彩色多普勒超声对原位肝移植患者的临床价值分析

目的：应用彩色多普勒血流显像（CDFI）评价原位肝移植（OLT）患者的肝血流动力学的改变及并发症的发生.方法：应用CDFI对45例患者进行术前、术中和术后检查及监测.结果：1周之内的移植肝脏血管重建显示再通良好.肝动脉峰值流速明显降低,门静脉平均流速略高于正常人,对OLT术后肝动脉（HA）狭窄、门静脉（PV）及下腔静脉（IVC）血栓及胆道等并发症可作出较为特异性的诊断.结论：CDFI对OLT患者血流动力学监测及并发症的早期诊断和鉴别诊断具有重要参考价值.     

肝细胞癌合并门静脉癌栓外科治疗的疗效观察

目的探讨肝细胞癌合并门静脉癌栓（PVTT）外科治疗的效果。方法对156例肝细胞癌合并门静脉主干或第一分支癌栓的患者,均行肝癌联同门静脉癌栓切除或取栓,其中94例患者术后行肝动脉和（或）门静脉化疗。结果术后3例死于肝功能衰竭,2例死于术后并发症,余术后恢复良好,术后1、3、5年生存率分别为58．1％（86/148）、18．9％（28／148）、5．4％（8／148）。结论肝切除和门静脉切开取栓术是肝细胞癌合并PVTT的有效治疗方法,术后联合肝动脉和（或）门静脉化疗能提高治疗效果,延长患者的生存期。     

肝癌再次切除术后肝移植的临床应用价值

目的:探讨肝移植在肝癌再次肝切除术后患者治疗中的合理适应证及其临床价值.方法:回顾性分析10例肝癌再次肝切除术后复发或肝功能衰竭患者肝移植的临床资料和随访结果.结果:肝癌再次肝切除术后患者肝移植围手术期(术后2个月内)死亡率为2/10,手术相关死亡率为1/10.术后并发症发生率为3/10.随访过程中肿瘤复发率为5/8(肺转移2例,肝内转移2例,骨转移1例),肝移植术后肿瘤中位复发时间17个月(3～25个月).4例患者分别于肝移植术后12、37、42和48个月死于肿瘤复发、进展,肿瘤复发诊断后中位生存时间25个月(9～45个月).目前生存4例,分别无瘤生存12、50、50和62个月.首次肝切除到肝移植的中位生存时间为93个月(41.5～147个月);从再次肝切除到肝移植的中位生存时间为60个月(10.5～105个月).结论:肝癌再次切除术后患者肝移植治疗是可行的,但要严格选择恰当的适应证,Milan标准是目前肝癌再次肝切除术后肝移植的理想标准.肝切除和肝移植相结合可使肝癌患者获得长期生存的机会.     

常规根治术、门静脉重建和肝动脉重建治疗肝门部胆管癌的安全性及近期疗效比较

目的 比较常规根治术、门静脉重建和肝动脉重建三种手术方式治疗肝门部胆管癌的安全性及近期疗效。方法 选取108例行胆管癌根治术的肝门部胆管癌患者，根据不同手术方式分为三组：常规根治术组（A组）28例，门静脉重建术组（B组）48例和肝动脉重建术组（C组）32例。比较三组患者围术期的相关指标、术后并发症及术后1年生存率、淋巴结转移等情况。结果 C组手术时间、术中出血量、住院时间及住院费用均高于A组和B组（均P<0.05）。三组患者术后并发症发生率差异无统计学意义（χ ²=0.110, P>0.05）。三组患者淋巴结转移率及术后1年生存率差异均无统计学意义（均P>0.05）。结论 与常规根治术和门静脉重建术比较，肝动脉重建患者近期生存率无差异，可提高根治性手术切除率；但其手术时间和住院时间较长、术中出血量较高、住院花费多。     

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

目的 探讨肝癌原位肝移植术后肿瘤复发的CT和MRI影像学表现及其诊断价值.方法 回顾性分析161例肝癌肝移植术患者的术后肿瘤复发情况,重点分析肿瘤复发患者的CT和MRI表现、复发部位及复发时间.结果 161例肝癌肝移植术患者术后复发29例,复发率为18.0%.复发者的原发肿瘤分期为Ⅱ期4例,Ⅲ期7例,Ⅳa期8例,Ⅳb期10例.肺部复发21例,呈2～3 cm左右结节状病灶,4例伴有胸膜复发.移植肝复发9例,呈多发结节型4例,弥漫型及巨块型各2例,单发结节型1例,其中2例伴有门静脉、下腔静脉栓形成.淋巴结复发9例,见于肝门区、小网膜区、胰头周围、腹膜后及后纵隔,其中1例伴有淋巴结融合、坏死.骨骼复发4例,呈溶骨性骨质破坏,CT呈不均匀低密度影,MRI呈不均匀长T1、长T2信号影,2例周围伴有软组织肿块.与移植肝、淋巴结、骨骼及其他部位相比,肺部肿瘤复发率最高(P=0.001).Ⅳb期肝癌肝移植术后肿瘤复发的发生率明显高于Ⅱ期～Ⅳa期患者(P=0.001).4例Ⅱ期肝癌肝移植后均在1年后复发,25例Ⅲ～Ⅳb期肝癌均在1年内复发.结论 肝癌肝移植肿瘤复发以肺部及胸膜最多见,移植肝、淋巴结次之.Ⅱ期肝癌肿瘤复发晚于Ⅲ～Ⅳb期肿瘤,Ⅳb期为肝癌肝移植手术的禁忌证.CT和MRI检查在肝癌肝移植诊断中具有重要意义.     

术中肝动脉合并门静脉插管化疗预防肝癌手术后复发

目的 :研究原发性肝癌根治性切除以后肝动脉和门静脉插管皮下埋置药物泵预防肝癌肝内复发的效果。方法 :回顾性研究 5 4例根治性切除肝癌术后的患者 ,其中切除肿瘤后肝动脉和门静脉插管的患者为 3 1例 ,未做插管的 2 3例。随访 2～ 3年 ,对结果进行比较。结果 :插管组 1、2年以及 3年的复发率均低于未插管组。结论 :原发性肝癌根治性切除手术合并肝动脉和门静脉插管皮下埋置药物泵是预防肝癌复发的有效方法     

彩超检测血流动力学对原发性肝癌合并门静脉高压及术后复发的临床评估价值

目的 探究彩色多普勒超声检测血流动力学对原发性肝癌合并门静脉高压及术后复发评估的临床价值。方法 选择原发性肝癌合并门静脉高压患者106例作为观察组,选择同期体检健康人100例作为对照组,均采用彩色多普勒超声进行检测。比较2组门静脉、脾静脉血流动力学指标。观察组患者均行手术,术后1年根据是否复发分为复发组及未复发组,比较2组的肝动脉、门静脉血流动力学指标。结果 观察组的门静脉内径、门静脉血流量、脾静脉内径及脾静脉血流量均高于对照组(P<0.05),观察组的门静脉血流速度、脾静脉血流速度速度均低于对照组(P<0.05)。不同门静脉主干内径、脾静脉内径患者的食管胃底静脉曲张程度比较,差异有统计学意义(P<0.05),且随门静脉主干内径及脾静脉内径增加,患者食管胃底静脉曲张程度加重。复发组的肝动脉内径、门静脉内径均较未复发组增粗;复发组的肝动脉血流速度、肝动脉血流量、门静脉血流速度、门静脉血流量、肝动脉血流量/门静脉流量均高于未复发组,差异有统计学意义(P<0.05)。结论 采用彩色多普勒超声检测血流动力学,有助于评估原发性肝癌合并门静脉高压,为临床诊断及治疗提供参考依...     

原发性肝癌患者手术前后入肝血流量的观察

作者用Ｂ超多普勒复合装置测定了６２例肝癌患者手术前后的入肝血流量。结果：①无门脉主干癌栓的肝癌患者术前肝固有动脉血流量和门静脉血流量均大于对照组；②肝固有动脉结扎加栓塞术后，门静脉血流量增加；③右半肝切除术后肝固有动脉血流量的减少较肝右动脉结扎加栓塞术后更为明显；④门静脉主干癌栓经治疗（肝动脉和门静脉灌注化疗）缩小后，门静脉血流量增加，肝固有动脉血流量减少；⑤门静脉血流增加的量与肝固有动脉血流量减     

肝动脉化疗栓塞术及射频消融术联合调强放疗治疗原发性肝癌合并门静脉癌栓的疗效及预后因素分析

目的 探讨肝动脉化疗栓塞术及射频消融术联合调强放疗治疗原发性肝癌合并门静脉癌栓的疗效,并分析相关预后因素.方法 回顾性分析63例原发性肝癌伴门静脉癌栓患者的临床资料,所有患者先行肝动脉化疗栓塞治疗1～3次,然后射频消融治疗肝内原发灶,最后采用调强放疗针对门静脉癌栓行外照射治疗.放疗结束后6～8周观察癌栓及肝内肿瘤的近期疗效,随访1、2、3年生存率观察远期疗效,对可能影响预后的因素进行分析.结果 近期疗效中门静脉癌栓完全缓解9例(15.0％),部分缓解36例(60.0％),稳定10例(16.7％),进展5例(8.3％),癌栓有效率为75.0％;肝脏原发肿瘤完全缓解19例(31.7％),部分缓解30例(50.0％),稳定6例(10.0％),进展5例(8.3％),肝内肿瘤有效率为81.6％.1、2、3年生存率分别为73.3％、45.0％、27.0％.美国东部肿瘤协作组(ECOG)评分(x2=53.046,P=0.000)、肝炎病史(x2=6.472,P=0.030)、肿瘤大小(x2=7.293,P=0.026)、肿瘤数目(x2=24.382,P=0.000)、癌栓类型(x2=28.085,P=0.000)、肝功能Child-Pugh分级(x2=6.184,P=0.040)是影响患者远期疗效的危险因素.结论 肝动脉化疗栓塞术联合射频消融术治疗肝内原发肿瘤,调强放疗治疗门静脉癌栓疗效较好,不良反应低,肿瘤反应率高;ECOG评分、肝炎病史、肿瘤大小及数目、癌栓类型、肝功能分级是影响其长期疗效的影响因素.     

入肝门静脉动脉化对肝部分切除大鼠肝细胞能量代谢的影响

目的 在大鼠肝部分切除基础上建立入肝门静脉动脉化加门腔分流术的动物模型,研究大鼠术后早期肝脏细胞能量代谢的变化.方法 90只Sprague-Dawley大鼠分为3组:肝切除组+门静脉动脉化组、单纯肝切除组及单纯门静脉动脉化组,每组30只.观察术前及术后5 min吲哚靛青绿15 min储留率(indocyanine green retention rate at 15 rain,ICGR15)、术后5 min及2 h动脉血酮体比率(arterial blood ketone body ratio,AKBR)及肝组织能荷(energy charge,EC)的变化情况.结果 肝部分切除或单纯门静脉动脉化手术均导致术后大鼠ICGR15明显升高(P<0.01),单纯门静脉动脉化大鼠肝脏吲哚靛青绿15 min储留率显著低于肝部分切除大鼠(P<0.01).肝切除附加门静脉动脉化后,大鼠术后ICGR15明显低于单纯肝部分切除组(P<0.01).肝部分切除或单纯行门静脉动脉化手术均导致术后大鼠AKBR及EC明显降低(P<0.01),单纯门静脉动脉化组大鼠术后2 h开始出现回升,而肝部分切除大鼠仍持续下降.肝部分切除附加门静脉动脉化组AKBR及EC术后均明显高于单纯肝部分切除组(P<0.01).结论 肝部分切除或门静脉阻断的手术操作均明显降低肝脏细胞能量代谢水平,入肝门静脉动脉化能有效促进肝部分切除术后大鼠残肝细胞能量代谢水平的恢复.     

Tumor and liver drug uptake following hepatic artery and portal vein infusion

Anatomic dye injection studies of the blood supply of colorectal hepatic metastases suggest that tumors are supplied predominantly by the hepatic artery. Using 13N amino acids with dynamic gamma camera imaging in patients with colorectal hepatic metastases, it has been shown that hepatic artery infusion results in a significantly greater nutrient delivery to tumor compared with portal vein infusion. However, direct measurements of drug levels in tumor following hepatic artery and portal vein infusion in humans have not previously been reported. Patients with metastatic colorectal cancer confined to the liver received fluorodeoxyuridine (FUdR) through the hepatic artery or through the portal vein. All patients had previously failed systemic chemotherapy. Five patients with hepatic artery catheters were matched (by age, serum lactic dehydrogenase levels, percent hepatic replacement, and tumor size) with five patients with portal vein catheters. At operation, 3H-FUdR (1 microCi/kg) and 99mTc-macroaggregated albumin (MAA) (6 mCi) were injected into the hepatic artery or portal vein. Liver and tumor biopsies were obtained two and five minutes later. 3H and 99mTc were measured per gram tissue by scintillation and gamma counting. The mean liver levels following hepatic artery infusion (23.9 +/- 11.4 nmol/g) and portal vein infusion (18.4 +/- 14.5 nmol/g) did not differ. However, the mean tumor FUdR level following hepatic artery infusion was 12.4 +/- 12.2 nmol/g, compared with a mean tumor FUdR level following portal vein infusion of 0.8 +/- 0.7 nmol/g (P less than .01). This low level of tumor drug uptake after portal vein infusion of FUdR predicts minimal tumor response to treatment via this route. Thus, regional chemotherapy for established colorectal hepatic metastases should be administered through the hepatic artery.     

Combined hepatic-artery and portal-vein chemoembolization for colorectal cancer metastatic to the liver

The purpose of the study was to evaluate the results of combined (hepatic artery and portal vein) oily chemoembolization (OCE) in patients with unresectable colorectal liver metastases. Courses of combined OCE were given to 45 patients (1990-2000). For arterial OCE (n = 150), 40-100 mg doxorubicin mixed with 10-15 ml iodized oil and gelatin sponge was used. OCE of the portal vein (n = 118) included injection of doxorubicin-in-oil without sponge. Response to treatment (partial tumor decrease or stabilization) was reported in 80%. Serious complications occurred in 3 patients (7%) but there was no mortality. The mean and median survival rates for those patients who died were 20.2 and 17 months, respectively. The 1-, 2-, and 3-year survival rates were 83, 40 and 14%, respectively. These results were significantly better than those for arterial OCE alone or hepatic arterial infusion. Combined (arterial and portal vein) OCE with doxorubicin appears the most effective locoregional treatment for unresectable colorectal liver metastases.     

Perfusion of colorectal hepatic metastases. Relative distribution of flow from the hepatic artery and portal vein

The importance of portal circulation in the delivery of drugs and nutrients to colorectal hepatic metastases is controversial. Using 13N (nitrogen 13) amino acids and ammonia with dynamic gamma camera imaging, we demonstrate, for the first time in human beings, a quantitative advantage of hepatic artery compared with portal vein infusion. Eleven patients were studied by hepatic artery injection, five patients were studied by portal vein injection, and two patients had injections through both routes. Data collected from the liver for 10 minutes after rapid bolus injection of 13N L-glutamate, L-glutamine, or ammonia were compared with 99mTc (technetium) macroaggregated albumin (MAA) images produced after injection through the hepatic artery or portal vein at the same session. Tumor regions defined from 99mTc sulfur colloid scans were compared with nearby liver areas of similar thickness. For the 13N compounds, the area-normalized count rate at first pass maximum (Qmax) and the tissue extraction efficiency were computed. The tumor/liver Qmax ratios for MAA and 13N compounds were highly correlated. Both tumor and liver extracted more than 70% of the nitrogenous compounds. The tumor/liver Qmax ratios reflect the relative delivery of injected tracer per unit volume of tissue. After hepatic artery injection the Qmax ratio was 1.03 +/- 0.33 (mean +/- SD), significantly exceeding the Qmax ratio of 0.50 +/- 0.34 after portal vein injection (P less than 0.003). Therefore, more than twice as much of a nutrient substrate is delivered per volume of tumor relative to liver by the hepatic artery as by the portal vein; the high extraction efficiency demonstrates that the hepatic artery flow is nutritive; and the delivery of substance in solution (such as nutrients or drugs) to tumor and liver tissue correlates with the distribution of colloids such as macroaggregated albumin after hepatic arterial and portal venous injection.     

Survival following self-administered chemotherapy for liver metastases

Fifty-three patients with unresectable liver metastases from colorectal cancer either self-administered or had a family member administer 5-fluorouracil (5-FU) (12 mg/kg/day for 5 days in alternate weeks) through intraoperatively placed hepatic artery and/or portal vein catheters. Twenty percent had failed previous systemic chemotherapy. Seventeen who were symptomatic received additional radiotherapy. Metastasis was confined to the liver in 38, while 15 also had extrahepatic metastases. Median survival for those with hepatic metastases only was 21 months from diagnosis and 16 months from catheter insertion. There are three long-term survivors in this group, alive 58, 69, and 86 months, respectively, from diagnosis. Median survival for those with hepatic and extrahepatic metastases was 10 months from diagnosis and 6 months from catheter insertion. No patient in this group has survived long term. Catheter-related complications occurred in 20% of the patients; none were fatal. Drug toxicities were minor. Self-administered chemotherapy is a safe, effective, and simple method of achieving prolonged survival in patients with unresectable hepatic metastasis from colorectal cancer.     

肝动脉化疗栓塞对原发性肝癌伴门静脉癌栓的治疗作用

目的:研究肝动脉化疗栓塞(HACE)对原发性肝癌伴门静脉癌栓的治疗作用及影响患者预后的临床病理因素。方法:随访35例HACE治疗的原发性肝癌伴门静脉癌栓患者,其中14例患者经导管肝动脉化疗栓塞,21例患者术中行肝动脉插管,术后经药物泵定期化疗栓塞。单因素分析各临床病理因素对患者预后的影响。多因素分析用Cox比例风险模型。结果:原发性肝癌伴门静脉癌栓行HACE治疗的患者中位生存时间8·3个月,其半年、1和2年生存率分别为57·5%、15·7%和0。单因素分析提示门静脉癌栓部位、化疗栓塞次数是影响患者预后的主要因素。多因素分析仅提示门静脉癌栓部位影响患者的预后。结论:HACE治疗原发性肝癌伴门静脉癌栓可以延长患者的生存期。门静脉癌栓的部位是影响患者预后的独立因素。     

碘化油阿霉素肝动脉及门静脉支分期栓塞治疗原发性肝癌

Despite recent advances in hepatic surgery, management of unresectable carcinoma of the liver is still a challenging problem. From September 1988 through March 1989, 10 primary liver cancer patients were treated by hepatic artery embolization (HAE) using lipiodol-adriamycin with or without hepatic artery ligation (HAL). One of them received HAE twice in seven weeks. In two of these patients, following right HAE and HAL, right portal vein embolization (PVE) by catheterization via the ileac vein was performed. Transcatheter portal vein embolization via the ileac vein was simple, easy and safe even it was impossible to expose the hepatic hilum. All patients are alive from 7 to 12 months after operation except one who died of hepatic failure after having survived for 54 days. There was marked alleviation of symptoms and tumor shrinkage was observed in 9 out of 10 patients. HAE and PVE using lipiodol-adriamycin may have the potential of improving the therapeutic effect in patients with hepatocellular carcinoma.     

Scanning electron microscopy study of the blood supply of human colorectal liver metastases

AIMS: The failure of hepatic artery directed treatment of colorectal liver metastases may reflect a major portal venous contribution to tumour blood supply. This study provides ultrastructural details of the blood supply of colorectal liver metastases and their association with the portal vein and hepatic artery. METHODS: Resected liver specimens from six patients with colorectal liver metastases were examined by histology and scanning electron microscopy (SEM), following vascular resin casting. RESULTS: Nine metastatic colorectal adenocarcinomas were identified. The main feature of all tumours on SEM was direct communication between hepatic sinusoids and tumour vessels. A direct portal venous connection with tumour vessels was observed in a single specimen, whilst a direct arteriole connection was not identified. CONCLUSIONS: It appears that both the hepatic artery and portal vein contribute to the blood supply of colorectal liver metastases through sinusoidal connections with tumour specific blood vessels. SEM provides useful additional information on the morphological features of tumour vasculature.     

Use of transportal balloon catheter occlusion of the portal triad in prevention of bleeding during liver resection

BACKGROUND: Operative blood loss is among the most important factors determining the prognosis of patients undergoing hepatic resection. The best method for preventing bleeding is preliminary selective vascular occlusion of lobar, sectoral, or segmental portal triads, although not always technically feasible. METHOD: Transportal occlusion of the portal triad with a balloon catheter was used in 35 hepatectomies for various tumors. RESULTS: In 27 out of 35 resections, there was absence or minimal bleeding from afferent vessels (portal vein, hepatic artery). In the remaining eight cases, there was significant bleeding from the hepatic artery. In these cases, transportal occlusion of portal triad was combined with a temporary interruption of the hepatic artery after the dissection of the hepatoduodenal ligament. The average intraoperative blood loss was 350-1,500 ml. CONCLUSION: The use of a balloon catheter occlusion of the portal triad during liver resection is often technically feasible. It facilitates temporary occlusion of hardly accessible portal veins in the hepatic hilus without their prior exposure and minimizes bleeding.     

Significance of duplex/colour Doppler sonography in hepatic arterial chemotherapy for patients with liver metastases from colorectal carcinoma.

AIMS: The aim of the study was to evaluate the importance of duplex/colour Doppler ultrasound in a protocol of hepatic regional chemotherapy, by measuring the blood flow in the hepatic artery, portal vein, hepatic veins, and inferior caval vein of patients with unresectable liver metastases from colorectal carcinoma. METHODS: Thirty-nine consecutive subjects were selected for this study, including 21 patients who had unresectable histologically confirmed liver metastases from colorectal carcinoma (Group A), and 18 asymptomatic volunteers as normal controls (Group B). All subjects of Groups A and B were examined using duplex/colour Doppler sonography. After the ultrasound study, all patients of Group A were submitted to the administration of high dose mitomycin C into the hepatic artery, with concomitant detoxication of post-hepatic venous blood. RESULTS: The mean value of the hepatic artery blood flow was significantly higher (P=0.0009) in liver metastases patients (361 ml/min, SEM=24 ml/min) than in normal controls (245 ml/min, SEM=20 ml/min). Also, the mean Doppler perfusion index was higher in liver metastases patients than in normal controls. For each patient of Group A, the total dose of mitomycin C to be infused was calculated based on the blood flow in the hepatic artery. In this way the concentration of mitomycin C in the hepatic artery was always greater than 3 microg/ml. The duration of detoxication was calculated based on the blood flow in the inferior caval vein. For two patients only, the blood flow was lower than 1000 ml/min, with the necessity to protract the duration of detoxication over 2 hours. CONCLUSIONS: The measurement of the blood flow in hepatic vessels of patients with liver metastases seems to be very important in establishing the total dose of drug which has to be infused in hepatic arterial chemotherapy, and to determine the duration of concomitant detoxication of post-hepatic venous blood.