单侧入肝血流联合肝静脉阻断在复杂肝切除中的应用

目的：探讨单侧入肝血流联合肝静脉阻断技术在复杂肝切除术中的应用价值。
方法：回顾性分析46例巨块型肝癌通过预先解剖、控制患侧入肝血流联合阻断出肝血流行切肝术患者的临床资料。
结果：46例患者均为原发性肝癌,肿瘤平均直径8.3 cm(6~15 cm),肿瘤侵犯1根主肝静脉20例,侵犯2根主肝静脉14例。行右半肝切除16例,右后叶肝切除14例,左半肝切除16例。平均患侧入肝血流阻断时间30 min(10~45 min),平均肝静脉阻断时间20 min(10~30 min)。行肝静脉修补5例。平均术中出血量540 mL(300~1 500 mL)。全组术后发生并发症14例次,均经治疗后痊愈,无死亡病例。
结论：单侧入肝血流联合肝静脉阻断技术在复杂肝切除术中能明显减少术中出血,降低术后肝功能衰竭发生率,是一种安全、可行实用的血流阻断技术。

     

尾状叶巨大海绵状血管瘤的外科处理

目的：探讨肝尾状叶巨大海绵状血管瘤的外科处理策略。 方法：回顾性分析4例肝尾状叶巨大海绵状血管瘤患者的临床治疗资料。 结果：术前将患者Child-Pugh评分均调整至A级,CT及三维立体重建检查,了解肿瘤与肝动、静脉及门静脉的关系;2例患者依照左右路径+前路劈肝路径切除,另2例行左半肝+尾状叶联合切除。患者均安全顺利地实行了肝尾状叶巨大血管瘤切除术,术后无严重并发症的发生。 结论：术前充分评估,术中精细操作,手术治疗肝尾状叶巨大血管瘤可取得满意疗效。

     

临时血管内转流术在肢体血管损伤修复中的应用

目的：探讨临时血管内转流术在治疗血管损伤中的价值。方法：总结2006年6月—2013年6月采用临时血管内转流术的血管损伤患者临床资料。结果：全组5例患者，共9条肢体血管受损（3例因外伤、2例因肿瘤切除手术）。5例患者共 8条临时血管内转流管（动脉5条,静脉3条）置入受损血管快速重建肢体血运，然后再行创面的处理及骨折手术；转流时间2~3 h，移除转流管后采用自体大隐静脉移植行血管重建术。全组无死亡，术后1例发生缺血肌挛缩，1例并发下肢深静脉血栓。结论：临时血管内转流术可快速重建肢体血供，缩短肢体缺血时间，为其他合并损伤的处理提供了条件。

     

肝癌肝切除的输血因素分析

目的：探讨肝癌肝切除输血的预测因素。
方法：回顾性分析222例肝癌肝切除病例的临床资料,分析影响肝癌肝切除输血的临床因素。
结果：Logistic单因素及多因素分析：肝硬化程度,肿瘤直径,大血管侵犯,切肝段数,谷草转氨酶,直接胆红素,间接胆红素,血红蛋白水平这8个变量为输血的独立影响因素（P＜0.05）,并依次建立了Logistic回归预测输血的方程式。
结论：通过对肝癌病人术前输血影响因素的分析,预测输血的概率,从而对高输血概率的肝癌病人选择实施自体输血,可以有效减少异体输血导致的不利影响。

     

解剖性右肝三段切除治疗右肝巨大或多发性肝癌

目的：探讨解剖性右肝三段切除治疗右肝巨大或多发性肝癌的疗效。方法： 12例右肝巨大或多发性肝癌患者术前CT肝脏体积测定显示，若行右半肝切除则预留肝脏体积百分率（%FLRV）不足，若行右肝三段切除则%FLRV平均增加14.3%，故行保留V段或VIII段的右肝三段切除术。术中通过选择性入肝血流阻断的方法确定出V段或VIII段的位置，从而在肝表面标记出一条“┏┛”或“┕┓”形的切除线；在切割横断肝实质时根据不同的切除平面采取右半肝入肝血流阻断或全肝的入肝血流阻断的方法，减轻肝脏缺血再灌注损伤。结果：全部患者顺利完成解剖性右肝三段切除术，平均手术时间285 min，平均失血量为720 mL。肿瘤均完整切除，术后V段或VIII段的出入肝血流均完整保留，无围手术期死亡，所有患者AFP均于 2个月内降至正常范围。术后全组12例患者至今10例仍存活，最长1例患者已无瘤生存3年；1例死于梗阻性化脓性胆管炎，1例死于肝脏多发转移肝功能衰竭，另外1例发现肝左内叶复发、2例发现肺部转移患者经综合治疗带瘤生存，其他患者无肿瘤复发、转移等情况，肝功能和AFP水平均在正常范围内。结论：解剖性右肝三段切除术能最大限度地保留无瘤肝组织，可作为V段或VIII段未受累的右肝巨大或多发性肝癌一种常规手术方法，从而提高肝癌的整体切除率。

     

肝门部胆管癌患者的手术治疗

目的：探讨影响可手术切除的肝门部胆管癌患者预后的相关因素。
方法：对6年间行手术切除的44例肝门部胆管癌患者的临床资料和生存情况进行回顾性分析。
结果：44例手术切除的类型,R0切除38例,R1切除6例,R2切除0例。25例患者切除后采用了将空肠袢断端前壁与胆管残端开口上方肝脏断向缝合的新胆管空肠吻合方式,19例患者采用了传统的胆肠吻合方式,新的吻合方式较传统吻合方式可明显减低胆瘘的发生(χ2=4.565, P=0.033)。单因素分析显示,影响患者术后生存期的因素为肿瘤的临床分期、手术切除的范围、是否R0切除以及淋巴结是否转移;而多因素分析显示,影响生存的独立危险因素为肿瘤的临床分期和是否R0切除(P＜0.05)。
结论：影响术后肝门部胆管癌生存期的因素为肿瘤的临床分期和R0切除;采用新的吻合方式,可在尽量减少正常肝组织切除的条件下,保证肿瘤切除的彻底性。

     

肝胆管结石合并肝脓肿和胆管癌：附14例报告

目的：探讨肝胆管结石合并肝脓肿和胆管癌的诊断和治疗方法。
方法：对2004年7月—2009年12月收治的14例肝胆管结石并肝脓肿和胆管癌的临床资料进行回顾性分析。
结果：全组肝胆管结石并肝脓肿和胆管癌的发生率为0.58%（14/2 432）,术前确诊5例（5/14,35.7%）;另术中快速病检发现7例,术后病检发现2例。肿瘤切除7例（7/14,50.0%）。随访的5例行肿瘤切除者生存期均超过1年,其中1例存活5年3个月;4例非切除性姑息性手术分别存活1,6,7,13个月。
结论：有多年肝胆管结石病史患者合并肝脓肿时要考虑胆管癌的可能。早期诊断及早行肿瘤根治切除是提高疗效的关键。

     

肝外伴肝内胆管结石的微创治疗现状与进展

肝外伴肝内胆管结石是普通外科常见病，其治疗方法既有传统手术，也包括内镜、腹腔镜及胆道镜技术在内的各种微创治疗措施。但单独应用每一项治疗的方案都有其局限性，也不能最大限度地发挥各自的优势。笔者通过查阅并总结近年来相关文献，就肝外伴肝内胆管结石的微创治疗现状与进展作一综述。

     

门静脉高压症CEAP诊断系统的建立

目的：建立门静脉高压症(PH) CEAP诊断系统。
方法：回顾性分析我院收治的251例PH患者的临床和病理资料，参照美国静脉论坛关于下肢慢性静脉性病变的诊断和治疗分类系统中的临床、病因、解剖、病理生理(CEAP)和布-加综合征的许氏临床病理分型，提出PH 的CEAP诊断系统。
结果：根据影像学(多普勒超声、经皮脾穿刺门静脉造影、选择性肠系膜上动脉造影或多排螺旋CT三维重建)检查结果和临床以及病理学资料，将PH 的CEAP诊断系统归纳为：临床表现(C)分为轻型和重型；病因(E)则有先天性、原发性和后天性；解剖(A)定位于肝脏、腔静脉、肝静脉和门静脉系；病理生理(P)变化包括肝脏的纤维化或硬化、血管的阻塞和血栓形成以及肝内侧支形成、肿瘤(Pt)等。
结论：CEAP诊断系统的建立对各种原因引起的PH的正确诊断、分型和个体化的治疗对策中具有重要的意义，有较高的临床应用和推广价值。

     

局麻下CT引导肝癌微波消融术中肿瘤位置与疼痛的关系

目的:探讨肝癌病灶距肝包膜或肝段以上门静脉分支远近与局麻下CT引导行微波消融(MWA)术中疼痛的关系。方法:选取先成功实施肝动脉栓塞化疗后行MWA治疗的78例肝癌患者,根据原发病灶位置分为近端组(病灶距离肝包膜或肝段以上门静脉分支距离≤5 cm,32例,37个病灶)和远端组(病灶距离肝包膜或肝段以上门静脉分支距离5 cm,46例,54个病灶),比较两组治疗效果及术中疼痛程度等指标的差异。结果:近端组的病灶完全消融率与远端组差异无统计学意义(75.86%vs.81.48%,P0.05);两组术后AFP水平均较术前明显降低(均P0.05),但无组间差异(P0.05)。按肿瘤大小(≤2 cm和2 cm)分层比较,近端组与远端组的术前VAS评分、可耐受的最大治疗功率、消融时间比较差异均无统计学意义(均P0.05),但近端组术中VAS评分、VAS相对值、哌替啶用量均明显的高于远端组(均P0.05);近端组和远端组病灶2 cm的患者的术中VAS评分、消融时间、哌替啶用量均明显高于本组病灶≤2 cm的患者(均P0.05)。近端组总并发症发生率明显高于远端组(15.63%vs.2.17%,P0.05)。结论:肝癌病灶距离肝包膜或肝段以上门静脉分支的位置≤5 cm会增加患者MWA治疗过程中的疼痛感受,尤其是病灶直径2 cm的患者增加会更加明显。     

Technical Refinement to Prevent Hepatic Outflow Disturbance in Right Lobe Living Donor Liver Transplantation: The New Simplified One-Orifice Venoplasty Technique

Middle hepatic vein (MHV) reconstruction is often essential to avoid hepatic congestion and serious graft dysfunction in living donor liver transplantation (LDLT). This article introduces the evolution of our MHV reconstruction technique and the excellent outcomes of a new simplified one-orifice venoplasty. We compared clinical outcomes among 3 types of one-orifice techniques through a retrospective review of 378 recipients who underwent LDLT using a modified right lobe graft at our institution from January 2008 to December 2018; group I (n = 34) received separate outflow reconstruction, group II (n = 166) received the one-orifice technique to create a wider single outflow with patchwork, and group III (n = 178) received the more simplified one-orifice technique in which neo-MHV was reconstructed into the right hepatic vein without patch venoplasty. Patient demographic characteristics did not differ significantly among the 3 groups, but cold ischemic time and operative time in groups II and III were significantly shorter than those in group I. Moreover, the early patency rates of MHV in groups II and III were higher than those in group I. In particular, group I received an MHV or right hepatic vein stenting more frequently than group II or III during the early posttransplant period. In conclusion, this new simplified one-orifice technique could be an effective method to overcome technical difficulties and the outflow disturbance during right lobe LDLT without complex benchwork to create a large outflow.     

腹腔镜下中下段胆管癌根治术中联合肝动脉切除重建的疗效与安全性：附3例报告（附视频）

背景与目的：中下段胆管癌临床上主要以下段胆管癌多见,下段胆管癌一般采用胰十二指肠切除术,中段胆管癌可以采用胰十二指肠切除术或胆管癌根治、胆肠吻合术。中下段胆管癌因胆管紧邻肝动脉和门静脉,因此更容易发生门静脉侵犯,因肝动脉有动脉外鞘,因此肝动脉受侵犯相对较少,但一旦侵犯,因为涉及肝动脉切除吻合重建,具有较高技术难度,常需联合肝动脉切除重建才能实现R0切除。目前肝动脉切除重建在临床逐渐成熟,但腹腔镜下完成肝动脉切除重建经验缺乏,需要进一步积累。因此,本研究对3例完成腹腔镜下联合肝动脉切除重建的胆管癌患者的临床资料进行回顾性分析并评估短期结果,以期为临床实践提供初步经验。方法：回顾性分析2021年11月—2022年11月中国人民解放军陆军军医大学第二附属医院肝胆外科的3例行联合肝动脉切除重建的中下段胆管癌根治术患者的临床资料。结果：3例患者中女性1例,男性2例,年龄分别为61、65、69岁;病例1为胆管中段癌,因肿瘤侵犯右肝动脉和门静脉,且胆管下端切缘阴性,行联合右肝动脉切除重建、门静脉切除重建、胆管癌切除、胆肠吻合术、肝门部胆管整形术、淋巴结清扫术;病例2为胆管下段癌,因肿瘤侵犯替代右肝动...     

Anatomical variations of donor portal vein in right lobe living donor liver transplantation: the safe use of variant portal veins

In right lobe (RL) living donor liver transplantation (LDLT), portal vein (PV) variations are of immense clinical significance. In this study, we describe in detail our PV reconstruction techniques in RL grafts with variant PV anatomy and evaluate the impact of accompanying biliary variations on the recipient outcomes. In a total of 386 RL LDLTs performed between July 2004 and July 2012, the clinical data on 52 (13%) transplants using RL grafts with variant PV anatomy were retrospectively analyzed. Portal vein anatomy was classified as type 2 in 20 patients, type 3 in 24 patients, and type 4 in eight patients. The PV reconstruction techniques utilized included back‐wall plasty (n = 21), back‐wall plasty with saphenous vein graft interposition (n = 6), saphenous vein graft interposition (n = 5), cryopreserved iliac vein Y‐graft interposition (n = 6), and quiltplasty (n = 3). There was no donor mortality. In a median follow‐up of 29 months, none of the recipients had vascular complications. Anomalous PV anatomy was associated with a high (54%) incidence of biliary variations; however, these variations did not result in increased biliary complication rate. Overall, the 1‐ and 3‐year patient survival rates of recipients were 91% and 81%, respectively. Vascular and biliary variations in RL grafts render LDLT technically more challenging. By employing appropriate reconstruction techniques, it is possible to successfully use RL grafts with PV variations without endangering recipient and donor safety.     

Simplified one‐orifice venoplasty for middle hepatic vein reconstruction in adult living donor liver transplantation using right lobe grafts

Middle hepatic vein (MHV) reconstruction is often essential to avoid hepatic congestion and serious graft dysfunction in living donor liver transplantation (LDLT). The aim of this report was to introduce evolution of our MHV reconstruction technique and excellent outcomes of simplified one‐orifice venoplasty. We compared clinical outcomes with two reconstruction techniques through retrospective review of 95 recipients who underwent LDLT using right lobe grafts at our institution from January 2008 to April 2012; group 1 received separate outflow reconstruction and group 2 received new one‐orifice technique. The early patency rates of MHV in group 2 were higher than those in group 1; 98.4% vs. 88.2% on postoperative day 7 (p = 0.054) and 96.7% vs. 82.4% on postoperative day 14, respectively (p = 0.023). Right hepatic vein (RHV) stenosis developed in three cases in group 1, but no RHV stenosis developed because we adopted one‐orifice technique (p = 0.043). The levels of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) in group 2 were significantly lower than those in group 1 during the early post‐transplant period. In conclusion, our simplified one‐orifice venoplasty technique could secure venous outflow and improve graft function during right lobe LDLT.     

Total en bloc spondylectomy for locally aggressive and primary malignant tumors of the lumbar spine

Purpose

To report outcomes after total en bloc spondylectomy (TES) for primary aggressive/malignant tumors of the lumbar spine.

Methods

We performed a retrospective review of 23 neurosurgical patients operated between 2004 and 2014. Outcomes included perioperative complication rates and reoperation rates for instrumentation failure. The relationship between patient/operative parameters and complication development/instrumentation failure was investigated.

Results

There were 15 men (65.2 %) and eight women (24.8 %), with a median of 47 years. The most common tumor was chordoma in 11 patients (47.8 %), followed by sarcoma in four (17.4 %), and giant cell tumor in three (13.0 %). All patients but one underwent a two-staged operation; median total estimated blood loss was 3200 mL and median total operative time was 18.5 h. Fifteen patients developed at least one perioperative complication (65.2 %), with the most common being wound infection and ileus (26.1 % each). There was one case of intraoperative iliac vein injury (4.4 %). Instrumentation failure occurred in 9 patients (39.1 %) at a median time of 23 months after index spondylectomy. Following logistic regression, there were no factors associated with complication development. On the other hand, postoperative radiation was significantly associated with instrumentation failure (OR 7.49; 95 % CI, 1.02–54.9). Local recurrence and 5-year survival was 8.7 and 84.4 %, respectively. Median follow-up time was 50 months.

Conclusions

Although favorable oncological outcomes after en bloc resection of spinal tumors may be achieved in terms of recurrence and survival, TES in the lumbar spine remains a challenging procedure. Future investigation into complication avoidance and reconstruction techniques is encouraged.

     

Microsurgical Hepatic Artery Reconstruction in Deceased Donor Liver Transplantation for Reduced Arterial Complications

Aberrant donor hepatic artery anatomy or hepatic artery injury during organ procurement or recipient preparation poses a surgical challenge during deceased donor liver transplantation. In this study, we aimed to investigate arterial reconstruction using microvascular techniques during deceased donor liver transplantation and suggest reasonable indications for the microsurgical approach in this setting. We retrospectively reviewed the outcomes of 470 deceased donor liver transplantations performed at our institution between July 2011 and December 2015. Of these, 128 recipients underwent microsurgical hepatic artery reconstruction and 342 underwent reconstruction with surgical loupes. Thirty-two patients (6.8%) experienced hepatic artery-related complications, including hepatic artery thrombosis (n = 8, 1.7%). In the propensity score-matched cohort, the surgical loupe group showed a higher complication rate (P = .782). On multivariate analysis, cold ischemia time (odds ratio, 0.995; 95% confidence interval, 0.9920-0.999; P = .009) and use of aortohepatic conduits (odds ratio, 5.254; 95% confidence interval, 1.878-14.699; P = .002) were independent predictors of arterial complications. The low incidence of hepatic artery complications in this study is likely attributable to the active application of microsurgical techniques. Active application of back-table microsurgical plasty and selective application of microsurgical techniques for main arterial reconstruction may help minimize operative difficulties and arterial complications.     

Robotic anatomic isolated complete caudate lobectomy: Left-side approach and techniques

BackgroundTo demonstrate the surgical procedures and techniques of the robotic anatomical isolated complete caudate lobectomy.MethodsA retrospective analysis was performed on the demographic, operative, postoperative outcomes of seven patients who underwent robotic anatomical isolated complete caudate lobectomy at our department from January 2018 to November 2019. Mobilization of the left lateral and Spiegel lobe, dissection of the short hepatic veins and liver parenchyma transection from the dorsal plane of middle and right hepatic vein were crucial procedures for the robotic left-side approach. Anatomic complete caudate lobectomy was defined as total removal of the caudate lobe, in which the dorsal middle and right hepatic vein, the inferior vena cava and its right side were fully exposed on the raw surface.ResultsAll patients successfully underwent the robotic anatomical isolated caudate lobectomy with a left-side approach without conversion to laparotomy, and without Clavien-Dindo Grade III or higher complications. The average tumor diameter was 65.00 ± 10.61 mm, the average operation time was 212.00 ± 74.53 min, the median bleeding loss was 100 mL, and the average postoperative hospital stay was 8.71 ± 4.89 d, respectively. There were four patients with primary hepatocellular carcinoma, one with tumor recurrence five months after surgery and three patients were free of recurrence. All patients survived at the last follow-up.ConclusionRobotic anatomical isolated complete caudate lobectomy with a left-sided approach is safe and feasible for selected patients.