三种不同肝血流阻断法在肝脏手术中的应用

本文采用第一肝门阻断，常温下全肝血流阻断以及氏温灌注下全肝血流阻断等三种不同的肝血流阻断技术，以处理累及肝脏不同部位的肝肿瘤及肝外伤，作者描述了三种肝血流阻断技术的方法，各个方法应用的指征，并对肝脏缺血耐受的时限以及肝血流阻断技术在肝硬化病人中的应用等问题进行了讨论。     

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目的对第一肝门阻断和选择性肝血流阻断(SHVE)在肝切除术的疗效进行综合比较及Meta分析。方法对1996年5月至2011年7月通过Medline、Elsevier、中国期刊全文数据库、万方数据检索、Pubmed发表的有关肝切除术中采用第一肝门阻断和SHVE进行肝血流阻断的相关随机对照研究(RCT)文献,采用Cochrance协作网提供的ReMan5.1软件用固定效应模型进行Meta分析。结果按照入选标准,有9项临床试验纳入。Meta结果显示:SHVE组术中出血量较第一肝门阻断组少131.29mL(P<0.001);手术时间SHVE组较第一肝门阻断组延长12.66min;住院时间SHVE组较第一肝门阻断组少2.68d(P<0.001);SHVE组术后肝功能衰竭发生率以及其他并发症(包括大量腹水、胸腔积液、肺部感染等)发生率较第一肝门阻断组明显降低(P<0.05);胆漏发生率两组差异无统计学意义(P>0.05)。结论肝脏手术中采用选择性肝血流阻断安全可靠,相比传统第一肝门阻断减少了术中出血、缩短术后住院时间,降低了肝功能衰竭等并发症发生率。     

选择性入肝血流阻断在合并肝硬化肝癌切除术中的应用

目的探讨原发性肝癌合并肝硬化患者行肝段切除手术中入肝血流阻断方法的更佳选择。方法总结分析合并肝硬化原发性肝癌32例,观察不同入肝血流阻断方法对手术中出血、术后肝功能及患者康复情况的影响。结果全组患者均成功切除肝癌,18例肝门部血流阻断(Pringle法)下的术后有3例患者出现上消化道出血,其中1例死亡;而14例选择性半肝血流阻断无上述情况出现,术后肝功能及腹腔血性引流及康复情况与前者相比,差异有统计学意义。结论合并肝硬化肝癌患者的手术切除,只要注意术前肝功能状况,确定合理的入肝血流阻断及手术方案,手术仍为安全可靠的选择。     

经腹常温下改良式全肝血流阻断无血切肝术

经腹常温下改良式全肝血流阻断是常温下肝血管隔离（ＮＨＶＥ）技术中创伤最小的一种术式。作者采用该技术治疗２例侵及肝右静脉、下腔静脉巨块型肝癌和１例右肝被膜下巨大血肿患者，疗效满意，并讨论其适应证、可行性、全肝热缺血时间与肝功能损害之间的关系，指出该技术是防止肝静脉出血和空气栓塞的有效措施，为切除侵及主肝静脉的肝肿瘤、修复外伤性近肝大静脉损伤提供了可靠保障，认为无肝硬化者，全肝阻断的安全时限可达３９ｍｉｎ以上，不会影响胃肠功能恢复，对有心、肺疾患者可慎重应用。     

常温下经腹全肝血流分步阻断切肝术8例体会

改良式无血切肝是简便，安全，可靠的肝外科技术，全肝血流分步阻断可在安全阻断时限内，较好地完成难以在一次阻断时限内完成的特大肝癌的切除，本文介绍了我们分步阻断的手术方法和效果，对伴有门静脉高压病人是否同时施行预防性手术的问题提出了意见，强调了围手术期处理。     

肝切除术中肝血流阻断术的发展

原发性肝细胞肝癌( Hepatocellula carcinoma,HCC)简称肝癌,是人类最常见的恶性肿瘤之一,每年新增病例超过100万人,死亡人数占全部肿瘤死亡人数的第三位,严重危害人类的生命健康[1].而我国是肝癌的高发区,发病人数居首位,年死亡数多达33万人左右,死亡率在各种恶性肿瘤中占据第二位[2],且发病隐匿,进展迅速,治疗难度大,生存期较短,发病率在我国一直处于上升的势态.     

半肝血流阻断在肝硬化肝癌半肝切除术中的意义

目的探讨半肝血流阻断在肝硬化肝癌半肝切除术中的意义。方法将26例肝癌合并肝硬化行半肝切除的病人分为半肝血流阻断组(HVC,n=14)和第一肝门阻断组(Pringle,n=12)。比较两组病人术中出血量和手术时间,术后肝功能的恢复,以及术后并发症。结果两组病人术中出血量和手术时间均无显著差异。HVC组术后3天和7天的血清谷丙转氨酶明显低于Pringle组,且下降程度也较后者明显。Pringle组有2例死于肝功能衰竭。Pringle组病人术后并发腹水显著高于HVC组。结论半肝血流阻断法比第一肝门阻断更利于术后肝功能恢复,减少手术并发症,降低死亡率。     

病肝血流阻断规则性肝叶切除6例

1998年10月～2000年5月本科共施行病肝血流阻断规则性肝叶切除6例,而同期本科施行肝切除术共15例,无手术死亡,均痊愈出院。现总结报告如下。1　临床资料1.1　一般资料本组共6例,男2例,女4例,年龄32～60岁。其中原发性肝癌3例,右半肝1例,左半肝1例,肝右三叶1例;肝脏外伤包膜下巨大血肿2例,均位于右半肝;肝内胆管结石致肝纤维化1例,位于左半肝。3例原发性肝癌中HBsAg(+)2例,AFP(+)2例。1.2　麻醉的选择2例肝严重外伤行单纯气管插管静脉复合麻醉,其余4例施行连续硬膜外+气管插管静脉复合麻醉。2　方法与结果2例肝外伤行右上经腹直肌切口;肝…     

肝切除术中肝血流阻断方法的评价

肝切除术中肝血流阻断方法的评价周信达，程树群（上海医科大学肝癌研究所上海２０００３２）肝血流阻断是肝切除术中控制出血的主要方法，选择一种合适的肝血流阻断方法，既可达到无血切肝，又可最大限度地减少肝热缺血操作，是肝外科手术成功的关键之一。近２０年来，随...     

Comparison of Two Methods of Selective Hepatic Vascular Exclusion for Liver Resection Involving the Roots of the Hepatic Veins

Background  Selective hepatic vascular exclusion (SHVE) is an effective hepatic vascular exclusion in controlling both inflow and outflow without interruption of caval flow, as it combines Pringle maneuver with extrahepatic selective occlusion of hepatic veins. But SHVE has not been widely used due to difficulty in extrahepatic dissection of hepatic veins. When the tumor is very close to the roots of the hepatic veins, dissecting the posterior wall of the hepatic vein may lead to rupture and massive bleeding of the hepatic vein. With our experience, clamping hepatic veins with Satinsky clamps is a safer and easier occlusion method by which the posterior wall of the hepatic veins does not need to be separated and encircled. In this report, we compared the results of selective hepatic vascular occlusion with tourniquet and Satinsky clamp for major liver resection involving the roots of the hepatic veins. Methods  Between January 2003 to June 2006, 180 patients who underwent major liver resection with SHVE were divided into two groups according to different methods of hepatic vascular occlusion: occlusion with tourniquet (tourniquet group, n = 95) and occlusion with Satinsky clamp (Satinsky clamp group, n = 85). In the tourniquet group, the hepatic veins were encircled and occluded with tourniquet. In the Satinsky clamp group, the hepatic veins were not encircled and clamped directly by Satinsky clamp. Results  Intraoperative and postoperative consequences of the patients were analyzed. The dissecting time for each hepatic vein was significantly shorter in the Satinsky group (6.2 ± 2.4 min vs 18.3 ± 6.2 min) than in the tourniquet group. In the tourniquet group, five hepatic veins (one right hepatic vein and four common trunk of left-middle hepatic veins) could not be dissected and encircled because the tumors involved the cava hepatic junction, and another common trunk of the left-middle hepatic vein had a small rupture during the dissection. These six patients then received successful occlusion with Satinsky clamp. There was no difference between the two groups regarding the operation duration, ischemia time, intraoperative blood loss, and postoperative complication rate. Conclusion  Both methods of the hepatic vein occlusion have the same effect on controlling hepatic vein bleeding, but occlusion with Satinsky clamp is safer, easier, and consumes less time in dissecting. Li Ai-Jun And Pan Ze-Ya contributed equally to this work.     

Recurrence and Survival Outcomes after Hepatic Resection with or without Cryotherapy for Liver Metastases from Colorectal Carcinoma

Background Some reports support resection combined with cryotherapy for patients with multiple bilobar colorectal liver metastases (CRLM) that would otherwise be ineligible for curative treatments. This series demonstrates long-term results of 415 patients with CRLM who underwent resection with or without cryotherapy. Methods Between April 1990 and January 2006, 291 patients were treated with resection only and 124 patients with combined resection and cryotherapy. Recurrence and survival outcomes were compared. Kaplan-Meier and Cox-regression analyses were used to identify significant prognostic indicators for survival. Results Median length of follow-up was 25 months (range 1–124 months). The 30-day perioperative mortality rate was 3.1%. Overall median survival was 32 months (range 1–124 months), with 1-, 3- and 5-year survival values of 85%, 45% and 29%, respectively. The overall recurrence rates were 66% and 78% for resection and resection/cryotherapy groups, respectively. For the resection group, the median survival was 34 months, with 1-, 3- and 5- year survival values of 88%, 47% and 32%, respectively. The median survival for the resection/cryotherapy group was 29 months, with 1-, 3- and 5-year survival values of 84%, 43% and 24%, respectively (P = 0.206). Five factors were independently associated with an improved survival: absence of extrahepatic disease at diagnosis, well- or moderately-differentiated colorectal cancer, largest lesion size being 4 cm or less, a postoperative CEA of 5 ng/ml or less and absence of liver recurrence. Conclusions Long-term survival results of resection combined with cryotherapy for multiple bilobar CRLM are comparable to that of resection alone in selected patients.     

肝门血流阻断在腹腔镜肝切除术的应用

目的探讨腹腔镜肝切除术中肝门血流阻断技术应用的技术要点及可行性。方法回顾性分析广西医科大学第一附属医院微创外科2005年5月至2011年6月期间95例行肝门血流阻断的腹腔镜肝切除术病例的临床资料。结果腹腔镜肝左外叶切除21例,左半肝切除13例,右半肝切除4例,肝段切除17例,局部性肝切除24例,血管瘤切除5例,中转开腹手术11例。39例应用间断性Pringle法行全入肝血流阻断,阻断时间为(30.84±9.51)min;56例行选择性入肝血流阻断,包括14例经Glisson鞘一并阻断肝蒂,42例打开Glisson鞘,分离并阻断鞘内动脉及门静脉。12例于断肝前阻断肝静脉,包括7例缝扎肝左静脉,4例分离肝左静脉,1例分离肝右静脉;其余病例则在断肝过程中于断面内处理肝静脉。手术时间(236.80±95.97)min,术中出血(551.55±497.41)ml,输浓缩红细胞(2.60±2.23)U,血浆(211.90±179.29)ml。术后并发症包括肝断面出血4例,胸腔积液4例,肺部感染3例,腹水7例,胆瘘2例,死亡1例。术后住院时间(12.47±4.18)d。截止2012年2月29日,72例肝癌获随访,随访时间(24.14±16.62)个月(5～81个月),1年生存率为68.4%(54/79),3年生存率为21.5%(17/79)。结论在腹腔镜肝切除术中应用肝门血流阻断技术是可行的。     

肝移植对肝硬变大鼠脾脏功能的影响

目的探讨肝移植对肝硬变大鼠脾脏功能的影响。方法制备四氯化碳中毒性肝硬变大鼠模型,采用“二袖套”法进行肝移植。观察肝移植前、后大鼠脾指数及脾脏组织形态学的变化;应用免疫荧光染色技术及流式细胞仪检测肝移植前、后大鼠脾脏T淋巴细胞亚群的变化。结果肝移植前,肝硬变大鼠脾指数增高,从(2.42±0.11)mg/g增至(3.62±0.14)mg/g,P<0.01;脾脏白髓面积缩小,从(23.47±2.30)%缩至(7.70±2.01)%,P<0.01;脾小梁面积扩大,从(1.75±0.61)%增加至(4.46±0.71)%,P<0.01;脾脏T淋巴细胞亚群CD4/CD8比值明显下降,从2.67±0.15降至1.18±0.15,P<0.01。肝移植后,随着时间的延长,大鼠脾脏白髓面积有所扩大,从(7.70±2.01)%增至(15.07±1.97)%,P<0.01;脾小梁面积有所缩小,从(4.46±0.71)%降至(3.11±0.51)%,P<0.05;脾指数逐渐降低,从(3.62±0.14)mg/g降至(2.62±0.11)mg/g,P<0.01;脾脏T淋巴细胞亚群中CD4/CD8比值也有所升高,从1.18±0.15升至2.32±0.11,P<0.01。结论肝硬变大鼠行肝移植后,因肝功能严重损害而导致的脾脏功能异常可得到改善。     

肝脏虚拟手术系统在肝右叶肿瘤手术中的临床应用

目的将新研发的肝脏虚拟手术系统(Li Virtue)应用于临床,制订合理的手术方案,降低手术风险,完成精准手术。方法应用Li Virtue系统对32例肝右叶肿瘤患者进行个体化分析,实现对肝脏精确测量、分割,测定各静脉的回流区域;直观显示肝内脉管的分布及变异情况;模拟肝切除的多种手术方式等,选择合理手术方案,并与术中实际情况进行对比。结果肝脏虚拟手术系统可对肝脏体积、区域分割、脉管吻合等情况进行快速准确的个性化分析;可模拟肝脏外科多种手术方式,有助于确定合理手术方案;与32例右肝肿瘤行肝切除术的术中对比,显示该系统虚拟性好,术前模拟结果准确,术中未损伤正常结构,降低了术中风险;所建立的模型也可在便携PC机上展示,方便于术中对照。结论Li Virtue系统有助于揭示个体肝脏的解剖特点,确定合理的手术方式,降低了手术风险,保证了手术安全。     

Quantitative Assessment of Hepatic Function and its Relevance to the Liver Surgeon

Background  Standard evaluation of patients undergoing hepatic surgery has been through radiological and quantitative determination of liver function. As more complex and extensive surgery is now being performed, often in the presence of cirrhosis/fibrosis or following administration of chemotherapy, it is questioned whether additional assessment may be required prior to embarking on such surgery. The aim of this review was to determine the current knowledge base in relation to the performance of quantitative assessment of hepatic function both pre- and post-operatively in patients undergoing hepatic resectional surgery and liver transplantation. Methods  An electronic search was performed of the medical literature using the MEDLINE database to identify relevant articles with cross-referencing of all identified papers to ensure full literature capture. Results and Conclusions  The review has identified a number of different methods of dynamically assessing hepatic function, the most frequently performed being through the use of indocyanine green clearance. With the recent and further anticipated developments in hepatic resectional surgery, it is likely that quantitative assessment will become more widely practiced in order to reduce post-operative hepatic failure and improve outcome.     

复杂巨大肝肿瘤的精确切除体会(附52例报道)

目的总结复杂巨大肝肿瘤的精确切除经验。方法 2008年4月至2009年8月期间四川大学华西医院肝胆胰外科行复杂巨大肝肿瘤精准切除52例,术前仔细进行肝脏储备功能、肝脏影像学等评估,术中选择适当的手术入路、血流阻断方式、断肝新技术、结合术中B超等方法。结果本组病例平均手术时间为350 min(210~440 min),半肝血流阻断时间平均为43 min(8~57 min),术中平均出血量为370 ml(250~1 150 ml),谷丙转氨酶恢复正常平均时间为10 d(7~14 d),总胆红素恢复正常平均时间为4.5 d(3~10 d);术后并发症发生率低,仅6例出现轻度漏胆,无肝功能衰竭等重大并发症,无死亡病例。结论精准肝切除治疗复杂巨大肝肿瘤安全、可行。     

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。     

Short- and Long-Term Outcomes after Hepatic Resection for Hepatocellular Carcinoma with Concomitant Esophageal Varices in Patients with Cirrhosis

Background Hepatic resection for hepatocellular carcinoma (HCC) in cirrhotic patients with esophageal varices (EV) is often avoided because of poor liver function reserve. Outcomes of resection in such cases have not been fully investigated. Methods We conducted a retrospective study of 134 cirrhotic patients (Child–Pugh class A or B) who underwent hepatic resection for HCC, comparing short- and long-term outcomes in patients with EV (n = 31) to those in patients without EV (n = 103). Results Patients with EV had higher tumor differentiation, fewer instances of portal invasion, lower liver function reserve, and more limited resections than did patients without EV. Of 31 patients with EV, four died of postoperative complication, and nine of liver failure, seven of HCC, two of ruptured EV, and two of other causes. Median survival time for patients who died of liver failure was 59 months. Mortality and morbidity rates after hepatic resection did not differ between patients with and without EV. The 5-year overall survival rate was significantly higher in patients with EV (70.1%) than in those without EV (47.5%, P = 0.045) but did not differ between patients without portal invasion with and without EV (P = 0.55). Presence of EV was not an independent predictor for survival. Conclusions Short- and long-term outcomes of hepatic resection in HCC patients with and without EV are similar. Limited hepatic resection for early-stage tumor is an option for Child–Pugh class A or B patients with EV.     

肝干细胞与肝癌关系的研究现状与临床价值

目的探讨肝干细胞与肝癌的关系及其临床应用前景。方法对国内、外相关研究成果进行回顾性分析。结果肝癌可能是肝干细胞分化不全或分化异常造成并由各种不同分化等级的细胞组成的。结论肝干细胞假说正逐渐得到广泛认同,对其的不断深入研究对揭示肝癌的细胞起源,研究肝癌的发生、转移机理等有重要意义。