89 patients with preoperative TACE; group B, 157 patients without preoperative TACE. The aim was to evaluate the influence of preoperative TACE on postoperative complications and long-term results of patients with large centrally located HCC. RESULTS: In the 89 patients of the TACE-MH group, a total of 123 (mean 1.4 per patient) preoperative TACEs were performed. The differences in postoperative complications (34.8 vs. 24.2%; p=0.075) and overall hospital mortality (3.4 vs. 0.6%; p=0.103) between the two groups were not significant. The postoperative recurrence rate in the remnant liver was higher in the MH group than in the TACE-MH group (79.6 vs. 73.0%), while the extrahepatic metastasis rate in the TACE-MH group was higher than that in the MH group (11.1 vs. 7.0%). Overall 1-, 3-, and 5-year survival rates were 87.1, 62.9, and 46.2%, respectively, for the TACE-MH group, and 82.2, 54.4, and 31.7%, respectively, for the MH group (p=0.001); 1-, 3-, and 5-year disease-free survival rates were 75.0, 46.2, and 31.8%, respectively, for the TACE-MH group, and 69.6, 38.0, and 16.5%, respectively, for the MH group (p=0.002). CONCLUSIONS: Long-term outcomes of patients with preoperative TACE were improved and the pattern of the recurrences after surgery was altered. The patients with large centrally located HCC could benefit more from this neoadjuvant treatment, although there was some influence of preoperative TACE on postoperative complications.     

机器人中央型肝癌切除手术的护理配合

目的总结中央型肝癌行机器人肝切除术的护理配合经验。方法对中央型肝癌行达芬奇机器人切除术的患者,通过人性化术前访视、规范体位安置、充分用物准备、精细化术中配合及全方位手术并发症预防等实施护理。结果 53例机器人中央型肝癌切除术中,除1例发生术中大出血及气栓中转开腹外,余手术安全实施,无严重并发症发生。结论科学规范的护理配合,有利于机器人复杂肝手术的顺利开展,保障患者的手术安全。     

Partial nephrectomy for centrally located tumors

Introduction. Interest in nephron-sparing surgery has been spurred by the good long-term results of patients treated with partial nephrectomy. Partial nephrectomy entails the complete resection of renal tumor while leaving behind clear surgical margins and maximum functional renal parenchyma.Technical Considerations. We prefer to access the renal tumor by a flank incision. Intraoperative sonography is used to define the operative lesion and to search for multicentric tumors. A vascular clamp is placed on the renal hilum for vascular control. Regional hypothermia protects the kidney during renal ischemia. The perinephric fat is excised in situ with the renal tumor. Tumor base biopsies ensure negative margins. Meticulous dissection and tying of vessels improves hemostasis. Diluted methylene blue is directly injected into the renal pelvis to inspect for any intrarenal leakage. The argon beam coagulator is used routinely, and collagen (Avitene) is placed into the renal defect for hemostasis. The renal parenchyma and Gerota’s fascia are reapproximated anatomically. A small drain is left in place, and the wound is closed in the usual manner.Conclusions. Recent studies continue to report that conservative surgery is as effective as radical nephrectomy for renal cell carcinoma, but the judgments in patient selection and operative management are paramount in determining its success.     

Breast-conserving therapy for centrally located breast cancer

OBJECTIVE: To analyze whether breast-conserving therapy (BCT) may be an oncologically safe approach and result in a good cosmesis in patients with centrally located breast cancer (CLBC). SUMMARY BACKGROUND DATA: Only underpowered, retrospective, single-arm studies have suggested that oncoplastic BCT for CLBC may be oncologically safe and may result in a good cosmesis. METHODS: The authors retrospectively analyzed the overall and recurrence-free survival in 1485 patients with breast cancer undergoing BCT comparing CLBC with non-CLBC. Moreover, the authors described 4 different oncoplastic techniques for BCT in patients with CLBC and compared the cosmetic results with simple lumpectomy according to a recently elaborated objective cosmetic evaluation system, the Breast Symmetry Index. RESULTS: Kaplan-Meier curves show no significant difference in a 5-year overall, local, or distant recurrence-free survival between patients with CLBC and non-CLBC after BCT (94% vs. 96%; 100% vs. 98%; 92% vs. 90%; median follow-up, 35.3 months). The cosmetic outcome after oncoplastic BCT compared with simple lumpectomy differed significantly (Breast Symmetry Index: 22 +/- 6%d vs. 44 +/- 12%d; P < 0.05). CONCLUSIONS: The results demonstrate that BCT for CLBC is oncologically safe and that oncoplastic techniques improve cosmesis.