腹腔镜肝切除治疗原发性肝癌

自1991年Reich首次报道腹腔镜切除肝脏肿瘤以来,随着肝脏外科技术和腹腔镜技术的不断发展,腹腔镜肝脏切除经历了对肝脏较小的、位置浅表的良性肿瘤切除;肝脏恶性肿瘤局部切除的尝试;到     

腹腔镜解剖性肝切除治疗位于中央部位肝癌单中心经验

目的探讨腹腔镜解剖性肝切除治疗中央部位肝细胞癌的安全性和可行性。方法2015年1月至2019年12月,12例肿瘤位于肝中央部位的肝细胞癌患者在佛山市第一人民医院肝脏外科实施了腹腔镜肝切除;其中男9例、女3例,平均年龄(55.5±6.8)岁,平均肿瘤直径(3.7±2.5)cm,术前肝脏储备功能ICG-R15(3.9±2.82)%,肝功能Child-Pugh分级A级。实施肝Ⅳ~Ⅷ段切除5例、肝Ⅴ~Ⅷ段切除6例、肝Ⅳ段切除1例。统计分析手术时间、手术切缘、术中出血量、术后并发症及住院时间等。结果12例患者均在腹腔镜下完成手术,无中转开腹,平均手术时间(398.8±115.4)min,平均术中出血量(420.8±279.2)ml,有1例输血,术后平均住院时间(9.1±2.2)d,无围手术期死亡病例,术后并发症包括肝断面出血1例、胆漏1例、膈下包裹性积液1例,平均手术切缘(1.2±0.6)cm。结论对位于肝中央部位的肝细胞癌,行解剖性肝Ⅳ~Ⅷ段切除、肝Ⅴ~Ⅷ段切除以及肝Ⅳ段切除是安全、可行的。采取肝内Glissonian鞘外的方法预先控制肝蒂有利于掌握断肝平面,术前精准的评估,术中有效的控制出血以及娴熟的腔镜外科技术能有效帮助术者安全实施手术。     

腹腔镜与开腹肝叶(段)切除治疗肝癌的近期效果对比研究

目的探讨腹腔镜肝叶切除治疗肝癌的近期效果. 方法将2001年1月～2004年6月17例肝癌行腹腔镜肝叶(段)切除者与同期22例肝癌开腹肝切除者进行对比,比较两组手术时间、术中出血量、输血量、手术前后肝功能和血象、并发症等. 结果腹腔镜组手术时间长于开腹组(中位数300 min vs 145 min,u=107.05,P=0.023).两组术中出血量、输血量相近.腹腔镜组胆红素、丙氨酸转氨酶改变比开腹组小.两组手术前后血象改变无显著差异.腹腔镜组术后无并发症,开腹组有伤口感染、膈下积液、胸腔积液及术后出血各1例. 结论电视腹腔镜肝叶(段)切除治疗肝癌有明显微创效果,安全、有效.     

手助腹腔镜肝癌切除23例

目的探讨手助腹腔镜肝癌切除的可行性和安全性。方法对病变位于肝脏外周部位(Ⅱ~Ⅵ段)的23例病人,肝细胞癌20例,肝内胆管细胞癌2例,肝囊腺癌1例。采用手助腹腔镜行肝切除术。结果23例手助腹腔镜肝切除均获得成功,规则性肝叶(段)切除17例,肝不规则切除6例,平均手术时间为105 m in,平均出血量187 m l,术后无严重并发症发生,术后平均住院日为9.5 d。结论手助腹腔镜肝切除是安全可行的,缩短手术时间,减少出血的微创手术方式。     

小肝癌手术切除82例临床分析

目的探讨影响小肝癌手术疗效的相关问题。方法回顾性分析８年间手术切除的８２例瘤径≤５０ｃｍ的小肝癌。其中ＨＢｓＡｇ（＋）６０例,合并肝硬变７１例。７８例肝细胞癌的高、中、低分化分别为１５、５３和１０例。行联合肝段切除１３例,肝段切除１４例,局部肝切除５５例。结果手术病死率为１２％,术后１、３、５年生存率分别为９２７％、７２５％、５４３％。高、中、低分化组术后５年生存率分别为７９６％、４９９％和４１１％。术后１、３、５年复发率分别为１２８％、４０７％、７１５％。结论小肝癌具有与大肝癌相同的肝病史,早期发现和限量肝切除是减少术后并发症、提高术后生存率的重要途径。     

完全腹腔镜下原发性肝癌切除32例报告

目的探讨腹腔镜肝癌切除的安全性、可行性和微创性。方法回顾性分析2008年10月—2011年2月行腹腔镜肝癌切除术32例原发性肝癌患者的临床资料。结果 32例患者腹腔镜下肝癌切除术成功,无中转开腹。病灶分别位于Ⅱ段(3例),Ⅲ段(8例),Ⅱ+Ⅲ段(10例),IV段(2例),V段(4例),VI段(5例)。病灶直径1.8～9.2 cm,平均4.3 cm,均为单病灶,均合并肝硬化。术前肝功能Child A级者27例,Child B级5例。术式包括:左半肝切除2例,左外叶切除15例,局部切除15例。术中采用结合超声刀和LigaSure或内镜下切割缝合器(Endo-GIA)联合断肝。2例患者临时阻断第一肝门,时间分别为15,22 min,3例患者术中输红细胞2 U。术后无创面出血及胆瘘等并发症,无肝功能衰竭发生,均痊愈出院。32例随访5～26个月,3例局部复发,无死亡病例。结论腹腔镜肝癌切除是安全、可行的,腹腔镜肝癌切除技术难度大,手术适应证应严格选择,病灶大小和位置是主要的参考指标;超声刀与Ligasure联合断肝止血效果好、解剖结构清晰。     

腹腔镜肝切除与开腹肝切除治疗原发性肝癌的临床比较

目的:探讨腹腔镜肝切除治疗原发性肝癌的安全性与有效性。方法:回顾性分析2014年10月—2015年12月67例肝切除患者的临床资料,其中腹腔镜肝切除组37例,开腹肝切除组30例,比较分析两组患者术中、围手术期及随访数据资料。结果:与开腹组比较,腹腔镜组切口长度(5.65 cm vs.18.33 cm)、禁食时间(1.53 d vs.2.74 d)、止痛药用量(136.20 mg vs.290.75 mg)、术后住院时间(7.52 d vs.13.65 d)均有明显优势(均P0.05);两组手术时间、术中失血量、围手术期肝功能指标,并发症发生率,术后6个月、1年生存率差异无统计学意义(均P0.05)。结论:腹腔镜肝切除具有创伤小、疼痛轻、恢复快等优点,且安全可行,值得临床开展。     

我国肝癌肝切除技术发展之路

肝细胞癌(以下简称肝癌)是我国常见的一种消化道肿瘤,肝切除手术是早中期肝癌的最主要的治疗手段之一.与发达国家相比,我国的肝切除技术起步相对较晚.经过了几代肝脏外科医师的不懈努力,我国的肝癌肝切除技术取得了令人瞩目的 成就.进入21世纪以来,随着外科理念的更新、影像学技术的进步、微创外科的发展以及手术器械的改进,肝癌肝切...     

腹腔镜下ALPPS治疗肝癌的临床效果分析

目的探讨腹腔镜下肝脏离断和门静脉结扎的二期肝切除术(ALPPS)治疗原发性肝癌合并肝硬化患者的临床效果。方法选取2014年6月至2015年8月实施腹腔镜下ALPPS手术的11例患者进行研究分析,第一期手术主要为门静脉右支结扎、肝脏离断手术,根据患者的一期手术后基本情况及未来残余肝脏体积(FLR)决定患者是否实施二期手术,分为二期手术组7例、非二期手术组4例。数据统计分析采用SPSS16.0进行处理,计量指标采用中位数(下四分位数~上四分位数)进行统计描述,组间比较采用秩和检验。P值0.05表示差异具有统计学意义。结果术后第1、5、7、10、14天,二期手术组患者的ALT、AST测定值均低于非二期手术组(P0.05),术后第5、7、10、14天,二期手术组患者的ALB、未来残余肝脏体积与标准肝脏体积(FLR/TLV)值均显著的高于非二期手术组(P0.05);二期手术组在第7天实施二期手术时,FLR/TLV值较术前增加了10.4%,非二期手术组仅增加4.4%;进行了二期手术的患者复发间隔时间长于非二期手术组患者(Z=-2.793,P=0.0190.005)。结论腹腔镜下ALPPS治疗原发性肝癌并肝硬化患者具有临床可行性,该手术方法能在一定程度延长患者的生存时间,对于传统方法无法根治的患者具有重要意义。     

腹腔镜肝切除治疗肝癌患者45例近期疗效分析

目的分析腹腔镜肝切除治疗肝癌患者的近期效果。方法随机将100例接受肝切除治疗的肝癌患者分为2组,每组50例。分别实施开腹手术和腹腔镜手术。比较2组手术时间、术后拔管时间、疼痛评分、住院时间、术后并发症及随访结果。结果腹腔镜组术后拔管时间、疼痛评分、住院时间均低于开腹组,2组比较,差异有统计学意义(P0.01)。腹腔镜组术后并发症发生率低于开腹组,2组比较,差异有统计学意义(P0.05)。2组患者手术时间、随访1a肿瘤复发率、转移率及存活率等指标比较,差异无统计学意义(P0.05)。结论在掌握手术适应证基础上,应用腹腔镜肝切除术治疗肝癌,术后并发症少,患者恢复快,住院时间短,且近期随访复发、转移及存活率与开腹手术相比无明显差别。     

Hepatectomy for Hepatocellular Carcinoma in Elderly Patients Aged 75 Years or More

Background  The aim of this study was to clarify the characteristics of elderly hepatocellular carcinoma (HCC) patients aged 75 years or more who underwent hepatectomy and to clarify whether elderly patients with HCC benefit from hepatectomy. Methods  Between January 1990 and December 2006, 570 patients underwent curative hepatectomy for HCC. Elderly patients were defined as those aged 75 years or more. Clinicopathological data and outcomes after hepatectomy for 64 elderly and 502 younger patients were prospectively collected and compared. Results  The proportion of elderly patients with chronic viral infection was less than that of younger patients (p < 0.001). Cirrhotic patients in the elderly group were less than those in the younger group (p = 0.03). The elderly patients had better liver function than did the younger patients (p = 0.007) but had more advanced HCC with microscopic vascular invasion than did the younger patients (p = 0.04). There was no operative mortality in the elderly patients and there was no significant difference in postoperative complication rates and long-term survival after hepatectomy between the two groups. Conclusions  Hepatectomy for elderly patients with resectable HCC is safe and feasible. Selected elderly patients with HCC might benefit from hepatectomy. This work originated from the Department of Surgery, Division of Frontier Medical Science, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan.     

腹腔镜小肝癌切除术难点与关键技术

近年来腹腔镜肝切除术技术发展迅速。随着影像学的发展、手术适应证的不断扩大、手术器械不断进步、手术流程的逐渐规范化,越来越多的小肝癌患者接受了腹腔镜肝切除治疗。与大肝癌相比,术中小肝癌更容易进行操作,小肝癌无疑是学习腹腔镜肝切除技术的最佳选择。但由于缺乏标准术式、术中大量出血难易控制以及术者学习周期较长等问题阻碍着这项技术的发展。本文结合实践体会,从病人的选择、肝脏肿瘤识别及定位、肝门血流阻断、控制性低中心静脉压、术野的暴露、切线及切除范围、肝实质的离断技术等方面,就腹腔镜肝切除术治疗小肝癌的难点及关键技术进行讨论。     

Long-term Outcomes and Prognostic Factors of Elderly Patients with Hepatocellular Carcinoma Undergoing Hepatectomy

Objective  The present study aimed to evaluate the long-term outcomes and prognostic factors of elderly patients with hepatocellular carcinoma (HCC) undergoing hepatectomy. Material and Methods  From January 1983 to December 2006, 2,283 patients with HCC received hepatectomy in Sun Yat-sen University Cancer Center. The clinicopathological data and treatment outcomes of 67 elderly HCC patients (elderly group, ≥70 years of age) and 268 patients (control group, <70 years of age) who were selected randomly from the 2216 younger patients were compared retrospectively. Results  The elderly HCC patients had lower hepatitis B surface antigen-positive rate (P < 0.001), lower rate of marked α-fetoprotein elevation (P = 0.004), higher infection rate of hepatitis C virus (P = 0.010), more preoperative comorbidities (P < 0.001), higher rate of tumor encapsulation (P = 0.040), and better overall survival rate (P = 0.017); whereas there were no significant differences between these two groups in other factors, including gender ratio, liver function, accompanying cirrhosis, pathological tumor–node–metastasis (pTNM) staging, satellite nodules, vascular invasion, tumor rupture, resection margin, intraoperative blood loss, incidence of postoperative complications, hospital mortality, and disease-free survival rate. Multivariate analysis showed that pTNM staging was an independent prognostic factor of long-term survival in elderly patients with HCC. Conclusion  HCC in the elderly was less HBV-associated, less advanced, and less aggressive. Hepatectomy for selected elderly patients with HCC possibly have a better curative effect compared with younger patients. For the elderly patients without preoperative comorbidities or with controlled comorbidities, hepatectomy is a safe and effective treatment. pTNM staging is the only independent predictor of postoperative overall survival in elderly HCC patients.     

腹腔镜与开腹手术治疗肝细胞癌疗效的Meta分析

目的系统评价腹腔镜与开腹手术治疗肝细胞癌的疗效。方法计算机检索PubMed、中国期刊全文数据库、万方数据库、中国博硕士学位论文数据库及中国重要会议论文数据库2000～2011年发表的有关腹腔镜肝切除术和开腹肝切除术治疗肝细胞癌的相关文献,采用RevMan 5.0进行Meta分析。结果共纳入11项临床对照试验,包括781例患者,其中经腹腔镜手术治疗325例,开腹手术治疗456例。Meta分析结果显示,与开腹手术相比较,腹腔镜肝切除术能明显缩短手术时间〔加权均数差值（WMD）=-20.85,95%CI（-29.54,-12.16）,P〈0.000 01〕,减少术中出血量〔标准化均数差值（SMD）=-0.42,95%CI（-0.65,-0.19）,P=0.000 4〕,降低术后并发症发生率〔优势比（OR）=0.43,95%CI（0.28,0.65）,P〈0.000 1〕,缩短住院时间〔WMD=-4.32,95%CI（-6.29,-2.34）,P〈0.000 1〕。但术后复发率（P=0.80）和术后1年总生存率（P=0.98）、3年总生存率（P=0.41）、5年总生存率（P=0.12）以及1年无瘤生存率（P=0.15）、3年无瘤生存率（P=0.62）和5年无瘤生存率（P=0.99）差异均无统计学意义。结论对于病变位于CouinaudⅡ、Ⅲ、Ⅳ、Ⅴ及Ⅵ段,其直径小于5 cm,并且不影响第一和第二肝门血管的暴露,肝功能在Child B级以上的肝细胞癌患者,在条件允许的情况下可优先考虑腹腔镜肝切除术。     

Laparoscopic Liver Surgery for Patients with Hepatocellular Carcinoma

Background Laparoscopic hepatectomy is feasible for hepatocellular carcinoma (HCC) today. This is a retrospective study of the patients with HCC treated by liver resection with a totally laparoscopic approach. Methods This study recruited 116 patients (92 male, 24 female) that underwent laparoscopic liver resection (LR) for HCC. Patients were divided into two groups: group I: (n = 97, 78 male,19 female) those with a volume of resection less than two segments; group II: (n = 19, 14 male, 5 female) those with a volume of resection of more than two segments. The distribution of the tumor-node–metastasis (TNM) stage of patients in the two groups was not significantly different. Results Patients resumed full diet on the second or third day after the operation, and the average length of hospital stay was 6 days. The operation time was 152.4 ± 336.3 min and 175.8 ± 57.4 min, while blood loss was 101.6 ± 324.4 mL and 329.2 ± 338.0 ml, for groups I and II, respectively. Five patients (5.2%) in group I and three patients (15.8%) in group II required blood transfusion (p = 0.122). The mortality rate was zero among our patients and complication rates were 6.2% and 5.2% for groups I and II, respectively. The 1-year, 3-year, and 5-year survival rates were 85.4%, 66.4%, and 59.4% for group I, and 94.7%, 74.2%, and 61.7% for group II, respectively, with no significant difference between two groups (p = 0.1237). Conclusion Laparoscopic liver resection is a procedure of significant risk and is more technically demanding in comparison with traditional open method. There was no significant difference in survival rates, based on the volume of resection. Laparoscopic surgery should be performed in selected patients as the postoperative quality of life of patients is better than that with open resection.     

原发性肝癌合并脾功能亢进患者肝脾联合切除对疗效的影响

目的探讨原发性肝癌合并脾功能亢进肝脾联合切除对疗效的影响。方法回顾分析23例原发性肝癌合并脾功能亢进的患者行肝癌切除联合脾切除（切脾组，n=10）和肝癌切除联合脾动脉结扎（非切脾组，n=13）手术前、后外周血中CD4、CD8、CD16、CD4／CD8、WBC及PLT的变化，并比较2组的生存率。结果术前2组患者的CD4、CD8、CD16、CD4／CD8、WBC及PLT差异无统计学意义；2组术中出血量和术后并发症发生率的差异亦无统计学意义的；术后3个月，切脾组CD4、CD16、CD4／CD8、WBC及PLT指标比术前显著升高（P〈0．01），且明显高于非切脾组（P〈0．01）；非切脾组术后上述各项指标无明显改变。2组生存率比较差异无统计学意义。切脾组中无一例因白细胞改变而影响术后辅助化疗，而非切脾组有7例因白细胞过低而被迫终止了化疗。结论肝癌切除联合脾切除有利于肝癌合并脾功能亢进患者术后免疫功能的恢复及术后化疗。     

Long-Term Safety of Autotransfusion During Hepatectomy for Hepatocellular Carcinoma

Purpose To evaluate the long-term safety of autotransfusion (AT) in hepatectomy for hepatocellular carcinoma (HCC). Methods Between 1988 and 1989, 46 patients with HCC underwent hepatectomy with AT (group 1). For a comparison, we matched 50 patients with HCC who underwent hepatectomy, and received homologous but not autologous blood (group 2). The 10-year cumulative survival curves and cancer-free curves of the two groups were examined, and the pattern of recurrence was compared. Results Group 1 had a significantly higher cumulative 10-year survival rate than group 2, at 20% vs 8%, respectively (P < 0.05). Among the patients who underwent curative resection, those in group 1 had significantly better cumulative survival and cancer-free survival rates than those in group 2, at 27% vs 11% (P < 0.05) and 13% vs 0% (P < 0.05), respectively. Among the patients with stage I–II HCC, those in group 1 had significantly better cumulative survival and cancer-free survival rates than those in group 2, at 30% vs 5% (P < 0.01) and 20% vs 5% (P < 0.05), respectively. However, the rates were similar among patients with stage III–IV disease in both groups. The pattern of recurrence in the two groups was similar. Conclusion Autotransfusion promoted survival in patients undergoing hepatectomy for stage I or II HCC.     

完全腹腔镜下右半肝切除

切除胆囊后,向左牵拉胆囊管,显露门静脉右支,分离,7号丝线结扎;分离出肝右动脉,结扎切断。显露左右半肝缺血线。游离肝结肠韧带,肝肾韧带,右侧冠状韧带,肝镰状韧带,右半肝充分游离。沿缺血线切开肝脏实质,结扎切断肝中静脉5段支,应用Endo GIA blue reload离断右肝蒂后沿下腔静脉前面结扎切段右侧肝短静脉,继续沿缺血面离断肝组织,结扎切断肝中静脉第8段支,显露肝右静脉,Endo GIA white reload离断。完整切除右肝。装入自制标本袋。取出!     

男性肝细胞癌患者的临床病理特点及影响因素

目的探讨男性肝细胞癌患者的临床病理特征、术后生存及预后影响因素。方法回顾性分析1995年1月至2002年12月期间我科行肝切除术之155例男性肝细胞癌患者的临床及随访资料,单、多因素分析确定预后影响因素。结果与同期24例女性患者比较,男性肝细胞癌患者年长5.7岁,并有较高的HBsAg阳性率(80.6%vs54.2%)和肝硬变比率(87.1%vs37.5%),P<0.05,其他临床病理指标差异无统计学意义(P>0.05)。多因素分析提示,Edmondson-Steiner分级和门静脉癌栓为男性患者术后总体生存和无瘤生存的独立影响因素,卫星灶和肿瘤大小仅影响总体生存。结论男性肝细胞癌患者主要的临床病理特征及术后生存情况与女性患者相似。肿瘤分化程度和生物学行为是影响男性肝细胞癌患者术后生存的主要因素。     

Prognostic Impact of Surgical Complications and Preoperative Serum Hepatocyte Growth Factor in Hepatocellular Carcinoma Patients After Initial Hepatectomy

Introduction  The relationship between postoperative complications and survival after hepatectomy is not completely understood. The purpose of this study was to determine if surgical complications would have a prognostic impact and to identify any difference of the prognostic factors between a complication group and complication-free group for hepatocellular carcinoma (HCC) patients after initial hepatectomy. Patients and Methods  One hundred consecutive HCC patients were analyzed in this study. Operative variables and liver functional markers were compared between the complication group and complication-free group. The diagnostic accuracy for predicting complications was evaluated by the receiver operating characteristic (ROC) curve. The Kaplan–Meier method with log-rank test was employed for survival analysis. Univariate and multivariate analyses were performed to identify the prognostic factors in each group. Results and discussion  A total of 45 complications in 32 patients were observed according to the modified Clavien classification. The albumin, γ-glutamyl transferase, choline esterase, indocyanine green retention rate at 15 min (ICGR₁₅), hyaluronic acid, prealbumin, hepatocyte growth factor (HGF), HH15, and LHL15 levels before hepatectomy, operative time, and blood loss were significantly different between the two groups. Multivariate analysis revealed that γ-glutamyl transferase, ICGR₁₅, and HGF were independent risk factors for postoperative complications. The values of the areas under the ROC curve for predicting complications proved the significance of the predictions. Although the recurrence-free survival rates were not significantly different, the overall survival rates were significantly different between the two groups. Univariate and multivariate analyses for the overall survival rate showed that the stage of the HCC and HGF for the complication group and tumor size for the complication-free group were independent prognostic factors for overall survival. Conclusion  Postoperative surgical complications could have a prognostic impact on overall survival in HCC patients after initial hepatectomy. Serum HGF could be a factor connected to complications and survival in this group.