肝细胞癌破裂危险因素及其行肝切除术后临床预后分析

目的 探讨肝细胞癌(以下简称肝癌)破裂行根治性肝切除术后的独立预测因素,分析肿瘤破裂本身对肝癌接受肝切除术预后的影响.方法 回顾分析2007年4月至2011年11月海军军医大学东方肝胆外科医院和武汉大学中南医院接受肝切除治疗的106例肝癌破裂病人(破裂组)和201例肝癌病人(未破裂组)的临床病理资料,采用倾向性评分和多...     

肝细胞癌自发破裂的预测和临床预后

目的 研究影响肝癌自发破裂的危险因素及预后因素,评估选择性一期肝切除的治疗效果.方法 从2002年4月至2006年11月在东方肝胆外科医院确诊为肝癌的4209例患者中,有200例肝癌自发破裂.回顾性分析200例自发破裂患者的临床特点和预后因素.评估不同治疗手段的预后,并与随机选取的202例同期未发生破裂的肝癌患者进行对比.结果 多因素回归分析显示肝硬化、高血压、血管癌栓、肝外侵犯及肿瘤大于5 cm是肝癌自发破裂的预测因素.在200例肝癌自发破裂患者中,105例行肝切除治疗、33例肝动脉插管化疗栓塞(TACE),62例保守治疗.所有肝癌破裂患者的中位生存时间为6个月(1 ～72个月),1、3、5年总体生存率分别为32.5％、10％和4％.肝切除组患者中位生存时间为12个月(1～72个月),TACE组为4个月(1～30个月),而保守组为1个月(1～19个月).行肝切除的肝癌破裂患者(105例)1、3、5年总体生存率分别为57.1％、19.0％和7.6％,而同期未破裂肝切除肝癌患者(98例)1、3、5年总体生存率分别为77.1％、59.8％和41.2％(P＜0.001).结论 对于伴有肝硬化、高血压、血管癌栓、肝外侵犯及肿瘤大于5 cm的肝癌患者,应警惕肝癌自发破裂的高风险.选择性一期肝切除治疗的肝癌破裂患者能够获得长期生存,尽管其总体预后较肝癌未发生破裂患者差.     

肝门胆管癌手术切缘残癌与预后

目的：探讨经手术切除肝门胆管癌（hepatic hilar cholangocarcinoma,HHCC) 手术切缘有无残癌对预后的影响,方法：比较切缘有残癌组（43例）和无残癌组（40例）患者的临床分型,手术方式,肿瘤分程度及生存情况,结果：切缘有残癌组患者1、2、3和5年生存率,分别为37．2％、6．3％、3．5％和2．4％,切缘无残癌组患者分别为82．2％、58．2％、41．65和27．75,结论：手术切缘残癌率与肿瘤分化程度关系密切,在BismuthIV型中发生率最主,BismuthIV型中的低分化型腺癌患者,手术切除疗效差,对无肝外转移者可以选择肝移植术。     

肝细胞癌肝切除术后预后影响因素分析

目的探讨影响肝细胞癌肝切除术后预后因素，为进一步治疗及判断预后提供依据。方法回顾性分析1994年10月至1998年10月中国医学科学院肿瘤医院手术切除的230例HCC病人资料。对可能影响预后的各种因素进行单因素分析，采用逐步回归法将可能对预后有影响的指标，依次引入Cox模型进行多因素分析。结果全组1、3、5年复发率分别为35．2％、52．1％、62．4％；总的1、3、5年生存率分别为79．1％、53．7％、40．2％。单因素分析显示肿瘤最大直径是否≥5cm、有无脉管瘤栓、术前AST、肝被膜受侵、肿瘤切缘为影响对肿瘤复发和无瘤生存率有影响（P〈0．05）。多因素分析显示脉管瘤栓、术前AST升高、肿瘤切缘、肝被膜受侵及肿瘤最大直径依次为影响预后的主要因素。结论肝细胞癌的预后是由多种因素决定的，脉管瘤栓、术前AST升高、肿瘤最大直径及肝被膜受侵是影响预后的最主要因素。早期发现、早期治疗是提高肝癌病人生存率的重要途径，对存在预后不良因素的病人，应加强术后随诊，及时发现术后复发和转移。     

肝细胞癌切除术后预后因素分析

目的探索影响肝细胞肝癌手术预后的因素。方法回顾性分析2000～2005年76例经病理证实的肝细胞肝癌手术切除患者,选择16项临床、病理学因素,分析其对生存率的影响。结果全组1,3,5年生存率分别为85.53%,48.05%,14.96%。60例获得根治者1,3,5年生存率分别为100%,58.93%和18.35%。影响预后的单因素为:肿瘤根治程度、肝癌结节数目、肝功能分级、肿瘤分期、门脉癌栓、术前血清胆红素、术前白蛋白水平。多因素分析表明:术前肝功能Child-Pugh分级、肿瘤结节数目、门脉癌栓和肿瘤根治程度与生存率有显著相关性。结论肿瘤结节数目、门脉癌栓、术前肝功能分级、肿瘤根治程度是影响肝细胞肝癌术后的高风险因素。     

原发性肝细胞癌行肝切除术后复发的预后因素分析

目的探讨HCC行肝切除术后影响患者复发的各预后因素。方法回顾性分析2006年6月～2011年6月行肝切除术治疗HCC的患者临床资料。应用Cox比例风险模型行单因素和多因素分析。结果所有患者均行根治性肝切除术,本组共84例患者出现术后复发,总体1、2、3、5年累积复发率分别为51.96%（53/102）、67.65%（69/102）、76.47%（78/102）、82.35%（84/102）。结论 HCC行肝切除术后复发早、晚期影响因素不同,应进行预后因素等级划分,有助于预测HCC患者术后复发。     

术前控制营养状态评分与肝细胞癌肝切除术后预后的研究进展

肝细胞癌(HCC)是最常见的恶性肿瘤之一。尽管在早期诊断和个体化治疗方面取得了进展,但经根治性切除等治疗后,HCC患者的临床预后仍不佳,复发率高。因此,在HCC患者中识别准确可靠的预后标志物是必要的。作为一种新的免疫营养生物标志物,控制营养状态(CONUT)评分已被报道用于预测癌症患者的预后。本文将对术前CONUT评分...     

WWOX基因在肝细胞癌及手术切缘中的表达意义

目的 探讨WWOX基因在肝细胞癌(HCC)和切缘中的表达状况和术后复发及预后的关系及其临床意义.方法 用免疫组化方法检测76例肝癌组织及其切缘组织、20例正常肝组织中WWOX基因蛋白产物表达水平,用TUNEL法检测76例肝细胞癌的细胞凋亡水平,结合临床病理指标和术后生存率进行分析.结果 WWOX基因蛋白产物在HCC中定位于细胞核,在癌旁组织中定位于细胞核与细胞浆.肝癌组织中WWOX基因蛋白表达指数为(35.2±20.1)%,低于癌旁组织和正常肝组织(P<0.05).并与肝癌的细胞凋亡率下降、PCNA增高、肿瘤较大、门脉分支浸润、低分化高恶性度以及术后复发等指标有关(P<0.05).肝癌切缘ww0X基因蛋白表达水平与术后复发率和生存率有关(P<0.05),而与1 cm以上切缘距离无关.结论 肝癌组织和手术切缘存在低WWOX表达和定位异常,并可能与影响肿瘤进展、预后的生物学行为有关.肝癌组织和手术切缘WWOX表达水平测定有望成为评估肝癌进展等生物学行为和预后的有用指标之一,并有助于确定较为安全的根治切除分子切缘.     

Spontaneous rupture of hepatocellular carcinoma: An approach with delayed hepatectomy

Two cirrhotic patients with ruptured hepatocellular carcinoma (HCC), presenting with hemoperitoneum, were successfully treated by elective hepatectomy. Both of these patients, a 67-year-old female and a 76-year-old male, had first been taken to other primary hospitals by ambulance due to hypovolemic shock. They were then found to have a mass of approximately 5 cm in the cirrhotic liver. In the initial management, however, neither any direct hemostasis by surgery nor indirect measures such as transcatheter hepatic arterial embolization were performed in either case. Instead, conservative treatment consisting mainly of fresh blood and plasma transfusions were continued for more than a month until the liver function stabilized. In both hepatectomies, the use of a microwave tissue coagulator resulted in minimal intra-operative blood loss and an appreciably excellent post-operative course. These cases point to the effectiveness of a wait and see policy for selected patients with ruptured HCC.     

TACE后二期手术治疗小肝癌破裂出血的临床研究

目的 探讨小肝癌破裂出血行TACE后二期手术的治疗效果.方法 21例小肝癌破裂出血患者先行TACE治疗,并于1～2个月后行手术切除（联合治疗组）;同时以18例小肝癌破裂出血患者行急诊手术切除作为对照（对照组）;比较两组止血成功率、围手术期输血量、住院病死率、术后并发症、术后生存率和住院天数.结果 两组患者止血成功率均为100％,联合治疗组与对照组相比围手术期输血量少、并发症发生率低、住院天数短,差异有统计学意义（P＜ 0.01）,但病死率和生存率无差异（P＞0.05）.结论 TACE治疗后二期手术治疗小肝癌破裂出血虽然不能延长患者生存时间,但更具安全性,是临床值得应用的治疗方法.     

自发性肝细胞癌破裂的处理策略

世界不同国家和地区肝癌和肝癌破裂发生率差异很大。同肝癌一样,肝癌破裂病死率很高。肝癌破裂的原因,推论很多而且十分具有争议性。肝癌破裂的诊断主要通过临床和影像学检查,确诊率很高。肝癌破裂的治疗主要分为3个处理阶段:(1)急症阶段。主要通过复苏治疗,稳定病人和停止肝癌破裂出血。停止肝癌破裂出血的方法包括改善病人凝血功能障碍,介入治疗(肝动脉栓塞)和手术治疗(围肝脏纱布填塞、肝动脉结扎、使用能量器械或化学制剂直接止血和急症期肝部分切除术)。(2)评估阶段。病人肝癌破裂停止出血后进行评估,包括病人整体情况、肝功能、肿瘤分期、肝癌(包括肿瘤位置)能否切除、剩余肝脏体积情况、是否伴有肝硬化或门静脉高压症。(3)决定性治疗阶段。该阶段主要分为治愈性和非治愈性。由于肝癌破裂是肝移植的禁忌证,肝部分切除术是唯一治愈性手段。术中使用蒸馏水或5-氟尿嘧啶灌洗腹腔,可有效降低术后肝癌腹膜转移率。肝部分切除术可在急症期(出血期间),延迟早期(肝癌破裂时间≤8 d)或延迟晚期(肝癌破裂时间>8 d)施行。在急症期或延迟早期施行肝部分切除术,术后肝癌腹膜转移率比延迟晚期低。肝癌破裂停止出血后,对于无法施行肝部分切除术的病人,其治疗方法与没有肝癌破裂的病人无较大差别。在可施行肝部分切除术的病人中,手术是最好的治疗手段。肝部分切除术病人的远期生存率高于其他任何非手术治疗(包括经肝动脉栓塞或化疗栓塞)。     

Factors affecting early mortality in spontaneous rupture of hepatocellular carcinoma

BACKGROUND: Spontaneous rupture of hepatocellular carcinoma (HCC) is a catastrophic surgical emergency with high mortality rates. The aim of this study is to determine the factors associated with the prognosis and to assess the outcome of different management strategies. METHODS: A retrospective study of 34 consecutive patients with spontaneous rupture of HCC was conducted from January 1996 to January 2004. Clinical, biochemical and operative factors influencing 30-day mortality were analysed. RESULTS: In our study, 30-day mortality rate was 32% (n = 11). Presence of cirrhosis, Child's C status, shock on admission, higher blood transfusion requirement, raised alpha-fetoprotein, raised alkaline phosphatase, raised aspartate transaminase, and raised indocyanine green at 15 min were all associated with increased risk of 30-day mortality on univariate analysis (P < 0.05). On multivariate analysis, only shock on admission (P = 0.001) and higher blood transfusion requirement (P = 0.01) were significant independent factors affecting early mortality. Surgical intervention was associated with a better 30-day survival as compared with medical therapy or transarterial embolization. The median survival time of patients undergoing curative resection was significantly longer than that of patients who had surgery for haemostasis only (420 vs 205 days). The overall median survival was 161 days. CONCLUSIONS: Spontaneous rupture of HCC is a potentially salvageable complication of HCC. Poor prognosis is associated with poor liver reserve, advanced disease and severity of haemorrhage. Shock and blood transfusion requirement are the only independent factors affecting early mortality.     

腹腔镜肝切除术与开腹肝切除术治疗肝细胞癌的疗效评估

目的 探讨腹腔镜肝切除术与开腹肝切除术治疗肝细胞癌的疗效。方法 采用回顾性分析方法。收集2015年1月31日至2017年1月31日160例在解放军总医院第五医学中心肝胆外科行肝切除术的肝细胞癌患者的临床及病理资料,其中行腹腔镜肝切除术（A组）患者80 例,行开腹肝切除术（B组）患者80例。观察指标：（1）手术时间、术中出血量、切口长度、术后首次下床时间、术后首次进食时间、住院时间;（2）术后第1天的肝功能、白细胞、降钙素原及术后并发症等情况;（3）两组患者术后生活质量量表（QLQC 30评分）情况;（4）随访患者术后生存时间,分析手术方式与患者长期生存及无复发生存率之间的关系。结果 （1）术中情况：A组患者手术时间、术中出血量、切口长度及住院时间均少于B组患者（P＜0.05）,术后首次下床时间、术后首次进食时间均早于B组患者（P＜0.05）。（2）术后情况：A组患者术后第1 天的肝功能、血常规及降钙素原等明显好于B组患者（P＜0.05）,A组患者术后发生腹腔感染、胸水等并发症低于B组患者（P＜0.05）。（3）两组患者术后3 个月的QLQ-C 30 较术前评分均升高,A组患者术后3 个月的QLQ-C 30 评分明显高于B组患者（P＜0.05）。（4）A组患者术后3 年生存率及术后1 年无复发生存率均好于B组患者。结论 腹腔镜肝切除术治疗肝细胞癌安全可行,并发症少,能提高患者生存质量,值得临床推广应用。     

Survival after transarterial embolization for spontaneous ruptured hepatocellular carcinoma

Objectives  To examine the survival of patients with spontaneous ruptured hepatocellular carcinoma treated with transarterial embolization (TAE). Methods and materials  Patients diagnosed with spontaneous ruptured hepatocellular carcinoma treated with TAE were retrospectively studied. Hospital records were reviewed and data were collected and analyzed from the years 2000–2006. A total of 62 patients who had been diagnosed with spontaneous ruptured hepatocellular carcinoma were managed in our hospital during this period. Results  All 62 patients (who had been diagnosed with ruptured hepatocellular carcinoma and were managed in our hospital) patients were treated with TAE, with a success rate of 91% (57/62). Early mortality (within 30 days after rupture) was 38%. Factors that were associated with early mortality were old age, low hemoglobin at presentation, elevated bilirubin at presentation, prolonged prothrombin time at presentation (INR > 1.3), low albumin level at presentation, and unsuccessful embolization. A low albumin level was the only independent risk factor for early mortality. The overall median survival time was 39 days. Surgical resections were possible in seven patients. Their cumulative survival was significantly longer (P = 0.002) than that of patients managed with non-operative treatment after embolization. Conclusion  Transarterial embolization (TAE) can achieve good hemostasis, though low albumin level, which reflects poor liver reserve, may predict early mortality. Portal vein thrombosis should not be regarded as an absolute contraindication for TAE. Staged surgical resection after embolization is safe and produces a good survival outcome.     

Feasibility and validity of hepatic vein reconstruction in hepatectomy for hepatocellular carcinoma

The majority of hepatocellular carcinomas are complicated by liver cirrhosis. Cirrhotic patients with a tumor located in segments 7 and 8 cannot tolerate right lobectomy. To perform curative resection without causing liver failure in such patients, resection of segments 7 and 8, together with resection of the right hepatic vein, is recommended. Nine patients underwent such resection. In four patients, the right hepatic vein was not reconstructed. One patient died of liver failure and the other two patients had postoperative liver dysfunction. Based on this experience, the right hepatic vein was reconstructed in the remaining five patients; the defect was repaired by transplanting a vein graft in three patients, and a patch graft was carried out in two. In one patient who underwent reconstruction with vein graft, veno-venous bypass was performed between the remnant hepatic vein and inferior vena cava. This procedure decompressed the remnant liver and facilitated secure anastomosis in reconstruction of the hepatic vein. There were no complications or deaths. The reconstructed veins were patent 2–3 years postoperatively. This procedure is feasible and valid, and should be widely practiced in patients with a diminished liver function reserve.