A case of polypoid carcinoma of the left hepatic duct

A case of polypoid carcinoma of the left hepatic duct in 50-year-old male was reported. Extended left hepatic lobectomy with total caudate lobectomy and resection of the right hepatic duct were performed because the tumor involved the right hepatic duct and bile duct branches of caudate lobe, medial and lateral segment. Papillary growth of the tumor was diagnosed definitely by percutaneous transhepatic cholangioscopy (PTCS) and computed tomography. The tumor infiltrated the liver parenchyma of medial segment and compressed the middle hepatic vein. These findings were revealed by selective middle hepatic venography preoperatively.     

中肝叶巨大肝肿瘤的手术切除

目的探讨中肝叶巨大肝肿瘤切除的安全性和可行性。方法对平均直径13．8cm的37例巨大中肝叶肿瘤,其中包括原发性肝细胞癌18例、胆管细胞癌3例、肝囊腺癌2例、肝海绵状血管瘤13例、肝局灶性结节增生1例,采用入肝血流阻断方法进行肝肿瘤切除。行中肝叶肿瘤切除30例（81．1％）,规则性肝切除7例（18．9％）。结果37例巨大中肝叶肿瘤均得以顺利切除,术后无严重并发症发生,肝门阻断时间平均22.6min,出血量平均672ml。结论中肝叶巨大肿瘤切除手术难度大,但只要方法得当,围手术期处理适宜,仍是安全可行的。     

计算机辅助手术系统在儿童肝脏原发性间叶肿瘤手术中的应用

目的 探讨Hisense CAS计算机辅助手术系统在儿童肝脏原发性间叶肿瘤手术中的应用优势。方法 收集2009年4月至2020年11月在青岛大学附属医院接受肝脏间叶肿瘤手术的8例肝脏间叶源性肿瘤患儿的临床资料,其中男3例,女5例,年龄0.9～9岁;间叶错构瘤4例,胚胎性肉瘤4例。其中4例运用Hisense CAS计算机辅助手术系统对其增强CT数据进行三维重建。结果 术前根据CT检查拟实施精准肝切除术,4例成功进行肝脏及肿瘤的三维重建,并进行模拟肝切除。根据术前制定的手术计划成功实施肝中叶切除术2例,肝右叶切除术1例,肝左叶切除术2例,肝脏肿瘤切除术3例。术后恢复好,病理检查证实皆为肝脏间叶肿瘤。随访3个月至5年未见并发症及复发。结论 肝脏间叶肿瘤影像学特征不明显,很难与其他肝脏肿瘤区分,肿瘤体积较大,术前规划难度较高,Hisense CAS计算机辅助手术系统的3D可视化技术能补充CT检查结果,辅助医师设计最优手术方案,有助于安全根治性切除肿瘤。     

Angiographic assessment of resectability in primary hepatic carcinoma.

The nature of primary hepatic malignancy and the magnitude of operative procedures for treatment dictate that hepatic resection be carried out only when there is the chance of cure. Following resection, a sufficient amount of liver with an intact afferent and efferent vascular system must remain to sustain life. Complete hepatic angiographic evaluation by arteriography, inferior vena cavography, hepatic venography and portal venography provides valuable information about extent of tumor involvement and the anticipated hepatic remnant. Complete preoperative knowledge of hepatic vascular anatomy should permit better selection of patients for potentially curative resection and avoid operation in patients with incurable tumors.     

Resection of hepatic hilar liver cancer

From January 1970 to January 1987, hepatic hilar liver cancer (or central type of hepatic cancer) resection was done in 51 cases. The resection was often extremely difficult, and sometimes complete occlusion of the hepatic blood supply was needed when the tumor lied close to, or already invaded the great blood vessels. The 1-, 3-, and 5- year postoperative survival rates were 65.7%, 45.3%, and 38.8%, respectively, in contrast to 93.8%, 86.1%, and 80.1% (P less than 0.001) obtained in 51 cases of peripheral type liver cancer of similar tumor size during the same period. It is considered that the difficulty involved in the resection of such a cancer, the limited extent of resection, and the easy entrance of tumor cells into the blood stream may explain the poor prognosis.     

The Clinical Study of Precise Hemihepatectomy Guided by Middle Hepatic Vein

Objective

This study was designed to analyze the feasibility of classification for hepatic veins preoperatively and to evaluate the safety and therapeutic efficacy of precise hemihepatectomy guided by middle hepatic vein.

Methods

Thirty patients who underwent precise hemihepatectomy (PH group) were subjected to multi-slice helical CT hepatic venography preoperatively to achieve Nakamura’s and Kawasaki’s classification of hepatic veins. The hemihepatectomy was performed precisely by the guidance of middle hepatic vein, which was revealed by the hepatic venography and confirmed with intraoperative ultrasound. The clinical data of these patients were compared with other 38 traditional hemihepatectomy patients (control group). The amount of intraoperative bleeding and blood transfusion, liver function recovery, postoperative complications, and 1-year follow-up data were compared between two groups.

Results

The ratios of Nakamura’s classification type I, II, and III of hepatic veins were 56.7?% (17/30), 26.7?% (8/30), and 16.7?% (5/30), respectively; The percentages of Kawasaki’s classification type I and II of hepatic veins were 36.7?% (11/30) and 63.3?% (19/30), respectively. The total 30 cases of precise hemihepatectomies were performed successfully, including 13 cases of right hemihepatectomy without MHV, 15 cases of left hemihepatectomy without MHV, 1 case of right hemihepatectomy with MHV, and 1 case of left hemihepatectomy with MHV. There was no significant difference in operation-related mortality, the amount of intraoperative bleeding and blood transfusion, as well as serum alanine aminotransferase, total bilirubin, and cholinesterase of the third postoperative day between the two groups. However, negative resection margin and albumin level were more favorable in precise hemihepatectomy group than control group. In addition, the incidence of postoperative pleural effusion and seroperitoneum was decreased significantly in precise hemihepatectomy group. The 1-year, tumor-free survival rate was 79?% (15/19) In PH group, which is 48?% in control group.

Conclusions

Preoperative evaluation of hepatic veins is of great value for individual operative program via determination of anatomical type of hepatic veins. Precise hemihepatectomy could preserve functional liver tissue with complete venous return to a great extent, resulting in fewer incidences of postoperative pleural effusion and seroperitoneum. Precise hemihepatectomy also has the potential to achieve more adequate tumor-free resection margin, which may result in higher tumor-free survival rate.     

Magnetic resonance of the hepatic veins with angular reconstruction: application in living-related liver transplantation.

BACKGROUND: Preoperative mapping of the hepatic venous system of the partial liver graft is indispensable to the success of living-related liver transplantation. We assessed the accuracy of magnetic resonance (MR) venography with angular reconstruction in depicting the tributaries of the middle hepatic vein and left hepatic vein in the donors, which was essential in graft retrieval and venoplasty. METHODS: Nineteen living-related liver transplantation donors underwent a pretransplantation survey, including sonography and MRI for hepatic venous evaluation. T1-weighted images were reconstructed manually, using the inferior vena cava as a fixed point for tilting to produce an oblique plane image where both the middle hepatic vein and left hepatic vein could be demonstrated draining into the inferior vena cava. The reconstructed images of the hepatic veins were compared with preoperative sonography, intraoperative sonography, and operative findings. RESULTS: Preoperative sonography and MR findings correlated well with the operative findings in the major hepatic veins. The MR venography of the ramification of the hepatic veins has an accuracy of 93%, the sonography, 84%. Sonography is slightly inferior in the evaluation of the hepatic vein in segment 4 and the left superior hepatic vein, with an accuracy of 73% and 67%, respectively. CONCLUSION: MR venography with angular reconstruction is accurate in depicting the complex distribution of the hepatic veins of the left liver, providing important information for decision making as to the cutting plane during graft retrieval and the method of venoplasty and anastomosis. Thus, unnecessary blood loss could be avoided and vascular complications could be prevented, as these conditions would be unacceptable for a healthy living donor. We propose that MR venography, a rapid and reliable technique, is an appropriate alternative examination or complementary modality to sonography in the pretransplantation evaluation of the living donor.     

选择性左肝动脉结扎在腹腔镜肝切除术中的应用

目的:探讨选择性左肝动脉结扎用于腹腔镜肝切除术的可行性。方法:回顾分析2008年10月至2009年7月我院为19例左肝内外胆管结石、血管瘤患者行腹腔镜肝切除术中行选择性左肝动脉结扎的临床资料。结果:19例手术均获成功,术中出血20~200ml,平均80ml,手术时间90~420min,平均240min,术后住院4~9d,平均5.9d,术后病理示无恶变,无肝脏衰竭、出血、胆漏及膈下脓肿等并发症发生。结论:腹腔镜左肝切除术中选择性左肝动脉结扎术能减少术中出血,安全可行。     

第Ⅳa肝段肿瘤切除术中肝中及肝左静脉损伤的预防与处理

目的探讨及总结第Ⅳa肝段肿瘤切除术中肝中静脉及肝左静脉主干损伤的预防和处理经验。方法回顾性分析1996年8月至2008年12月47例第Ⅳa肝段肿瘤切除合并肝中静脉及肝左静脉主干损伤患者的临床资料。切除术式包括：Ⅳa肝段肿瘤局部切除12例、Ⅳa＋部分Ⅳb肝段切除（左内叶切除）10例、Ⅳa＋部分Ⅳb＋Ⅱ＋Ⅲ肝段切除（左半肝切除）25例。结果全部病例手术切除及术中止血均获成功,均涉及肝中（左）静脉主干的处理。行肝左静脉主干结扎者27例,肝左静脉主干修,b8例;肝中静脉主干结扎者4例,肝中静脉修补者16例。通过术前CT或MRI评估,肝中静脉或肝左静脉损伤发生的符合率97．2％（35,36）。术后并发症发生率10．6％（5／47）,其中活动性出血再手术1例,胆汁瘘并膈下感染2例,肝功能代偿不全2例。无围手术期死亡。结论第Ⅳa肝段肿瘤是可以安全切除的。肝中静脉及肝左静脉损伤的预防和处理是手术的重点与难点,损伤处理的具体措施包括肝中静脉及肝左静脉结扎和（或）修补术。术前CT或MRI可以较准确判断术中肝中静脉及肝左静脉损伤发生的可能性。     

Hepatic metastases from leiomyosarcoma: A single-center experience with 34 liver resections during a 15-year period

OBJECTIVE: To describe a large single-center experience with hepatic resection for metastatic leiomyosarcoma. SUMMARY BACKGROUND DATA: Liver resection is the treatment of choice for hepatic metastases from colorectal carcinoma. In contrast, the role of liver resection for hepatic metastases from leiomyosarcoma has not been defined. METHODS: The records of 26 patients who between 1982 and 1996 underwent a total of 34 liver resections for hepatic metastases from leiomyosarcoma were reviewed. There were 23 first, 9 second, and 2 third liver resections. The records were analyzed with regard to survival and predictive factors. RESULTS: In the 23 first liver resections, there were 15 R0, 3 R1, and 5 R2 resections. Median survival was 32 months after R0 resection and 20.5 months after R1/2 resection. The 5-year survival rate was 13% for all patients and 20% after R0 resection. In 10 patients with extrahepatic tumor at the time of the first liver resection, 6 R0 and 4 R2 resections were achieved. After R0 resection, the median survival was 40 months (range 5-84 months), with a 5-year survival rate of 33%. After repeat liver resection, the median survival was 31 months (range 5-51 months); after R0 resection, median survival was 31 months and after R1/2 resection it was 28 months. There was no 5-year survivor in the overall group after repeat liver resection. CONCLUSIONS: Despite frequent tumor recurrence, the long-term outcome after liver resection for hepatic metastases from leiomyosarcoma is superior to that after chemotherapy and chemoembolization. Although survival after tumor debulking also seems to be more favorable than after nonoperative therapy, these data indicate that only an R0 resection offers the chance of long-term survival. The presence of extrahepatic tumor should not be considered a contraindication to liver resection if complete removal of all tumorous masses appears possible. In selected cases of intrahepatic tumor recurrence, even repeated liver resection might be worthwhile. In view of the poor results of chemoembolization and chemotherapy in hepatic metastases from leiomyosarcoma, liver resection should be attempted whenever possible.     

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目的 总结肝癌切除术中并发大出血的原因和处理中的经验与教训，提高手术的安全性和彻底性。方法 对1999～2002年43例术中、术后并发大出血病例的病因、出血部位和应急处理以及预防进行分析讨论。结果 大出血的原因：(1)术野显露差；(2)过度牵拉肝脏撕裂大血管；(3)术野粘连，操作粗疏；(4)判断失误，误伤大血管；(5)创面处理不当。发生于肝短及肝后下腔静脉区域、肝右静脉为最多。发生率：肝短静脉22．4％，肝右静脉18．4％，肝创面16．3％，肝中静脉12．2％，肝后段腔静脉10．2％，瘤体破裂6．1％，肝左静脉6．1％，门静脉支、肝动脉支4．1％，其他4．1％。结论 对高难度肝癌的手术切除应重视适应证选择、手术操作技术，应急措施和围手术期处理等，这些是保证手术安全性的重要因素。     

联合肝叶和肝门血管切除治疗肝门胆管癌

目的　探讨治疗肝门胆管癌理想的肝叶切除术式 ,以期提高其疗效、降低并发症和病死率。方法　对 16例侵犯肝门血管的肝门胆管癌 ,采用肝I ,IV段连同肝门胆管肿瘤与受侵血管整块切除及肝十二指肠韧带骨骼化淋巴清扫。结果　 15例获手术切除 ,切除率为 93 .8% ,12例获R0 切除。无手术死亡和住院死亡。发生暂时性胆漏 1例 ,腹腔感染 1例 ,并发症发生率为 13 .3 % ,均行非手术治愈。随访病例中位生存期为 2 2个月 ,7例尚存活。结论　合并肝叶、肝门血管切除可提高肝门胆管癌的切除率和生存率 ;肝中叶和肝尾叶是肝门胆管癌手术联合切除的主要部位。肝门受侵血管的切除对提高该病切除率和根治率是有意义的 ,应酌情重建或不重建肝门血管。     

133例结直肠癌肝转移外科手术疗效评价

目的评价手术治疗结直肠癌肝转移的疗效。方法分析复旦大学附属中山医院2000年1月1日至2005年12月31日收治的470例结直肠癌肝转移患者的资料,评价手术治疗对其生存的影响。结果196例同时性肝转移患者中手术30例（15．3％）,274例异时性肝转移患者中手术103例（37．6％）。同时性肝转移组手术死亡率（3．3％）高于异时性肝转移组（1．9％）（P〈0．05）。以2006年6月31日为随访终点,随访率100％,手术患者中同时性肝转移组1、3、5年生存率和中位生存时间与异时性肝转移组相似（P〉0．05）,但术后复发率较高（36．7％比20．4％,P=0．030）。49例具有手术指征而未手术的患者其1、3、5年生存率明显低于手术患者（P=0．003）。同时性肝转移组中22例Ⅰ期手术切除原发灶和肝转移灶和8例Ⅱ期手术患者的1、2．3年生存率和中位生存时间相似（P〉0．05）。生存因素风险分析发现手术切缘达1cm（P=0．036）和复发后再次手术（P=0．041）是生存的保护性因素,而术后复发（P=0．023）是生存的危险因素。结论手术治疗是结直肠癌肝转移的首选治疗措施,可以明显改善患者的术后生存。     

胃癌肝转移的肝切除治疗及预后分析

目的 探讨胃癌肝转移肝切除治疗的疗效以及不同临床病理因素与预后的关系.方法 回顾性总结24例胃癌肝转移行肝转移灶手术切除患者的临床资料并对预后进行单因素和多因素分析.结果 全组病例均获得随访,胃癌肝转移外科治疗后1年生存率为67%,3年生存率为21%,5年生存率为13%.单因素分析显示淋巴结转移、脉管瘤栓、R0切除、转移灶大小为重要预后因素;多因素分析显示转移灶大小、脉管瘤栓为独立预后因素.结论 严格适应证的胃癌肝转移手术切除可以改善预后.综合治疗有望进一步提高疗效.     

胃癌肝转移31例外科治疗体会

目的 探讨胃癌肝转移的外科治疗效果.方法 对我院1997年10月～2006年10月收治的原发性胃癌338例中伴肝转移的31例的临床资料进行回顾性分析.对其中施行同时性胃癌肝转移灶切除术(切除组)的19例和仅行胃癌根治术而未行肝转移灶切除术(未切除组)的12例的术后生存时间进行对比.结果 全组除1例术后死于肝功能衰竭外,其余30例均获得随访.胃癌肝转移灶切除术后1年、3年和5年生存率分别为83.3%、44.4%和33.3%;未切除组术后1年生存率为50.0%,3年及5年生存率为0.两组术后生存时间有显著性差异(P＜0.05).切除组病例中有68.4%在肿瘤和周围肝组织间形成纤维假膜.结论 假包膜形成是有利的预后因素.对于胃癌肝转移病人,特别是有假包膜形成者采用外科治疗预后更好.     

肝血流阻断方法对肝切除术中大出血的影响

目的 分析不同肝血流阻断方法对肝切除术中大出血的影响.方法 回顾性分析1995年1月至2009年8月收治的接受肝切除术的2238例患者的临床资料,分析其中大出血(出血量≥1000 ml)的原因、不同肝血流阻断方法切肝时术中的出血量及大出血的发生率.结果 全组共有215例(9.6%)发生大出血,主要原因依次为门静脉主干取癌栓出血(26.0%)、肿瘤周围广泛粘连出血(24.7%)、肝断面出血(23.7%)、肝血管损伤出血(15.8%)及肿瘤破裂出血(9.8%);无门静脉主干取癌栓的2182例肝切除中,159例(7.3%)发生大出血,1257例(57.6%)出血量≤400 ml.不同肝血流阻断方法下肝切除术中出血量及大出血发生率不同.结论 Pringle联合肝下下腔静脉阻断法和经肝裸区隧道肝脏双悬吊法能更有效减少肝切除术特别是巨大肝肿瘤切除的出血量和大出血发生率.遵循"安全、有效、简便"的原则可根据肝肿瘤大小及位置、肝硬化程度及肝功能代偿情况、术者经验和条件采用不同的切肝方法,能有效减少术中出血量.     

虚拟肝脏手术规划应用于肝切除术的研究

目的 探讨虚拟肝脏手术规划对肝切除术的指导价值.方法 基于患者螺旋cT断层图像,应用自主研发的虚拟肝脏手术规划系统软件Liv 1.0对2007年5月至2009年5月收治的142例肝肿瘤患者进行虚拟肝脏手术规划,将虚拟手术规划结果与手术中所见进行对比.结果 (1)重建的142例三维可视化肝脏效果满意,清晰显示肝肿瘤的大小、位置、数目及其与肝内管道的空间毗邻关系,并可从任意角度观察,与术中所见匹配良好.(2)通过虚拟肝脏手术规划,可显示肝切除过程中需切除或保留的肝内管道,计算出余肝组织可能出现缺血和淤血的范围;通过反复的手术模拟,改变手术切除界限,优化手术方案.其中29例经CT图像判断无法切除而应用该系统进行手术规划后完整切除肿瘤,92例经虚拟手术后优化了手术方案.(3)127例肝癌患者虚拟肝脏手术规划所测预切除肝脏体积为(477±223)ml,实际切除肝脏体积为(451±209)ml,误差率为6.1%,两者间呈正相关(R=0.922,P<0.01).结论 应用软件Liv 1.0进行肝脏三维重建及虚拟肝脏手术规划可以为复杂的肝切除术提供重要的术前参考,有利于提高手术预见性和安全性,有利于提高复杂性肝切除的成功率.     

Pringle′s法联合肝静脉阻断技术在复杂肝切除术中的应用

目的: 探讨Pringle′s法联合肝静脉阻断技术在复杂肝切除术中的应用价值。方法: 对37例第二肝门区肿瘤施行Pringle′s法＋肝静脉阻断切肝术患者的临床资料进行回顾性分析。结果:37例患者中原发性肝癌27例，转移性肝癌2例，肝巨大血管瘤8例。肿瘤平均直径12.7cm（6～35cm）。肿瘤侵犯1根主肝静脉6例，侵犯2根主肝静脉20例，侵犯3根主肝静脉11例。行右三叶切除11例，右半肝切除5例，中肝叶切除9例，Ⅷ段切除4例，左三叶切除5例，尾状叶切除3例。平均第一肝门阻断时间29min（17～48min），平均肝静脉阻断时间21min（8～32min）。行肝静脉修补1例。平均术中出血量950mL（200～4 000mL）。全组术后发生并发症18例次，均经治疗后愈。无死亡病例。结论:Pringle′s法联合肝静脉阻断技术在复杂肝切除术中既能达到减少术中出血的目的，又能防止术中肝静脉破裂导致空气栓塞，还避免了下腔静脉阻断所引起全身血流动力学紊乱，是一种更安全、有效的血流阻断技术。     

Caudate lobectomy: tumor location, topographic classification, and technique using right- and left-sided approaches to the liver

BACKGROUND: Resection of the caudate lobe (involving segments I [dorsal sector] and/or IX [right paracaval region]) often presents a technical challenge. It is difficult to perform because of its deep location and adjacency to the major hepatic vessels (ie, the left and middle hepatic veins). METHODS: A literature review was performed based on a Medline search to identify articles on caudate lobectomy published from 1990 to 2005. This article describes the right and left-sided approaches to the liver for caudate resection according to caudate lobe tumor location and topographic classification. RESULTS: The results of 377 lobectomies were analyzed in this review. The left-sided approach to the liver was used in 55 (14.58%), the right-sided approach in 24 (6.36%), and both approaches in 298 (79.04%) caudate lobectomies. Primary benign and malign liver tumors, as well as secondary liver tumors, were resected. CONCLUSIONS: Access to and resection of the caudate lobe should be determined on the basis of tumor location and hepatic function. The left or right approach to the caudate lobe can be recommended for local resection of tumor located at Spiegel's portion or process portion. Approaches to caudate lobectomy are therefore largely dependent on size and location of the lesion, type of associated resection, and presence of scarring from previous resection.     

肝脏罕见肿瘤的诊断和治疗

目的 探讨肝脏罕见肿瘤的诊断和治疗方法.方法 回顾性分析我院2005年5月至2010年1月收治的25例肝脏罕见肿瘤患者的临床病理资料.结果 25例患者中肝局灶性结节性增生6例,肝血管平滑肌瘤、肝门部神经鞘瘤、肝左叶动脉瘤、肝胆管囊腺瘤、肝错构瘤、肝胆管绒毛状腺瘤、肝弥漫性大B细胞淋巴瘤各1例,肝血管平滑肌脂肪瘤2例,肝原发间质瘤2例,肝母细胞瘤5例,肝胚胎性肉瘤3例;术前行B超检查24例,CT检查22例,MRI检查6例,仅有3例(16.7%)检查和术后病理结果一致.术前诊断和术后病理符合5例(20%).25例均行手术切除治疗,包括半肝切除术7例,肝叶切除术7例,肝段切除术9例,肿瘤局部挖除2例.肝脏良性、低度恶性肿瘤及1例弥漫性大B细胞淋巴瘤术后无复发,5例恶性肿瘤随访中3例术后复发行再次手术切除,术后随访无复发;另2例死亡,平均术后生存期4个月.结论肝脏罕见肿瘤影像学诊断率低,手术切除是主要的治疗手段,对能切除的复发性肿瘤性病变应争取再次手术切除.