原发性肝癌规则性肝切除和非规则性肝切除的手术适应证分析

目的分析原发性肝癌规则性肝切除和非规则性肝切除手术适应证,为临床手术提供参考。方法回顾性分析我院收治原发性肝癌患者336例,患者均采取肝切除手术治疗,整理患者临床资料。结果规则性肝切除患者切除部位多是左外叶、左半叶,非规则性肝切除患者病变部位在多个位置,肝段切除较多,数目远远小于实际数目。规则性肝切除对患者肝功能要求相对严谨,非规则性肝切除缩短手术时间,术后利于恢复,并发症较少,切除3段数目大于3段者比例较低,术后非规则性肝切除患者肝功能指标显著Alb(32.16±4.87)g/L、ALT(69.86±22.35)IU/L显著低于规则性肝切除患者Alb(35.26±4.53)g/L、ALT(83.65±23.24)IU/L,P0.05,非规则性肝切除患者TBil(25.93±4.26)μmol/L、DBil(13.58±3.26)μmol/L显著高于规则性肝切除患者TBil(20.18±4.38)μmol/L、DBil(9.29±2.07)μmol/L,P0.05。结论肝癌小于5 cm患者采用非规则性肝切除更加有利于患者术后恢复,保留更多功能性肝实质。     

原发性肝癌治疗方法的评价——肝切除术治疗原发性肝癌

在我国，肝切除术治疗原发性肝癌已有近50年的历史。尤其随着手术技术的不断改进，手术切除肝癌的疗效也在不断提高。近些年来，在原发性肝癌的治疗中，逐步开始采用经肝动脉置管栓塞化疗(TACE)、射频消融术和生物治疗等综合措施。但上述疗法均不能完全替代肝切除术。尤其随着手术技术的不断改进，手术切除肝癌的疗效也在不断提高。     

原发性肝癌切除术前后的肝动脉化疗栓塞

我国原发性肝癌的治疗已取得显著的进展，肝癌切除术是根治性治疗的最有效手段，也是肝癌患者获得长期生存的最主要途径。然而切除率低和复发率高仍是制约肝癌手术治疗的关键。近年来，以外科治疗为中心与各种非手术治疗方法优化组合的综合治疗日益发展，成为进一步提高肝癌疗效的新途径。肝动脉化疗栓塞（ＴＡＣＥ）在肝癌的综合治疗中具有举足轻重的作用。 人体肝脏接受肝动脉和门静脉双重血供，原发性肝癌的血供９０％以上来自肝动脉。肝动脉阻断后，肝癌血流减少９０％～９２％，肿瘤发生严重缺血坏死而缩小，但正常肝组织血流量仅减少…     

原发性肝癌治疗方法的评价——肝切除术前后肝动脉置管化疗栓塞治疗原发性肝癌

原发性肝癌手术前后辅助治疗中的一个重要手段就是经肝动脉置管栓塞化疗(TACE)。但对于能够手术切除的原发性肝癌，是否需要行TACE治疗和何时行TACE治疗仍存在着争论。其焦点在于，TACE治疗是否能提高手术切除率，减少术后复发，是否能改善患者的预后，选用什么样的TACE治疗方案才能充分发挥其治疗作用而使其副作用降到最低。     

规则性肝部分切除术治疗老年肝内胆管结石的疗效

目的探讨规则性肝部分切除术治疗老年肝内胆管结石的临床疗效。方法肝内胆管结石老年患者92例,随机分成对照组和观察组各46例。对照组接受非规则性肝部切除术,观察组接受规则性肝部分切除术。结果观察组术中失血量低于对照组(P0.01)。观察组优良率(95.65%)高于对照组(76.09%)(P0.01)。观察组术后的并发症率、复发率及结石残留率均低于对照组(P0.05)。结论规则性肝部分切除术在老年肝内胆管结石的治疗中具有较高的应用价值,创伤小、疗效确切、并发症和复发率低,是治疗老年肝内胆管结石的一种十分有效的外科术式。     

肝动脉栓塞化疗联合肝叶切除术治疗原发性肝癌患者临床疗效观察

目的 观察肝动脉栓塞化疗（TACE）联合肿瘤切除手术治疗原发性肝癌（PLC）患者的临床疗效。方法 2015年10月~2016年10月我院诊治的PLC患者95例,其中47例接受TACE治疗,48例在TACE治疗后1月行手术切除肿瘤治疗,观察并对比两组患者病灶根除和生存率情况。结果 联合组术后病灶清除率、术后1 a生存率、2 a生存率分别为100.0%、83.3%和68.8%,均显著高于TACE组的53.2%、61.7%和46.8%（P<0.05）,术后复发率为16.7%,明显低于对照组的51.1%（P<0.05）;治疗后联合组肝功能指标改善情况显著优于TACE组（P<0.05）;TACE组患者术后出现肺栓塞5例,肿瘤破裂出血2例,肺部感染3例,而联合组出现肺栓塞2例,肝断面胆瘘1例,肿瘤破裂出血1例,肺部感染1例（P<0.05）。结论 在TACE术后再行手术切除肿瘤治疗PLC患者具有一定的临床应用价值。     

不同入肝血流阻断技术下腹腔镜肝切除术治疗原发性肝癌患者近期效果研究

目的 探讨不同入肝血流阻断技术腹腔镜肝切除术(LH)治疗原发性肝癌(PLC)患者的效果。方法 2021年2月～2022年11月我院收治的PLC患者132例,均行LH术治疗。术中,69例观察组采用区域性入肝血流阻断,对照组63例采用间歇性全入肝血流阻断。常规测量心率(HR)和平均动脉压(MAP),使用超声检测门静脉血流速度(PVV)。结果 观察组手术输血率、手术时间和住院日分别为15.9%、(240.3±42.9)min和(14.7±2.3)d,与对照组【分别为19.1%、(231.7±39.5)min和(15.0±2.9)d】比,无统计学差异(P>0.05),而观察组肝血流阻断时间为(0.0±0.0)min,显著短于对照组【(26.8±7.1)min,P<0.05】,术中出血量为(301.2±52.5)mL,显著少于对照组【(369.8±59.4)mL,P<0.05】;在术后7 d,观察组HR、MAP和PVV分别为(79.1±7.2)次/min、(80.7±3.6)mmHg和(21.3±2.0)cm/s,与对照组【分别为(78.9±6.8)次/min、(81.9±4....     

使用大功率高频电刀行肝叶切除术治疗原发性肝癌患者效果研究

目的 比较使用大功率高频电刀与物理钳夹联合超声刀行肝叶切除治疗原发性肝癌（PLC）患者的手术效果。方法 2013年8月~2016年8月在我院接受肝叶切除治疗的139例PLC患者,观察组（n=72）和对照组（n=67）,在72例观察组患者使用大功率高频电刀,在67例对照组使用物理钳夹联合超声刀行肝叶切除,比较两组手术效果。结果 观察组肝门阻断时间、出血量、手术时间分别为（11.5±4.8）min、（317.9±68.2）ml、（161.3±41.5）min,显著低于对照组【分别为（19.6±5.7）min、（435.9±51.6）ml、（186.7±40.4）min,P<0.05】;术后1 w,观察组血清ALT和AST水平分别为（237.8±85.6）U/L和（133.4±47.4）U/L,显著低于对照组【分别为（311±102.5）U/L和（186.8±55.9）U/L,P<0.05】;术后观察组患者胆漏发生率为2.8%,显著低于对照组的10.4%（P<0.05）。结论 使用大功率高频电刀用于PLC患者肝叶切除术具有手术时间短、出血量少的特点,并发症发生率更低,安全性明显提高。     

解剖性肝叶切除术治疗原发性肝癌患者对肝功能及预后的影响

目的 探讨解剖性肝叶切除术（AH）对原发性肝癌（PLC）患者肝功能及预后的影响。方法 2012年3月~2013年2月我院收治的PLC患者86例,其中43例接受AH术,另43例接受非解剖性肝叶切除术（NAH）术。比较两组手术相关指标、肝功能变化、并发症及预后情况。结果 观察组手术时间为（279.72±85.68） min,明显长于对照组的（184.41±69.43） min,术中出血量为（543.25±95.65） ml,输血量为（325.16±73.04） ml,明显少于对照组的（721.72±112.45） ml和（596.78±92.17） ml,住院时间为（16.58±2.04） d,明显短于对照组的（18.12±2.12） d（P<0.05）;术后1周,观察组血清丙氨酸氨基转氨酶（ALT）为（368.12±45.32） IU/L,天冬氨酸氨基转移酶（AST ）为（330.25±8.50）IU/L,总胆红素（TBIL）为（29.58±4.02） μmol/L,均明显低于对照组的（440.36±62.54） IU/L、（445.32±10.05） IU/L和（35.12±4.36） μmol/L（P<0.05）;观察组胸腔积液等并发症发生率为27.91%,明显低于对照组的48.84% （P<0.05）;随访10~36个月,观察组肝内肿瘤复发率为18.60%,远处转移率为16.28%,均明显低于对照组的39.53%和34.88%（P<0.05）,两组病死率比较差异无统计学意义（P>0.05）。结论 解剖性肝叶切除术治疗PLC患者有助于减少术中出血,减轻围术期肝功能损害,降低术后并发症及肿瘤复发率。     

Propensity score analysis demonstrated the prognostic advantage of anatomical liver resection in hepatocellular carcinoma

AIM:To compare the prognoses of hepatocellular carcinoma(HCC)patients that underwent anatomic liver resection(AR)or non-anatomic liver resection(NAR)using propensity score-matched populations.METHODS:Between January 2002 and December2010,268 consecutive HCC patients,including 110 and158 patients that underwent AR and NAR,respectively,were retrospectively enrolled in this study.Forty-four patients from each group were selected and matched using logistic multivariate analysis followed by propensity score analysis.RESULTS:In the whole analysis set,the histological background of the liver,liver function,and tumor marker levels differed significantly among the groups.Although the overall survival(OS)and recurrence-free survival rates of the two groups did not differ significantly in the whole analysis set,the OS of the AR group was significantly longer than that of the NAR group after propensity matching(76.2±6.3 mo vs 58.9±6.3mo;P=0.0039).Although AR(HR=0.456,P=0.039)was found to be a prognostic factor in the univariate analysis,only vascular invasion(HR=0.228,P=0.002)and the hepatocyte growth factor level(HR=52.366,P=0.035)were subsequently found to be independent prognostic factors.CONCLUSION:AR conveys a survival advantage over NAR in specific subpopulations of HCC patients with tumors of less than 5 cm in diameter,single tumor,and good liver function.     

Comparative study and systematic review of laparoscopic liver resection for hepatocellular carcinoma

AIM: To compare the surgical outcomes between laparoscopic liver resection (LLR) and open liver resection (OLR) as a curative treatment in patients with hepatocellular carcinoma (HCC).METHODS: A PubMed database search was performed systematically to identify comparative studies of LLR vs OLR for HCC from 2000 to 2014. An extensive text word search was conducted, using combinations of search headings such as “laparoscopy”, “hepatectomy”, and “hepatocellular carcinoma”. A comparative study was also performed in our institution where we analysed surgical outcomes of 152 patients who underwent liver resection between January 2005 to December 2012, of which 42 underwent laparoscopic or hand-assisted laparoscopic resection and 110 underwent open resection.RESULTS: Analysis of our own series and a review of 17 high-quality studies showed that LLR was superior to OLR in terms of short-term outcomes, as patients in the laparoscopic arm were found to have less intraoperative blood loss, less blood transfusions, and a shorter length of hospital stay. In our own series, both LLR and OLR groups were found to have similar overall survival (OS) rates, but disease-free survival (DFS) rates were higher in the laparoscopic arm.CONCLUSION: LLR is associated with better short-term outcomes compared to OLR as a curative treatment for HCC. Long-term oncologic outcomes with regards to OS and DFS rates were found to be comparable in both groups. LLR is hence a safe and viable option for curative resection of HCC.     

Meta-analysis of laparoscopic vs open liver resection for hepatocellular carcinoma

AIM: To conduct a meta-analysis to determine the safety and efficacy of laparoscopic liver resection (LLR) and open liver resection (OLR) for hepatocellular carcinoma (HCC).METHODS: PubMed (Medline), EMBASE and Science Citation Index Expanded and Cochrane Central Register of Controlled Trials in the Cochrane Library were searched systematically to identify relevant comparative studies reporting outcomes for both LLR and OLR for HCC between January 1992 and February 2012. Two authors independently assessed the trials for inclusion and extracted the data. Meta-analysis was performed using Review Manager Version 5.0 software (The Cochrane Collaboration, Oxford, United Kingdom). Pooled odds ratios (OR) or weighted mean differences (WMD) with 95%CI were calculated using either fixed effects (Mantel-Haenszel method) or random effects models (DerSimonian and Laird method). Evaluated endpoints were operative outcomes (operation time, intraoperative blood loss, blood transfusion requirement), postoperative outcomes (liver failure, cirrhotic decompensation/ascites, bile leakage, postoperative bleeding, pulmonary complications, intraabdominal abscess, mortality, hospital stay and oncologic outcomes (positive resection margins and tumor recurrence).RESULTS: Fifteen eligible non-randomized studies were identified, out of which, 9 high-quality studies involving 550 patients were included, with 234 patients in the LLR group and 316 patients in the OLR group. LLR was associated with significantly lower intraoperative blood loss, based on six studies with 333 patients [WMD: -129.48 mL; 95%CI: -224.76-(-34.21) mL; P = 0.008]. Seven studies involving 416 patients were included to assess blood transfusion requirement between the two groups. The LLR group had lower blood transfusion requirement (OR: 0.49; 95%CI: 0.26-0.91; P = 0.02). While analyzing hospital stay, six studies with 333 patients were included. Patients in the LLR group were found to have shorter hospital stay [WMD: -3.19 d; 95%CI: -4.09-(-2.28) d; P < 0.00001] than their OLR counterpart. Seven studies including 416 patients were pooled together to estimate the odds of developing postoperative ascites in the patient groups. The LLR group appeared to have a lower incidence of postoperative ascites (OR: 0.32; 95%CI: 0.16-0.61; P = 0.0006) as compared with OLR patients. Similarly, fewer patients had liver failure in the LLR group than in the OLR group (OR: 0.15; 95%CI: 0.02-0.95; P = 0.04). However, no significant differences were found between the two approaches with regards to operation time [WMD: 4.69 min; 95%CI: -22.62-32 min; P = 0.74], bile leakage (OR: 0.55; 95%CI: 0.10-3.12; P = 0.50), postoperative bleeding (OR: 0.54; 95%CI: 0.20-1.45; P = 0.22), pulmonary complications (OR: 0.43; 95%CI: 0.18-1.04; P = 0.06), intra-abdominal abscesses (OR: 0.21; 95%CI: 0.01-4.53; P = 0.32), mortality (OR: 0.46; 95%CI: 0.14-1.51; P = 0.20), presence of positive resection margins (OR: 0.59; 95%CI: 0.21-1.62; P = 0.31) and tumor recurrence (OR: 0.95; 95%CI: 0.62-1.46; P = 0.81).CONCLUSION: LLR appears to be a safe and feasible option for resection of HCC in selected patients based on current evidence. However, further appropriately designed randomized controlled trials should be undertaken to ascertain these findings.     

Role of surgical resection for hepatocellular carcinoma based on Japanese clinical guidelines for hepatocellular carcinoma

In the Algorithm for Diagnosis and Treatment in the Japanese Evidence-Based Clinical Practice Guidelines for Hepatocellular Carcinoma, the treatment strategy is determined by three major factors: liver function and the number and size of tumors. The algorithm is quite simple, consisting of fewer components than the Barcelona-Clinic Liver Cancer staging system. In this article, we describe the roles of the treatment algorithmin hepatectomy and perioperative management of hepatocellular carcinoma.     

Laparoscopic liver resection facilitates salvage liver transplantation for hepatocellular carcinoma

Background/Purpose

In patients with hepatocellular carcinoma (HCC), a previous liver resection (LR) may compromise subsequent liver transplantation (LT) by creating adhesions and increasing surgical difficulty. Initial laparoscopic LR (LLR) may reduce such technical consequences, but its effect on subsequent LT has not been reported. We report the operative results of LT after laparoscopic or open liver resection (OLR).

Methods

Twenty-four LT were performed, 12 following prior LLR and 12 following prior OLR. The LT was performed using preservation of the inferior vein cava. Indication for the LT was recurrent HCC in 19 cases (salvage LT), while five patients were listed for LT and underwent resection as a neoadjuvant procedure (bridge resection).

Results

In the LLR group, absence of adhesions was associated with straightforward access to the liver in all cases. In the OLR group, 11 patients required long and hemorrhagic dissection. Median durations of the hepatectomy phase and whole LT were 2.5 and 6.2 h, and 4.5 and 8.3 h in the LLR and OLR groups, respectively (P < 0.05). Median blood loss was 1200 ml and 2300 ml in the LLR and OLR groups, respectively (P < 0.05). Median transfusions of hepatectomy phase and whole LT were 0 and 3 U, and 2 and 6 U, respectively (P < 0.05). There were no postoperative deaths.

Conclusions

In our study, LLR facilitated the LT procedure as compared with OLR in terms of reduced operative time, blood loss and transfusion requirements. We conclude that LLR should be preferred over OLR when feasible in potential transplant candidates.     

Evaluating the current surgical strategies for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the second leading cause of cancer-related death worldwide. Despite careful surveillance programs and the development of antiviral therapy for hepatitis virus infection, the occurrence rate of HCC remains high. Liver resection and liver transplantation are mainstay curative treatments. Most patients with HCC have impaired liver function, and surgical treatment is always accompanied by the risk of decompensation of the remnant liver, especially when the volume of the remnant liver is too small and the liver function too low to meet metabolic demands. The mortality of liver resection has dramatically decreased over the last three decades from 20% to less than 5% due to the accumulation of knowledge of liver anatomy, perioperative management and preoperative assessment of liver function. Here we provide an overview of the multidisciplinary treatments and current standard treatment strategies for HCC, to explore the possibility of expanding surgical treatments beyond the current standards.     

Development of a nomogram to predict outcome after liver resection for hepatocellular carcinoma in Child-Pugh B cirrhosis

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Repeated liver resection for recurrent hepatocellular carcinoma

Background and Aim: Tumor recurrence after liver resection occurs in the majority of patients with hepatocellular carcinoma (HCC). This study was conducted to clarify the safety and effectiveness of repeated liver resection as a curative option for intrahepatic HCC recurrence. Methods: Between July 1990 and January 2009, 483 patients underwent 514 curative hepatic resections for HCC in our institution. Among this collective, 27 patients underwent 31 repeated resections due to recurrent HCC (27 s resections, three third resections and one forth resection). The outcome of these patients was retrospectively reviewed using a prospective database. Results: Perioperative morbidity and mortality was 11% (three of 27) and 0%. Six patients showed multiple liver lesions, 23 underwent minor liver resections (fewer than three segments) and five patients underwent major resections (three or more segments). The majority of the patients showed no signs of chronic liver disease (16 of 27). The median tumor free margin was 1.5 mm (range: 0 to 20 mm). The median tumor diameter was 40 mm (range: 10 to 165 mm). Tumor dedifferentiations at time of tumor recurrence were not observed. The 1‐, 3‐ and 5‐year overall survival rates after second liver resection were 96%, 70% and 42%. Conclusions: Repeated liver resection is a valid and safe curative therapy option for recurrent HCC and results in significant prolongation of survival in comparison to interventional treatment strategies in selected patients. However, due to impaired liver function, multifocal intrahepatic or extrahepatic recurrence repeated resection is only feasible in a minority of patients.