Hepatic blood inflow occlusion with/without hemihepatic artery control versus the Pringle maneuver in resection of hepatocellular carcinoma: a retrospective comparative analysis

Background The Pringle maneuver, which has been the standard for hepatic resection surgery for a long time, has the major flaw of ischemic damage in the liver. The aim of this research was to evaluate hepatic blood inflow occlusion with/without hemihepatic artery control vs. the Pringle maneuver in hepatocellular carcinoma （HCC） resection. Methods Two hundred and eighty-one cases of resection of HCC with hepatic blood inflow occlusion （with/without hemihepatic artery control） and the Pringle maneuver from January 2006 to December 2008 in our hospital were analyzed and compared retrospectively; among them 107 were in group I （Pringle maneuver）, 98 in group II （hepatic blood inflow occlusion）, and 76 in group III （hepatic blood inflow occlusion without hemihepatic artery control）. The operation time, intraoperative blood loss, postoperative liver function and complications were used as the endpoints for evaluation. Results The operative duration and intraoperative blood loss of three groups showed no significant difference; alanine aminotransferase, total bilirubin and incidence of postoperative complications were significantly lower in groups II and Ill postoperation than those in group I. Conclusion Hepatic blood inflow occlusion without hemihepatic artery control is safe, convenient and feasible for resection of HCC, especially for cases involving underlying diseases such as cirrhosis.     

Revascularization for Iliac-femoral Artery Pseudoaneurysm with Greater Saphenous Vein

Objective To investigate the role of revascularization procedures with autologous greater saphenous vein in surgical management of iliac-femoral artery pseudoaneurysm in parenteral drug abusers. Methods Twenty-one patients with iliac-femoral artery pseudoaneurysm caused by parenteral drug abuse from 2004 to 2007 were enrolled. Among them,15 patients were male and 6 were female; their average age was 31.3 years. The size of pseudoaneurysms ranged from 3.0 cm to 7.5 cm. Common femoral artery and distal external iliac artery were often involved. We performed arterial reconstruction on these patients with autologous greater saphenous vein as a graft after excising iliac-femoral artery pseudoaneurysm through a single curved inguinal incision. All patients were followed up,and the complications were recorded. Results The surgical procedures were finished without intraoperative mortality or perioperative complications. All patients were free of claudication symptoms after the surgery except one case with preoperative popliteal artery stenosis. One case of infection and wound tissue fistula was found later. One case had inguinal incisional hematoma and another complained of numbness in thigh skin. Conclusions The use of autologous greater saphenous venous grafts for arterial reconstruction after pseudoaneurysm excision in drug abusers is safe and effective. This technique offers more advantages than arterial ligation alone without revascularization. An optimal greater saphenous venous graft is a prerequisite for revascularization.     

Radical surgery for Budd-Chiari syndrome through exposure of the entire inferior vena cava of the hepatic segment

Background Several kinds of radical surgery for the treatment of Budd-Chiari syndrome （BCS） have been devised. We have described preliminary efforts to treat BCS using a novel radical resection technique to expose the entire inferior vena cava （IVC） of the hepatic segment. Methods Sixty patients with BCS were treated by radical resection, including 46 men and 14 women. BCS patients ranged in age from 11 to 62 years, with 3 months to 11 years since the BCS diagnosis. The lesions included membrane occlusion of the IVC in 16 patients, double membranes within the IVC in 2 patients, double membranes within the IVC and the hepatic vein （HV） in 3 patients, IVC membrane with distal thrombosis in 10 patients, long segment thrombosis of the IVC in 5 patients （organized thrombosis in 2 patients, fresh thrombosis in 3 patients）, occlusion of the outlet of the HVs due to mural thrombosis in 2 patients, segmental occlusion of the IVC in 3 patients, membranes within the HV with IVC stenosis due to protrusion of HV stent in 1 patient, HV membranes in 11 patients, extensive occlusion of HVs in 1 patient, the whole IVC tumor thrombus with tumor thrombus of 2/3 right atrium resulting from a posterior peritoneum tumor in 1 patient, IVC leiomyosarcoma in 2 patients, IVC leiomyosarcoma with tumor thrombus into 1/2 right atrium in 1 patient, IVC thrombosis extending into right atrium in 1 patient, compression of supra-hepatic segment of IVC due to fiber trabs in 1 patient. Results All lesions were successfully resected under direct supervision. Three procedures were performed under extracorporeal circulation, 52 patients with catheterization of the right atrium, 4 patients with a cell saver, and one patient with auto-retrieval of blood. The retrieved blood was from 300 ml to 4000 ml. Transfusion of banked blood was from 400 ml to 2000 ml for 14 patients. For the other patients no transfusion of banked blood was required. One patient died of renal failure peri-operatively. Newly formed IVC membrane was found for one recurrent patient whose IVC thrombosis was removed one year prior. Restenosis of the IVC was observed post-operatively without symptoms in one patient. In the other patients, no recurrent symptom was found during the follow-up periods. Conclusion This novel surgery provides a clear visual field during the procedure and yields satisfactory short and Iona-term results.     

Laryngotracheal flap for reconstruction of hypopharynx and upper esophagus after resection of advanced pyriform sinus cancer.

Reconstruction of the hypopharynx and upper esophagus after resection of advanced pyriform sinus cancer, is usually complicated and time-consuming. Laryngotracheal flap was used in hypopharyngoesophageal reconstruction for 26 elderly patients with advanced pyriform sinus cancer Pharyn-gocutaneous fistula developed in 5 patients and healed spontaneously without further surgery. Full diet was resumed in all the patients. The surgical technique and its advantages and disadvantages are discussed. The laryngotracheal flap in the reconstruction of hypopharyngoesophageal defect for elderly patients is a procedure of choice.     

Regional redical resection combined with vessel resection and reconstruction (Fortner type Ⅰ,Ⅱ) for the treatment of pancreatic cancer

Objective To evaluate the effect of regional radical pancraticoduodenectomy (PD) combined with resectionand reconstruction of invaded blood vessel (Fortner typeⅠ , Ⅱ procedure) for pancreatic cancer. Methods Resultof 5 Fortner Ⅰ cases undergoing PD and resection ofsuperior mesenteric-portal vein (SMPV), and Ⅰ FortnerⅡ case with resection of SMPV, superior mesentericartery (SMA) and hepatic artery (HA) was reviewed.Results The case undergoing Fortner Ⅱ surgerysurvived for 13 months. The 5 Fortner Ⅰ cases werefollowed-up for 5 - 34 months, with patent graft asidentified by CT and ultrasonography and with norecurrence. Conclusion Regional pancreatectomycombined with resection of invaded blood vessel can becarried out in carefully selected patients of pancreaticcancer with favourable long term-result. 5 refs.     

Radical correction of Budd-Chiari syndrome

Background Interventional therapy is widely accepted as the first choice for the treatment of the Budd-Chiari syndrome but the use of radical correctional therapy should not be discarded. This study describes radical correction by controlling bleeding from distal end of pathological segment of the inferior vena cava （IVC） and discusses potential surgical errors and postoperative complications. Methods Of the 216 patients in the study, 78 were treated with simple membranectomy, 64 with dissection of the pathological segment of the IVC and vascular prosthesis or pericardial patch plasty, 60 with resection of the pathological segment of the IVC and orthotopic graft transplantation with vascular prosthesis, and 14 with resection of the occlusive main hepatic vein and its upper IVC, hepatic venous outflow plasty and vascular prosthesis orthotopic graft transplantation from the hepatic venous entrance to the IVC of right atrial ostium. Results Except 14 cases who were discharged after hepatic vein outflow plasty, four cases died postoperatively, and 198 patients were discharged without complications. The symptoms of 15 patients were relieved partially and 2 without any change. There were no deaths intraoperatively. Of the 112 cases who were followed up for 72 months, 13 suffered from a relapse. Conclusions Radical correction is a beneficial therapy in the treatment of Budd-Chiari svndrome.     

Digital medical technology based on 64-slice computed tomography in hepatic surgery

Background With the rapid development of computer technology, digital medicine has become a new direction in surgery. The application of digital medicine in hepatic surgery is still at the early stage and less reported in the literature. The aim of this study was to apply digital medical technology in the context of hepatic surgery. Methods Data from 64-slice helical computed tomography of 17 patients, including 13 with hepatocellular carcinoma and 4 with hepatic hemangioma, were imported into independently developed medical image software program, segmentation and three-dimensional reconstruction were performed. The three-dimensional models were then processed with the FreeForm Modeling System. We used virtual surgical instruments to perform surgery on the models. Simulated surgeries included six hepatic segmentectomies, four left hemihepatectomies, three right hemihepatectomies for hepatocellular carcinoma, one hepatic segmentectomy, two stripping surgeries, and one irregular segmentectomy combined with stripping surgery for hemangioma. For resections involving more than three hepatic segments, total and residual functional hepatic volumes were measured before and after simulation surgery, and the resection ratio was calculated.Results The anatomy of the models was distinct and was used to localize lesions. We used virtual surgical instruments to perform simulated surgeries and used the models to optimize actual surgeries. We were able to minimize resection volume as well as surgical risk.Conclusions Digital medical technology is helpful in the diagnosis of hepatic disease and in optimizing surgical plans. Three-dimensional models can decrease surgical risk and help prevent postoperative hepatic failure.     

13.6.Cyst and tumor of liver

930321 Prognostic facters for surgical treat-ment of hilar cholangiocarcinoma.ZHOUNingxin (周宁新),et al.Dept Hepatobili Surg,General Hosp,PLA,Beijing,100853.NatlMed J Chin 1993;73(4):232-234.Forty—five patients with hilar choiangiocar-cinoma were operated on at our department.The tumor was resected in 29 patients (64%).There were no operative deaths and the survivalrate was 41% and 21% at 12 and 24 months re-spectively.In patients with no tumor resectionthe 60—day mortality rate was 37.5% and noneof them survival for 12 monthrs.Significant dif-ference waa noted in survival rates of the pa-tients with radical resection,those with resec-     

Clinical and pathological features and surgical treatment of Budd-Chiari syndrome-associated hepatocellular carcinoma

Background Budd-Chiari syndrome （BCS） is characterized by liver sinusoidal congestion,ischemic liver cell damage,and liver portal hypertension caused by hepatic venous outflow constriction.The aim of this research was to investigate the clinicopathological features of BCS-associated hepatocellular carcinoma （HCC） and explore its surgical treatment and prognosis.Methods Clinical data from 38 patients with BCS-associated HCC who were surgically treated in our hospital from July 1998 to August 2010 were retrospectively analyzed.The clinicopathological features and prognosis of patients with BCS-associated HCC and surgical treatment for BCS-associated HCC were investigated.Results Compared to the patients with hepatitis B virus （HBV）-associated HCC,the patients with BCS-associated HCC showed a female predominance,and had significantly higher cirrhosis rate,higher incidence of solitary tumors,lower incidence of infiltrative growth,higher proportion of marginal or exogenous growth,lower rate of portal vein invasion,and higher degree of differentiation.Median survival was longer in patients with BCS-associated HCC （76 months） than in those with HBV associated HCC （38 months）.Of 38 patients with BCS-associated HCC,22 patients who received combined surgery mainly by liver resection plus cavoatrial shunts exhibited hepatic venous outflow constriction relief,while the other 16 patients only underwent liver resection.The combined surgery group had significantly longer survival and lower incidences of post-operative lethal complications （P 〈0.05）.Multivariate analysis showed that relief of hepatic venous outflow obstruction was a protective factor for survival of patients with BCS-associated HCC,whereas portal vein invasion was a risk factor.Conclusions BCS-associated HCC has a more favorable biological behavior and prognosis than HBV-associated HCC.For patients with BCS-associated HCC,tumor resection accompanied with relief of hepatic venous outflow obstruction can reduce the incidence of complications and extend survival.     

Aneurysm repair in vitro and renal revascularization and renal autogenous transplantation for complex renal artery aneurysm in solitary kidney

Objective To discuss the safety and feasibility of aneurysm repair in vitro and renal revascularization and renal autogenoua transplantation for complex renal artery aneurysm in solitary kidney. Methods A complex hilar renal artery aneurysm involving the bifurcantion of renal artery and its branches in a solitary left kidney was diagnosed by computed tomography angiography （CTA）. After temporary nephrectomy, aneurysm repair in vitro and renal revascularization were done with the kidney protected by hypothennia and continuous perfusion with preservation solution, and then the kidney was replanted into the right iliac fossa. Results The operation was done successfully and there were no significant perioperative complications. Although a serum creatinine level temporarily exceeded above 200 μmol/L after the surgery, it recovered gradually within half a month. CTA two weeks later demonstrated patent reconstructed renal arteries and its branches and patent renal vein in the right iliac fossa, and also a patent reconstructed ureter. Conclusion This technique is safe and feasible to manage complex renal artery aneurysm in solitary kidney and provide an alternative for similar complex renal diseases. 8 refs. 6 figs.     

联合肝动脉切除重建的肝门部胆管癌根治术技术要点

目的总结对于进展期肝门部胆管癌患者行肝脏切除联合动脉切除重建的处理经验。方法回顾性分析2008年1月-2013年12月我院收治的15例行肝门部胆管癌根治联合肝动脉切除重建的进展期肝门部胆管癌患者的临床资料,总结其手术情况及预后。结果15例中,肝右动脉与肝固有动脉端端吻合5例,肝右动脉与胃、十二指肠动脉端端吻合3例,肝右动脉与肝左动脉端端吻合1例,肝右动脉与肝右动脉端端吻合1例,肝右后与肝右后端端吻合1例,肝固有动脉与门静脉端侧吻合3例,肝右动脉与门静脉端侧吻合1例,其中4例同时联合门静脉切除重建。本组根治性切除（R0切除）11例,非根治性切除（R1切除）4例。3例术后出现胆瘘,1例出现胆瘘合并腹腔内感染,1例出现腹腔内感染,1例出现上消化道出血,均经保守治疗痊愈。2例于术后因肝功能衰竭死亡。术后4例肿瘤复发,时间为6～26个月,平均复发期为17．5个月;其中1例（25％）为R0切除,3例（75％）为R1切除。术后6个月、1年、3年生存率分别为85．6％、78．6％、33．7％。结论对于动脉受侵犯的肝门部胆管癌患者行肝脏切除联合动脉切除重建,可提高根治切除率并可改善患者预后。熟练掌握血管吻合技巧可大大降低术后并发症发生率。     

肝右三叶切除并门静脉切除和重建治疗肝门胆管癌

目的总结肝右三叶切除并门静脉切除和重建在肝门部胆管癌中应用的临床经验.方法 BismuthⅢa型肝门部胆管癌患者1例,肿瘤侵犯门静脉右支及分叉处,进行肝右三叶切除联合门静脉重建根治性切除肿瘤.结果手术过程顺利,完整切除肿瘤,术中出血约500 mL,未输血;术后恢复良好,第13天出院;术后6月复查未见肿瘤复发与转移,病人精神及身体状况良好,现在仍存活.结论肝门胆管癌患者有可能直接耐受联合右三叶切除及门静脉重建.     

老年高位胆管癌的手术治疗方法与疗效分析

目的探讨老年人高位胆管癌的手术治疗方式及临床疗效。方法对17例经手术治疗的老年高位胆管癌病人的临床资料进行回顾性分析。结果完成根治性切除7例（根治组）,仅行姑息性切除10例（非根治组）。根治组中位生存期为23.2个月,非根治组中位生存期为11.3个月,两者有显著差异（P〈0.05）。非根治组中内引流者中位生存期为12.7个月,而外引流者中位生存期仅为5.6个月,两者有显著差异（P〈0.05）。结论积极提高手术切除率是改善老年人肝门部胆管癌预后的惟一有效方法,清扫肝十二指肠韧带、适宜的肝部分切除可提高根治性切除率;姑息性切除、胆道引流特别是外引流有助于改善患者生活质量,但对延长生存期贡献有限。     

限制流量部分门静脉动脉化的临床应用研究

目的通过对8例肝门部胆管癌根治性切除术后用限制流量的部分门静脉动脉化重建肝血流的病人进行长期临床观察,以了解限制流量是否可以防止继发的门静脉高压。方法 8例肝门部胆管癌病人在进行根治性切除术后均因肝动脉无法进行修复而通过部分门静脉动脉化来恢复肝脏动脉血流,为防止可能继发的门静脉高压,我们在术中对用于门静脉动脉化的肝动脉进行了限流,术后通过增强CT检查观察门静脉动脉化是否通畅以及门静脉是否有增宽的情况进行了为期半年到2年的随访。结果除1例因其他原因去世和1例失访外,其他6例均得到正常随访。其中3例分别在为期6个月,9个月和2年的随访时表明门静脉动脉化的吻合口已闭塞(闭塞时无门静脉高压的发生),另外3例在随访中CT检查均未显示门静脉明显增宽。结论部分门静脉动脉化后通过限制流量的方法能有效地防止有可能继发的门静脉高压,从而使部分门静脉动脉化的应用更加安全有效。     

三维可视化联合3D打印在Bismuth-Corlette III、IV型肝门部胆管癌个体化精准外科治疗中的应用

目的 探讨三维可视化3D打印在Bismuth-Corlette Ⅲ、Ⅳ型肝门部胆管癌个体化精准外科治疗中的应用价值。方法 回顾性分析南方医科大学珠江医院肝胆外科2016年5月~2019年3月在三维可视化3D打印指导下10例肝门部胆管癌外科手术治疗患者。收集患者薄层CT数据,进行三维重建后打印3D模型,观察肿瘤与肝内胆管、肝动脉、门静脉和肝静脉系统的三维立体关系,进行术前模拟手术并制定手术方案,将3D打印模型带入手术室进行术中实时导航,指导手术治疗。结果 10例患者均成功构建三维可视化打印3D模型,进行 Bismuth-Corlette三维可视化分型：Ⅲa型4例、Ⅲb型4例、Ⅳ型2例,其中门静脉变异4例,肝动脉变异3例。门静脉“三分叉”变异2例;“工字型”变异1例;1例罕见的门静脉右前支缺如变异;2例既有门静脉变异又出现肝动脉变异。肝动脉变异3例,1例肝左动脉起自胃左动脉,2例肝右动脉起自肠系膜上动脉。其中Ⅲb型4例行左半肝切除术; Ⅲa型4例行右半肝切除;Ⅳ型1例行围肝门区域切除,1例行左半肝切除术。此组患者术前三维可视化3D打印模型及术前规划与术中情况均一致。手术时间452±75.12 min,术中出血量356±62.35 mL,术后住院时间15±4.61 d。术后出现胆漏1例,少量胸 腔积液3例,经通畅引流及内科治疗后康复出院,围手术期无肝功能衰竭及死亡病例。结论 三维可视化联合3D打印对Bismuth-Corlette Ⅲ、Ⅳ肝门部胆管癌进行准确的术前评估、手术规划,优化手术方案,尤其在肝内血管变异情况下,有助于提高手术安全性,降低手术风险。     

多层螺旋CT血管造影对肝门胆管癌周围血管受累的评价

目的探讨多层CT血管造影对肝门胆管癌对周围血管侵犯的诊断价值及其临床意义。方法应用64排螺旋CT（Siemens,sensation Cardiac 64）对明确或怀疑肝门胆管癌患者进行增强扫描,并进行肝门血管CTA三维重建。利用CT轴位图像和三维图像对肝门病变对周围血管是否侵犯进行评价,并与手术对照。结果经CT检查明确肝门区胆管癌34例,其中32例肝门胆管癌患者接受手术治疗。32例中,术中见血管受侵21例,CTA三维图像显示血管受侵20例（19例与手术结果相符,1例诊断不准确）,CT轴位图像显示血管受侵15例。肿瘤累及血管显示为病变包绕血管并导致血管狭窄、肿瘤与血管接触节段,血管边缘不规则;肝门部胆管细胞癌血管受侵的CTA诊断的敏感性为90.48%,特异性为91.67%。而仅依赖横轴位增强CT图像诊断血管受侵的敏感性为71.43%,特异性为64.71%。结论多层螺旋CT血管造影可以明确判断肝门胆管癌周围血管受累情况;三维重建比轴位CT图像能够更准确显示血管受累;术前观察肝门区血管是否受累,有助于手术方案选择。     

肝门部胆管癌52例外科治疗体会

目的:探讨肝门部胆管癌的治疗方法。方法:回顾性分析我院1996￣2004年间52例肝门部胆管癌的临床病例资料。结果:手术切除组、手术引流组、介入支架组及剖腹探查组的平均生存时间分别为19.08、6.6、4.3、1.2个月。围手术期死亡2例。结论:肝门部胆管癌肿瘤切除术疗效明显优于其他治疗方式,对此病患者应积极争取行根治性切除术。对不能切除病例积极行引流术治疗,以延长生命、提高生存质量。     

肝门胆管癌的手术治疗(附8例切除报告)

目的探讨肝门胆管癌的外科手术治疗经验。方法回顾性分析该科从2000年6月～2003年6月收治的10例肝门胆管癌病人的临床特点、诊断、手术切除及随访结果。结果10例病人中8例行切除术，其中根治性切除7例，姑息性切除1例，根治性切除病人中1，2和2．5生存率分别为83％，60％和37％，无手术死亡病例。结论早期诊断、良好的肝叶切除胆道重建技术能取得较满意的治疗效果。     

联合半肝切除治疗中晚期肝门胆管癌

目的 探讨联合半肝切除治疗肝门胆管癌的优势以及降低并发症和病死率的对策.方法 回顾性分析1998年-2006年北京大学临床肿瘤学院外科收治并手术治疗的50例肝门胆管癌病例.结果 手术治疗50例中,41例获得切除,切除率56.9%,RO根治性切除22例(53.6%).实施术前PTCD减黄30例.肝门胆管癌联合半肝切除19例,其中RO根治性切除14例(73.6%),手术死亡2例(10.5%).全组并发症发生率62%,半肝切除组78%.随访半肝切除组1年生存率57.1%,2年生存率27.3%.结论 联合半肝切除治疗肝门胆管癌能够提高手术的根治性改善预后,增加术中显露,简化了切除后重建,是肝门胆管癌尤其是Bismuth Ⅲ～Ⅳ型的安全而有效的术式.对于需联合大范围肝切除的肝门胆管癌病例术前减黄是必要的.     

肝门部胆管癌外科手术治疗的进展

肝门部胆管癌是一种胆道常见恶性肿瘤,临床上出现症状较晚,早期诊断困难,而且肝门部胆管癌所处的解剖位置特殊及其向周围组织、血管、神经浸润的特点,外科根治性切除率低,因而预后较差。实施肝门部胆管癌的根治性切除能够有效地提高患者生存率,包括对于侵犯的血管或转移的淋巴结的扩大切除以及肝移植术的应用均能提高患者的生存率。因此,寻求胆管癌外科手术有效的新的治疗方法,对于提高胆管癌的临床治疗具有十分重要的意义。