肝门部胆管癌术前门静脉栓塞的血流动力学与肝再生的关系

Objective To detect the changes of hemodynamics in patients with portal vein embolization (PVE) before surgery for hilar cholangiocarcinoma, and analyze the relationship between hemodynamics and liver hypertrophy. Methods The clinical data of 21 patients with hilar cholangiocarcinoma who were admitted to the Eastern Hepatobiliary Surgery Hospital from April 2008 to December 2009 were retrospectively analyzed.Relevant hemodynamic variables were detected and analyzed before and 3, 7, 14 days after PVE. Data were processed using Student t test or linear correlation analysis. Results The main portal vein pressure after PVE was (25.9 ± 4.1 ) cm H2O ( 1 cm H2O = 0.098 kPa), which was ( 3.5 ± 2.5 ) cm H2O higher than that before PVE [( 22.4 ± 4.1 ) cm H2O] ( t = - 6. 504, P ＜ 0.05 ). The blood flow velocity in the non-embolized branch of portal vein increased after PVE, and reached peak [(26 ±9)cm/s] at the seventh day after PVE. A positive correlation was found between the hypertrophic rate of the non-embolized lobes and the ratio of embolized lobes to total liver volume ( r = 0. 593, P ＜ 0. 05 ). Conclusion Greater scope of the embolized vascular bed of portal vein induces higher hypertrophic rate of non-embolized liver.     

肝门部胆管癌术前行门静脉栓塞16例分析

目的 探讨未来残余肝较小的肝门部胆管癌病人行门静脉栓塞是否安全有效。 方法 对2007年1月至2009年3月第二军医大学附属东方肝胆外科医院拟行大部肝切除、未来残余肝/全肝体积（FLR/ TLV）比<50%的16例接受钢圈门静脉栓塞（portal vein embolization,PVE）的临床资料进行分析。 结果 术前16例（PVE组）因肝功能损害、FLR/TLV < 50%者行PVE治疗,33例（非PVE组）FLR/TLV > 50%者行肿瘤联合肝切除。PVE后3例出现并发症,原因为胆漏和钢圈移位,但未推迟肝切除术日期。16例PVE中1例合并肝硬化出现非栓塞肝叶增生不全而未能接受外科治疗,2例术中发现肿瘤进展、腹膜播散未能接受肝切除术,余13例（81.3%）行联合肝切除的肿瘤切除术。PVE组和非PVE组的手术并发症发生率分别为69.2%及63.6%,手术死亡率为0及9.1%。二者相比差异无统计学意义。结论 PVE能安全、有效地诱导肝门胆管癌术前未来残余肝增生。     

术前门静脉栓塞术在肝门部胆管癌扩大肝切除术中的应用研究

目的 评价肝门部胆管癌扩大肝切除术前行门静脉栓塞术的有效性及安全性,比较门静脉栓塞手术切除术与非门静脉栓塞手术切除术后结果.方法 2007年5月至2010年10月收治肝门部胆管癌患者57例,分为两组,将预保留肝占全肝体积＜50％、术前接受门静脉栓塞(PVE)者设为PVE组(26例),男16例,女10例,年龄(56.48...     

经皮经肝门静脉栓塞术在肝门部胆管癌手术中的应用

目的探讨对肝门部胆管癌行扩大右半肝切除术前使用经皮经肝门静脉栓塞术（portal vein embolization，PVE）的疗效。方法2005年10月对1例伴有肝硬化的肝门部胆管癌施行经皮经肝门静脉栓塞术（percutaneous portal veinembolization，PTPE），记录肝脏在血流动力学、体积、功能、病理方面的改变。结果PTPE术后第5天体温升至39．2℃，然后逐渐下降，同时伴有轻度右上腹痛，无恶心呕吐，未见腹腔出血及胆漏。PTPE术后左叶体积从417．0ml增加到522．4ml（肥大率125．2％）；右叶体积从1041．3ml减少到1017．4ml（萎缩率97．7％）；左叶占全肝的体积比从28．6％升至33．9％。左矢状部血流速度术前为12．8ml／s，术后当日、第6天分别为23．2、17．1ml／s。较原流量增加100％和39％（术后当日，第6天）。PTPE术后17d左肝胆汁的引流量超过右肝。PTPE术后34d患者接受扩大右半肝切除术，术中见肝左叶可见明显的肥大，肝脏5、6、7段（S5，6，7）与其余肝段间有明显的界限，术后3个月病情平稳。术后病理：栓塞叶门静脉狭窄及闭塞而肝细胞变性，坏死及凋亡。结论PVE能有效诱导未栓塞肝叶的肥大，从而提高对伴有肝损害的患者行扩大肝脏切除的安全性。     

肝门部胆管癌的诊断

肝门部胆管癌（Hilar bile duct carcinoma)是指累及胆囊管开口以上1／3的肝外胆管并常扩展至肝管汇合和一侧或双侧肝管的癌，自1954年Browns完成第1例手术切除，到1965年美国耶鲁大学内科医生Klastkin对13例手术结果进行7总结，并指出此类肿瘤局限生长而远处转移少，早期诊断困难，根治性切除率低，姑息性切除或引流可有效延长生命。这些最初的认识都符合实际并不在不断深化和积累中，随着临床上认识和警惕性的提高及影像学检查手段的进步，肝门部胆管癌的报道呈增多的趋势，但其术前诊断困难，根治性切除率低，预后差，仍期待着人们进一步探索和研究。     

肝门部胆管癌术前诊断方法的研究

对２０例肝门部胆管癌的术前诊断方法进行研究。结果提示；胆汁脱落细胞检查，刷取细胞检查和钳取组织活检的阳性率分别为１０％，５２．６％和７５％。联合应用三种检查方法可使诊断的敏感性提高到８４．２％。６０％的病人血清ＣＡ１９－９值显著升高，达正常值的６倍以上。Ｂ超，电脑彩超，ＣＴ和磁共振胆道成像的确诊率分别为５５％，８５％，９１．４％。     

肝门部胆管癌诊治进展

肝门部胆管癌（hilar cholangiocarcinoma,HCCA）,解剖部位隐蔽,早期临床表现不典型,手术切除率低,预后较差。HCCA的诊断和治疗一直是肝胆外科医师公认的难题。近年来随着以肝胆外科为中心的多学科综合治疗日渐成为趋势,影像诊断技术及外科手术技术的不断进步,HCCA的诊断和治疗取得了一定进步。本文结合近年来相关文献报道就HCCA的诊治进展作如下综述。     

肝门部胆管癌的外科治疗

肝门部胆管癌（Klatskin瘤）主要指左、右肝管至肝总管的恶性肿瘤，占胆管瘤的56％一58％，不包括肝内的胆管癌。我院近5年来收治胆管癌97例，肝门部癌占53．6％。90％以上的病人初期症状为梗阻性黄疽。胆管瘤的外科治疗与其解剖关系非常密切，常因技术原因而显得困难。目前最有效的治疗仍然是切除肿瘤。1手术前治疗1·1护肝治疗血清蛋白＜30g/L可影响因手术期病死率[3]，通过适当治疗可纠正低蛋白、贫血，增强手术耐受力。1．Zat黄治疗术前PTCD减黄可能带来引流管脱落、胆管炎、水电解质平衡紊乱、只引流了需要切除的一侧肝脏等问题。术…     

肝门部胆管癌52例分析

探讨肝门部胆管癌早期诊断方法和手术方式对患者预后的影响。方法 回顾性分析经手术和病理确诊的肝门部胆管癌５２例临床特征，手术方式和随访结果。结果 本组手术切全２８全我院总手术切除５３．８％，其中根治性切除１９例，姑息性切除９例，行胆管内，外引流术２４例。     

肝门部胆管癌

肝门部胆管癌是指位于胆囊管开口以上的肝总管,左、右肝管汇合部和左、右肝管的胆管黏膜上皮癌.由于肝门部特殊的解剖学位置及肝门部胆管癌生物学特性,其极易早期侵犯肝门区血管、神经、淋巴结组织及邻近肝组织,因此,手术难度大,患者预后差.在现代影像学指导下的扩大肝切除术可能给这个凶险的疾病予以希望.但国内外学者就扩大肝切除术存在诸多争议,目前尚无统一的标准.因此,肝门部胆管癌外科治疗亟待规范化,以提高其根治性切除率,减少手术相关并发症发生率和病死率.     

三维可视化系统在肝门部胆管癌治疗中的应用

目的 探讨三维可视化系统在肝门部胆管癌治疗中的应用价值.方法 回顾性分析2012年1月至9月厦门大学附属成功医院收治的10例肝门部胆管癌患者的临床资料,采用三维可视化系统将CT二维图像转换成三维图像,测量肝脏体积、肿瘤体积、预切除肝脏体积、剩余肝脏体积,并在三维图像上制订预手术方案,模拟肿瘤切除,按照根治理念进行手术,术后比较实际手术方案与预手术方案的区别.术前预切除肝脏体积与术后实际切除肝脏体积的相关性检验采用Pearson等级相关分析.结果 本组10例患者均成功进行三维重建,测得平均肝脏体积为(1496±162) ml,肿瘤平均体积为(67±18) ml,预切除肝脏平均体积为(335±241)ml,剩余肝脏平均体积为(1140±197)ml.预切除肝脏体积的平均误差率为6.4％.本组患者按照根治性切除原则进行手术方案制订,左半肝切除4例、右半肝切除2例、局部切除3例、姑息性切除1例.模拟手术方案与实际手术方式符合率为9/10.实际行R0切除7例、R1切除1例、姑息性切除2例,其中l例行限制性门静脉动脉化.根据术中探查证实,术前三维可视化重建对重要血管、胆管及肿瘤的解剖学评估结果与术中所见大致相符.术前三维可视化对肿瘤分型诊断准确率为8/10.实际切除肝脏平均体积为(325±258) ml,术前预切除肝脏体积与术后实际切除肝脏体积呈正相关(r=0.902,P＜0.05).结论 三维可视化系统在肝门部胆管癌治疗中具有一定的临床应用价值.     

肝门部胆管癌的精准外科手术治疗

医学及相关领域学科的持续发展推动着传统外科向以精确决策和精准操作为特征的精准外科转化.最大化清除病灶、最小创伤侵袭和最大程度脏器保护是精准外科的追求目标.由于特殊的解剖学位置和生物学特性,肝门部胆管癌的治疗极具挑战性.为了达到精准外科的要求,术前需对肝门部解剖结构、肿瘤的生物学特征以及肝脏功能储备情况等予以充分了解,同时对于术前预处理、肝切除技术和血管、胆管重建技术应予充分掌握.     

Portal vein embolization vs. portal vein ligation for induction of hypertrophy of the future liver remnant

The objective of this study was to assess the efficacy of right portal vein embolization (PVE) vs. right portal vein ligation (PVL) for induction of hypertrophy of the left lateral liver lobe before extended right hepatectomy. Thirty-four patients with primary or secondary liver tumors and estimated remnant functional liver parenchyma of less than 0.5% of body weight underwent either right PVE (transcutaneous, n= 10; transileocolic, n =7) or right PVL (n=17). Liver volume was assessed by CT scan before occlusion of the right portal vein and prior to resection. There were no deaths. The morbidity rate in each group was 5.8% (PVE, 1 abscess; PVL, 1 bile leak). The increase in liver volume was significantly higher after PVE compared with PVL (188±81 ml vs. 123±58 ml) (P= 0.012). Postoperative hospital stay was significantly shorter after PVE in comparison to PVL (4±2.9 days vs. 8.1±5.1 days;P<0.01). Curative liver resection was performed in 10 of 17 patients after PVE and 11 of 17 patients after PVL. PVE and PVL were found to be feasible and safe methods of increasing the remnant functional liver volume and achieving resectability for extended liver tumors. PVE results in a significantly more efficient increase in liver volume and a shorter hospital stay. Presented at the Forty-Third Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, California, May 19–22, 2002 (oral presentation).     

Arguments for a selective approach of preoperative portal vein embolization before major hepatic resection

Preoperative PVE can induce hypertrophy of the future liver remnant volume resulting in a decrease of surgical risk after major hepatic resection. However, the number of patients with normal liver at risk is small and there is no arguments for inducing hypertrophy before standard right hepatectomy. Therefore, in patients with normal liver PVE is indicated in patients in whom very extended liver resection or associated major gastro-intestinal surgery is planned. In patients with chronic liver disease and in those with injuried liver (chemotherapy, major steatosis, cholestasis), PVE is indicated before major liver resection.     

肝脏肿瘤肝切除术前选择性门静脉栓塞的临床应用

目的 探讨选择性门静脉栓塞技术细节及其在残余肝容积不足患者肝切除术前应用的临床意义.方法 2008年1月至2012年7月,6例肝脏肿瘤因残余肝容积不足,二期肝切除术前行选择性门静脉栓塞术.结果 6例选择性门静脉栓塞术均成功.无手术并发症,栓塞对肝功能影响轻微.术前,6例残余肝容积平均(474.33 ±89.19) cm3,术后6周,平均(722.67±151.51) cm3,术前术后残余肝容积比较差异有统计学意义(t=-5.587,P=0.003).术前6例肝脏肿瘤负荷(瘤体总体积)平均(134±181) cm3,栓塞术后6周,肿瘤负荷平均为(270±346) cm3,栓塞前后肿瘤负荷比较差异无统计学意义(t=-1.64,P=0.16).5例二期肝切除术顺利.1例未行肝切除术.随访中位时间为37个月,4例存活(2例无瘤生存),1例死亡.结论 门静脉选择性栓塞是肝切除前增加残余肝容积的有效技术手段;经同侧(患侧)人路并选择弹簧圈作为栓塞材料简单易行、安全、有效.门静脉栓塞前,应以化疗或选择性肝动脉化疗栓塞等手段有效控制肿瘤生长.     

Portal and mesenteric vein thrombosis after portal vein embolization in a patient with protein S deficiency

Portal vein embolization can be performed safely, and so far no major complications have been reported. We report an extremely rare complication of portal vein embolization, a case of portal and mesenteric thrombosis in a 65-year-old patient with protein S deficiency. Right portal vein embolization was carried out prior to extended right hepatectomy for advanced gallbladder carcinoma involving the hepatic hilus. Computed tomography 14 days after embolization revealed massive thrombosis of the portal and the superior mesenteric veins. A protein S deficiency was found by means of an extensive workup for hypercoagulable state. Portal vein embolization may have triggered a cascade of events that was expressed as portal and mesenteric vein thrombosis resulting from deficiency of protein S. It may be better to determine the concentrations of such coagulation regulators prior to portal vein embolization.     

Risk factors of posthepatectomy liver failure after portal vein embolization

Background/Purpose. Major hepatectomy has been successfully performed after portal vein embolization (PE). However, posthepatectomy liver failure following hyperbilirubinemia (HB) sometimes occurs even after PE. Our objective was to determine what factors affected post-hepatectomy HB and liver failure. Methods. Forty-two patients underwent PE before major hepatectomy or repeat hepatic resection after partial hepatectomy. Having a prognostic score over 40, they all belonged to a high-risk group. They were classified into two groups according to posthepatectomy levels of total bilirubin: normal group and HB group. The HB group was further divided into two subgroups: recovered subgroup and fatal subgroup. We investigated the differences between the two groups and the two subgroups. Results. Ten of 14 cases (71%) in the HB group were biliary tract disease with jaundice before PE. The indocyanine green retention rate (ICGR15) before PE, skeletonization of the hepatoduodenal ligament (HDL), and portal venous pressure after PE were significantly different between the two groups as shown by multivariate analysis. Postoperative complication was the only factor significantly different between the two subgroups by univariate analysis. Conclusions. When the patients underwent major hepatectomy combined with skeletonization of the HDL for biliary tract disease with jaundice, they were subject to posthepatectomy HB even after PE. If they had postoperative complications, fatal hepatic failure must have occurred.     

部分性脾动脉栓塞对肝硬化门静脉高压血流动力学的影响

门静脉高压症是临床多发并发症,常继发于肝硬化,其主要表现为脾肿大,侧支循环的建立和腹水,同时亦可引起脾功能亢进.大量临床研究报道,部分性脾栓塞（PSE）是治疗门静脉高压症的一种有效方法.本文总结了近年来门脉高压症、脾肿大的发病机制,分析了门脉高压与脾脏的血流动力学关系,从门静脉高压症的发病机制及脾脏与门静脉高压症的发生、发展的密切关系出发,进一步总结了PSE对脾脏及门静脉血流动力学影响的机制.