脾切除术对肝硬化病程的影响及机制

脾肿大是肝硬化门静脉高压常见的病理改变,并可进展为脾功能亢进,导致患者血细胞减少,增加临床出血、感染等风险。脾切除术是治疗脾大伴脾功能亢进的重要手段,但面临着感染、手术出血、术后血栓形成、术后胰瘘等风险。然而,随着现代研究的不断深入,脾切除术后肝硬化患者的病情在一定程度上得到了改善,例如降低消化道出血的风险、降低门静脉的压力、改善内脏等的血流动力学、促进肝组织的再生、改善肝纤维化、调节免疫、改善营养状况、降低肝癌发生的风险等。本文结合现有的临床和实验研究,综述了脾切除术对肝硬化病程的影响及其机制,以期为临床脾切除术的选择和开展提供可靠的参照和依据。     

原发性肝癌合并门静脉癌栓的外科治疗

目的:探讨原发性肝癌合并门静脉癌栓的外科治疗及提高疗效的方法。方法:采用肝叶切除和经门静脉残端或主干切开取癌栓术治疗32例PHC合并PVTT患者,12例术后联合门静脉、肝动脉介入化疗,5例合并门静脉高压联合行断流术、脾切除或脾动脉结扎术。总结其临床资料、治疗方法、术后并发症及疗效预后,并进行统计学分析。结果:①本组病例术中出血量、输血量、肝门阻断次数时间、术后并发症发生率与同期50例单纯肝癌切除组比较无显著性差异(P>0.05)。②术后并发症:9例肝功能不全,3例术后肝断面出血、5例右胸腔积液、2例上消化道出血,1例术后3个月死于肝功能衰竭,其余恢复良好。③疗效与预后:随访26例,1、2、3年生存率分别为50％、34.6％、15.4％;术后化疗、术前肝功能状况对预后有显著影响。结论:肝叶切除和经门静脉残端或主干切开取癌栓是治疗原发性肝癌合并门静脉癌栓最有效的方法,改善术前肝功能及术后联合化疗,对提高生存期意义重大;门静脉取癌栓联合贲门周围血管断流、和/或脾切除、脾动脉结扎术能有效治疗肝癌合并门静脉高压,减少上消化道出血并发症;对于难以切除的PHC合并PVTT应争取行TACE术,仍有二期手术切除的机会。     

Embospher生物微粒球介入治疗原发性肝癌合并脾功能亢进104例

<正>原发性肝癌为我国常见也是最难治疗肿瘤之一,由于肝癌发生的肝硬化背景及其发生的多中心性、肝内播散等问题,使得肝癌的外科手术治疗显得力不从心。随着医学影像学的进步,其创伤小、疗效显著的经肝动脉化疗栓塞术的介入治疗显得日益重要,是治疗原发性肝癌的首选措施之一。于此同时肝癌患者常合并脾大、脾功能亢进及食管静脉曲张等门静脉高压     

脾动脉阻断技术在射频消融治疗门脉高压性脾功能亢进症中的应用

目的探讨脾动脉阻断技术联合脾脏射频消融（RFA）治疗门静脉高压性脾功能亢进症（脾亢）的有效性和临床应用前景。方法对阻断或未阻断脾动脉主干的接受脾脏RFA治疗的肝硬化性门静脉高压合并重症脾亢患者,分析随访6个月的临床疗效;并评估脾动脉阻断对肝硬化合并脾动脉盗血综合征的治疗效果。结果阻断或未阻断脾动脉主干的接受脾脏RFA治疗的门脉高压性脾亢患者各15例,术后未发生严重并发症。阻断脾动脉后实施脾脏RFA组消融（56±35）%脾脏体积,较未阻断脾动脉组消融体积（38±21）%显著增加（P〈0.01）;且阻断脾动脉组治疗后血小板计数、Child-Pugh评分和分级改善明显优于未阻断脾动脉组。合并巨脾的脾动脉阻断组15例患者经影像学诊断都符合脾动脉盗血综合征诊断,经脾动脉栓塞（13例）和脾动脉结扎（2例）后肝动脉内径显著增粗,肝动脉供血明显改善。结论脾动脉阻断联合脾脏射频消融术是治疗门静脉高压性脾亢,可以显著提高脾亢治疗的安全性和有效性,同时纠正脾动脉盗血综合征和有效改善肝功能。     

原发性肝癌患者CT引导下经皮微波消融术中肿瘤位置与疼痛程度的关系

目的探讨肝癌患者局部麻醉下CT引导肝癌微波消融(MWA)术中,肿瘤位置与患者疼痛程度的关系。方法 35例肝癌患者42个肿瘤病灶经肝动脉化疗栓塞术治疗后实施CT引导经皮MWA治疗。临近肝包膜组16例患者、19个病灶,病灶临近肝包膜和(或)肝段以上门静脉分支≤5 mm;远离肝包膜组19例患者、23个病灶,病灶距肝包膜及肝段以上门静脉分支均5 mm。采用视觉模拟评分法(VAS)对两组患者疼痛程度进行评估。记录和比较两组患者的肿瘤大小、基础VAS评分、术中VAS评分(MWA中最大痛觉评分)、相对VAS评分(术中VAS评分减去基础VAS评分)、可耐受最大功率、消融时间、哌替啶用量。组间各参数比较采用Mann-Whitney U检验。结果 16例临近肝包膜组患者的术中VAS评分、相对VAS评分(3.25±0.68和3.00±0.52)明显高于19例远离肝包膜组患者(2.74±0.73和2.47±0.61),差异均有统计学意义(P值分别为0.042和0.009),即消融治疗时临近肝包膜组患者的疼痛比远离肝包膜组患者更明显。临近肝包膜组患者的哌替啶用量[(78.1±20.2)mg]亦高于远离肝包膜组患者[(64.5±17.3)mg],差异有统计学意义(P=0.039)。给予高剂量哌替啶治疗后,可耐受最大功率和消融时间在临近肝包膜组[(73.8±15.4)W、(6.6±1.8)min]与远离肝包膜组[(75.8±17.7)W、(6.4±2.1)min]之间差异无统计学意义(P值均0.05)。结论临近肝包膜及门静脉分支的肝癌病灶行MWA治疗时,患者疼痛更明显。追加用哌替啶剂量后,可完成MWA治疗。     

经皮经肝动脉,门静脉介入治疗肝癌的临床研究

对３０例原发性肝癌患者在肝动脉化疗栓塞的基础上,联合应用经皮经肝门静脉化疗栓塞。结果治疗后门静脉癌栓消失和缩小２１例,肝癌缩小２３便,术后０．５、１、２年生存率分别为６６．７％、２０％和６．６％。认为经皮经肝动脉及门静脉双重介入治疗肝癌是一种有效可靠的方法。     

食管横断法门奇静脉断流术联合肝脾切除术治疗原发性肝癌并脾功能亢进的临床研究

目的探讨原发性肝癌合并肝硬化门静脉高压并脾功能亢进患者手术方式及病例选择对手术效果及安全性的影响。方法对2005-05～2011-11我院收治的60例肝癌合并肝硬化门静脉高压并脾功能亢进行手术治疗患者的临床资料进行回顾性分析。观察组30例应用食管横断法门奇静脉断流术联合肝脾切除术,对照组30例单纯行肝癌切除术。比较两组肝功能分级、肝硬化程度、术前与术后血常规及肝功能变化、术后并发症等指标,判断手术安全性及病例选择对手术效果的影响。结果 60例患者随访5个月～5年,平均(12,3±2)个月,观察组治愈20例,总有效率为96.7%,复发率为16.7%;对照组治愈15例,总有效率为80%,复发率为30.0%,两组差异无统计学意义(P0.05)。对照组术前术后血小板、白细胞变化无明显差异。观察组术后血小板、白细胞较术前明显升高(P0.01)。观察组和对照组术后5年无瘤生存分别为10例(33.3%)和5例(16.7%),差异有统计学意义(P0.05)。结论原发性肝癌合并肝硬化门静脉高压并脾功能亢进患者同期行食管横断法门奇静脉断流术联合肝脾切除术是可行的。     

射频消融治疗临近特殊部位肝癌的并发症及预防

射频消融是治疗肝癌的重要方法之一,具有创伤小、操作简单、可重复治疗等优点。但是对于肝门静脉一、二级分支5 mm以内,肝静脉、下腔静脉主干旁,靠近胆囊、肠道5 mm以内或者肝包膜下、膈肌等特殊部位的肝癌,射频消融存在完全消融率低、局部复发率高以及严重并发症等问题。介绍了射频消融治疗靠近特殊部位肝癌的并发症及其预防。指出随着个体化、规范化的射频消融推广,这些"禁区"成为可能。     

原发性肝癌切除术中联合残肝断面射频消融对术后局部复发的预防

背景手术切除是可能治愈肝癌的主要方法,小肝癌的射频消融治疗也能达到手术切除的相同效果,但术后的高复发率很大程度上制约了其治疗效果,为预防或减少术后肝断面的局部复发,我们设计了本联合处理方法,初步效果良好.目的为探讨原发性肝癌切除手术中残肝断面处理的新方法对患者术后肿瘤局部复发的预防作用.方法回顾2016-10/2019-09期间17例原发性肝癌切除术中联合残肝断面使用射频消融(腹腔镜手术8例,开腹手术9例)患者的临床资料,分析其术后肿瘤局部复发情况.结果所有患者无严重术后并发症,术后每3 mo随访复查,已坚持随访6-36 mo,中位随访时间25.7 mo±4.4 mo,所有患者残肝断面局部无复发;术后15 mo腹腔淋巴结转移1例,术后18 mo远离肝断面的新发肝内癌灶1例,这2例患者均采用现代中西医结合模式进一步治疗,现带瘤生存良好,其他患者状况良好,全组无死亡.结论原发性肝癌切除术中应用射频消融处理残肝断面可显著降低肿瘤局部复发,在提高患者生存方面有积极的临床意义,值得临床推广应用.     

经颈静脉肝内门体分流术对酒精性肝硬化导致门静脉高压的治疗效果与安全性分析

目的分析经颈静脉肝内门体分流术(TIPS)治疗酒精性肝硬化导致门静脉高压的有效性及安全性。方法回顾性总结2006年6月至2011年6月本院30例接受TIPS治疗的酒精性肝硬化导致门静脉高压的患者资料,记录术前及术后门静脉压力、腹水、脾功能亢进、肝功能等指标。随访终点为术后2 a,观察术后并发症包括消化道再出血、支架堵塞、腹水及肝性脑病发生情况,并分析肝性脑病发生与患者临床参数的关系。穿刺前、后门静脉压力差别采用配对t检验分析;Kaplan-Meier方法用于术后临床参数与肝性脑病发生相关性分析。结果 TIPS手术成功率为100%(30/30),门静脉压力术前(37.27±2.52)cm H2O降为术后(24.6±2.58)cm H2O,差异具有统计学意义(P0.05)。术后2 a内,消化道再出血率为3.3%(1/30);腹水治疗有效率达88.9%(16/18);支架狭窄发生率为6.7%(2/30);肝性脑病发生率为40%(12/30)。Kaplan-Meier分析发现患者术前Child-Pugh分级与术后肝性脑病发生密切相关(P=0.04)。结论 TIPS是治疗酒精性肝硬化门静脉高压相关并发症安全有效的微创方法,术前ChildPugh分级是影响患者肝性脑病发生的重要因素。     

Pharmacological therapy of portal hypertension--focused on Korean data]

Portal hypertension as a consequence of liver cirrhosis is responsible for serious complications such as variceal bleeding, ascites and hepatic encephalopathy. Successful pharmacological treatment of portal hypertension can prevent the risk of the variceal bleeding, and contribute to reduce the morbidity and mortality in patients with liver cirrhosis. To identify the effect of drugs on portal hypertension, portal pressure was evaluated accurately before and after the drug administration. The hepatic venous pressure gradient has been accepted as the gold-standard method for assessing the severity of portal hypertension and the response to drug treatment. The mean hepatic venous pressure gradient was 15.1+/-5.4 mmHg in Korean cirrhotic patients who had experienced variceal bleeding. Non-selective beta blockers are the treatment of choice for primary and secondary prevention of variceal bleeding. The dose of propranolol should be subsequently adjusted until the resting heart rate had been reduced by 25% or less than 55 beats per minute. It has been reported that the optimal dose of propranolol is variable due to racial differences in cardiovascular receptor sensitivity. In Korean patients with portal hypertension and liver cirrhosis, the mean required dose of propranolol to reach target heart rate was 165 mg (range; 80-280 mg). This review covers mainly the results of the pharmacological therapy of portal hypertension in Korean cirrhotic patients.     

The use of TIPS in chronic liver disease

The development of cirrhosis and portal hypertension in the natural history of chronic liver disease is associated with many complications. A transjugular intrahepatic portosystemic stent shunt (TIPS) is a metal prosthesis that has been shown to be very effective in lowering sinusoidal portal pressure, and therefore is effective in the management of complications of cirrhosis, especially those related to portal hypertensive bleeding and sodium and water retention. In patients with acute variceal bleeding not responding to pharmacologic and endoscopic treatments, a reduction of the hepatic venous pressure gradient to < 12 mmHg or by > 20% with TIPS has been shown to be effective in controlling the acute bleed and in preventing rebleeding. For stable patients whose acute variceal bleed is controlled, TIPS is equal to combined beta-blocker and band ligation in the prevention of recurrent variceal bleed. TIPS is also more effective than large volume paracentesis in the control of refractory ascites, and may confer a survival advantage over repeated large volume paracentesis. TIPS has also been used in the management of other complications related to portal hypertension including ectopic varices, hepatic hydrothorax, and hepatorenal syndrome with some success, but experience is still rather limited. Miscellaneous uses include treatment of Budd Chiari Syndrome, portal hypertensive gastropathy and hepatopulmonary syndrome. Careful patient selection is vital to a successful outcome, as patients with severe liver dysfunction tend to die post-TIPS despite a functioning shunt. All patients who require a TIPS for treatment of complications of cirrhosis should be referred for consideration of liver transplant.     

Transarterial chemoembolization in hepatocellular carcinoma treatment: Barcelona clinic liver cancer staging system

Hepatocellular carcinoma(HCC),the fifth most common cancer that predominantly occurs in liver cirrhosis patients,requires staging systems to design treatments. The barcelona clinic liver cancer staging system(BCLC) is the most commonly used HCC management guideline. For BCLC stage B(intermediate HCC),transarterial chemoembolization(TACE) is the standard treatment. Many studies support the use of TACE in early and advanced HCC patients. For BCLC stage 0(very early HCC),TACE could be an alternative for patients unsuitable for radiofrequency ablation(RFA) or hepatic resection. In patients with BCLC stage A,TACE plus RFA provides better local tumor control than RFA alone. TACE can serve as bridge therapy for patients awaiting liver transplantation. For patients with BCLC B,TACE provides survival benefits compared with supportive care options. However,because of the substantial heterogeneity in the patient population with this stage,a better patient stratification system is needed to select the best candidates for TACE. Sorafenib represents the first line treatment in patients with BCLC C stage HCC. Sorafenib plus TACE has shown a demonstrable effect in delaying tumor progression. Additionally,TACE plus radiotherapy has yielded better survival in patients with HCC and portal venous thrombosis. Considering these observations together,TACE clearly has a critical role in the treatment of HCC as a stand-alone or combination therapy in each stage of HCC. Diverse treatment modalities should be used for patients with HCC and a better patient stratification system should be developed to select the best candidates for TACE.     

Evidence-based diagnosis and locoregional therapy for hepatocellular carcinoma

Early identification of hepatocellular carcinoma (HCC) is crucial to improving the results of therapy and for patients to be eligible for liver transplantation. Recent advances in noninvasive imaging technology include various techniques of harmonic ultrasound, new ultrasound contrast agents, multislice helical computed tomography and rapid high-quality magnetic resonance. The imaging diagnosis relies on the hallmark of arterial hypervascularity with portal venous washout. Since the use of better radiological techniques has improved the accuracy of noninvasive diagnosis, the role of liver biopsy in the diagnosis of HCC has declined. With recent advances in genomics and proteomics, a great number of potential markers have been identified and developed as new candidate markers for HCC. Locoregional therapies currently constitute the best options for early nonsurgical treatment of HCC. Percutaneous ethanol injection shows similar results to resection surgery for single tumors less than 3 cm in diameter. Radiofrequency ablation is superior to percutaneous ethanol injection in terms of local recurrence. Transarterial chemoembolization is currently the most common approach for the management of HCC without curative options since it improves patient survival, but the optimal embolizing agent, length of interval between sessions and whether the chemotherapeutic agent has any effect have not yet been determined. Combining transarterial chemoembolization with antiangiogenic agents, as well as with other techniques, such as radiofrequency ablation, may improve the results. Injection of radioisotopes such as yttrium-90, via the hepatic artery, may be particularly useful in patients with portal vein thrombosis. Comparisons with other transarterial techniques are needed.     

Hepatectomy for hepatocellular carcinoma in the era of liver transplantation

The aim of management of hepatocellular carcinoma (HCC) is to improve the prognosis of the patients by radical resection and preserve remnant liver function. Although liver transplantation is associated with a lower tumor recurrence rate, this benefit is counteracted by long-term complications. Therefore, hepatectomy could be the first choice of treatment in selected patients with HCC. However, the higher frequency of tumor recurrence and the lower rate of resectability after hepatectomy for HCC led to an unsatisfactory prognosis. New strategies are required to improve the long-term outcome of HCC after hepatectomy. In this paper, we introduce some strategies to increase the low rate of resectability and reduce the high rate of tumor recurrence. Some aggressive treatments for tumor recurrence to extend long-term survival are also involved. We believe that hepatectomy combined with other therapies, such as portal vein embolization, transarterial chemoembolization, radioembolization, antiviral treatment, radiofrequency ablation and salvage transplantation, is a promising treatment modality for HCC and may improve survival greatly.     

Outcome of patients with hepatocellular carcinoma referred to a tertiary centre with availability of multiple treatment options including cadaveric liver transplantation.

Hepatocellular carcinoma (HCC) is a primary cancer of the liver with an established causal link to viral hepatitis and other forms of chronic liver disease. Aims: The aim of this study was to analyse the determinants of outcome in patients with HCC referred to a tertiary centre for management. Method: Two hundred and thirty-five prospective patients with HCC and minimum 12-month follow-up were studied. Results: The cohort was heterogeneous, with 52% Caucasian, 40% Asian and 5% of Middle-Eastern origin. Independent predictors of outcome included tumour size and number, the presence of ascites or portal vein thrombosis, alpha-foetoprotein >50 U/L and an impaired performance status. Treatment was determined on an individual case basis by a multidisciplinary tumour team. Surgical resection was primary treatment in 43 patients, liver transplantation in 40 patients, local ablation (percutaneous radiofrequency ablation or alcohol injection) in 33 patients, transarterial chemoembolisation in 33 patients, chemotherapy or other systemic therapy in 30 patients and no treatment in 56 patients. After adjustment for significant covariates, both liver transplantation (P<0.001) and surgical resection (P=0.029) had a significant effect on patient survival compared with no treatment, but local ablation (P=0.410) and chemoembolisation (P=0.831) did not. Liver transplantation resulted in superior overall and, in particular, disease-free survival compared with surgical resection (disease-free survival 84 vs 15% at 5 years). Conclusion: In conclusion, both surgical resection and liver transplantation significantly improve the survival of patients with HCC, but improvements need to be made to the delivery of loco-regional therapy to enhance its effectiveness.     

Colorectal liver metastases:An update on multidisciplinary approach

Liver metastasis is the commonest form of distant metastasis in colorectal cancer.Selection criteria for surgery and liver-directed therapies have recently been extended.However,resectability remains poorly defined.Tumour biology is increasingly recognized as an important prognostic factor;hence molecular profiling has a growing role in risk stratification and management planning.Surgical resection is the only treatment modality for curative intent.The most appropriate surgical approach is yet to be established.The primary cancer and the hepatic metastasis can be removed simultaneously or in a two-step approach;these two strategies have comparable long-term outcomes.For patients with a limited future liver remnant,portal vein embolization,combined ablation and resection,and associating liver partition and portal vein ligation for staged hepatectomy have been advocated,and each has their pros and cons.The role of neoadjuvant and adjuvant chemotherapy is still debated.Targeted biological agents and loco-regional therapies(thermal ablation,intra-arterial chemo-or radio-embolization,and stereotactic radiotherapy) further improve the already favourable results.The recent debate about offering liver transplantation to highly selected patients needs validation from large clinical trials.Evidencebased protocols are missing,and therefore optimal management of hepatic metastasis should be personalized and determined by a multi-disciplinary team.     

Venous thromboembolism and cancer: prevention and therapy

Venous thromboembolism (VTE) is a common problem in patients with cancer that complicates management and predicts for a worse prognosis. Hence, effective methods to prevent and treat VTE can reduce morbidity and mortality. Low molecular weight heparins have simplified and improved management of VTE and recent studies suggest these agents may improve survival in cancer patients. This review will provide an update on the primary prevention and treatment of VTE, as well as prophylaxis for central venous catheters, in patients with malignancy.     

肝硬化门静脉高压外科治疗的现状及进展

肝硬化可以导致门静脉压力病理性持续升高,出现食管胃底静脉曲张、腹水、肝性脑病以及继发循环功能障碍等多种并发症。门静脉高压症以综合治疗为主,其中外科治疗主要是控制并预防食管胃底静脉曲张破裂大出血。介入治疗和肝移植已逐渐成为手术干预的一种常规手段,能够显著提高患者生活质量,但断流术和分流术仍是目前的主流术式。肝硬化门静脉高压的每一种手术策略都有其自身的特点,综合评估患者一般情况及病情特点,采用个性化治疗方案以达到最佳疗效将是未来的趋势。     

Current treatment for liver metastases from colorectal cancer

The liver is the commonest site of distant metastasis of colorectal cancer and nearly half of the patients with colorectal cancer ultimately develop liver involved during the course of their diseases. Surgery is the only therapy that offers the possibility of cure for patients with hepatic metastatic diseases. Five-year survival rates after resection of all detectable liver metastases can be up to 40 %. Unfortunately, only 25 % of patients with colorectal liver metastases are candidates for liver resection, while the others are not amenable to surgical resection. Regional therapies such as radiofrequency ablation and cryotherapy may be offered to patients with isolated unresectable metastases but no extrahepatic diseases. Hepatic artery catheter chemotherapy and chemoembolization and portal vein embolization are often used for the patients with extensive liver metastases but without extrahepatic diseases, which are not suitable for regional ablation. For the patients with metastatic colorectal cancer beyond the liver, systemic chemotherapy is a more appropriate choice. Immunotherapy is also a good option when other therapies are used in combination to enhance the efficacy. Selective internal radiation therapy is a new radiation method which can be used in patients given other routine therapies without effects.