乙酸灌注兔肝门静脉分支后兔肝组织超声改变的实验研究

观察乙酸灌注兔肝门静脉分支后兔肝组织的二维超声、彩色多普勒、脉 冲多普勒变化。选19只兔,分5组,剖腹后经门静脉右外支注入50％乙酸（按公斤体重）,行彩色多普勒和脉冲多普勒检测,发现灌注区门静脉无血流信号或有极少的血流信号,伴行的肝动脉血流速度明显降低甚至未能测到。认为经门静脉分支灌注乙酸可同时降低或阻断灌注区肝组织的门静脉和肝动脉血供。     

肝癌介入治疗的基本原理

1．经导管肝动脉栓塞术（TAE）：肝癌的血供主要来自肝动脉，因此阻断肝动脉可使肝癌血供减少90％以上，使肿瘤坏死，而对正常肝组织影响较少。但肝动脉阻断（结扎）后由于侧支循环建立较快，所以疗效短暂。而使用各种栓塞剂可以阻断肝动脉大部分分支，有效地延缓侧支循环的建立，疗效持久。     

复方莪术油微球肝动脉栓塞治疗大鼠移植性肝癌的机制

目的研究复方莪术油微球(CCAO-MS)肝动脉栓塞治疗大鼠移植性肝癌的机制。方法制备45只大鼠移植性肝癌模型,随机分为生理盐水组、空白微球组、复方莪术油微球组,每组15只。经肝动脉插管分别灌注0.2⁰.3 ml生理盐水、空白微球(B-MS)10 mg/kg、CCAO-MS10 mg/kg。末端脱氧核苷酸转移酶介导化DUTP缺口末端标技技术(TUNEL)法检测肝癌大鼠肝肿瘤细胞凋亡情况,免疫组织化学法检测肿瘤组织表达增殖核抗原(PCNA)和半胱氨酸天门氨酸蛋白酶(Caspase)-3的影响。结果 CCAO-MS经肝动脉栓塞给药可明显促进肝肿瘤细胞的凋亡,下调肿瘤组织PCNA的表达,上调肿瘤组织Caspase-3表达。结论 CCAO-Ms经肝动脉栓塞对大鼠移植性肝癌的治疗作用与下调PCNA的表达,上调Caspase-3的表达,从而抑制肿瘤细胞的增殖,促进肿瘤组织的凋亡有关。     

肝动脉栓塞化疗结扎与瘤内无水酒精注射治疗中晚期肝癌

目的我们对20例不能手术切除的中晚期肝癌施行肝动脉栓塞化疗结扎与瘤内无水酒精注射,方法简单疗效好.肝动脉结扎(HAL)对肝癌有一定姑息疗效,但HAL后肿瘤的侧支循环4d～14d便恢复到HAL前的血供,未死亡后残存的癌细胞重新分裂,生长更快致治疗失败,为避免HAL后肿瘤侧支循环短时间重新出现,我们用明胶海绵做栓塞剂,同栓塞时做抗癌药物的一次性灌注来提高疗效.肝动脉栓塞结扎主要使肿瘤发生中心性坏死,对肿瘤包膜或包膜外周围的癌浸润缺乏有效控制,酒精注入肿瘤中心与四周后使癌细胞及附近血管内皮等迅速脱水固定,蛋白变性凝固至瘤组织缺血,坏死纤维化,使癌组织、肿瘤被膜及补膜外的周围癌浸润发生凝固性坏死弥补了肝动脉栓塞结扎的不足,20例的疗效结果如下①肿瘤缩小1cm～4cm②生存期延长,为7mo～11mo,平均8.5mo远高于肝癌自然生存期<3mo的报道.③减轻了症状,患者均觉上腹部胀痛基本消失,食欲明显好转,体重增加3kg～6kg.④无1例有腹腔内出血,腹膜炎和肝功衰竭的并发症,对无法手术切除的中晚期肝癌本方法是简单可靠的有效治疗.     

多层螺旋计算机X线体层扫描肝脏灌注成像的临床应用初步研究

目的 探讨多层螺旋CT肝脏灌注成像技术在肝脏疾病诊断中的应用价值。方法 48例接受多层螺旋CT肝脏灌注成像检查,其中20例为无明显肝脏疾病的志愿者,17例肝硬化患者,11例肝癌患者。计算各组受检者的各项灌注指标并进行比较。结果 (1)肝硬化组与正常组相比,门静脉灌流量(HPP,ml·min~(-1)·ml~(-1))与门静脉灌流指数(PPI)明显减低(HPP:0.49±0.19与0.60±0.16,P=0.038;PPI:0.58±0.14与0.67±0.06,P=0.015),门静脉与肝动脉灌流比率(HPP/HAP)亦明显减低(1.63±0.87与2.12±0.65,P=0.04),肝动脉灌流指数升高(0.42±0.14与0.33±0.06,P=0.015),提示肝硬化时门静脉的灌流量减少,门静脉血流在肝脏血供中的比例减少,而动脉的灌流比重增加。(2)肝癌组的肝动脉灌流量明显高于正常组与肝硬化组(F=11.71,P<0.0001),而HPP明显下降(F=22.84,P<0.0001),HPP/HAP也明显减小(F=20.67,P<0.0001),说明肝癌主要由动脉供血,动脉、门静脉两部分对其供血的比例与正常肝和肝硬化相反。结论 多层螺旋CT肝脏灌注可分别评价肝脏动脉、门静脉的灌注情况,以灌注特点及测得的灌注指标反映肝脏病变的血流动力学改变,且此方法具有无创性和可重复性,在肝脏疾病的诊断、鉴别诊断等方面具有重要的临床实用价值。     

原发性肝癌患者肝动脉结扎加栓塞前后入肝血流量的变化

作者观察了41例原发性肝癌患者肝动脉结扎加栓塞前后的入肝血流量、肝功能和血中AFP浓度变化。结果:原发性肝癌患者的肝固有动脉和门静脉血流量均高于对照组;肝固有动脉结扎加栓塞后门静脉血流量明显增加,肝功能变化和AFP下降显著;一侧肝动脉结扎加栓塞后肝固有动脉血流量仅减少四分之一,门静脉血流量有所增加,对肝功能的影响不明显,AFP的下降也明显差于上组。提示了肝癌的血供特点和肝动脉阻断后经门静脉化疗的必要性。     

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…     

肝动脉栓塞治疗肝癌48例护理体会

临床证实，肝癌血供主要来自肝动脉，故选择性的减少或阻断肝动脉血供可使肝癌组织缺血、坏死、癌肿缩小。2001年8月～2002年12月，我院采用肝动脉栓塞术治疗肝癌患者48例，效果满意。现将护理体会报告如下。     

彩色多普勒超声检测肝癌导致的肝动脉血流动力学变化

目的为了了解供应肝癌的肝动脉分支与非供应肝癌肝动脉分支的血流动力学差异，我们对两种动脉的多普勒速度频谱进行了比较．方法我们用脉冲多普勒超声对49例肝脏一叶单发性肝癌及38例慢性肝病患者进行了检查，分别测量左、右肝动脉分支多普勒速度频谱角度矫正的峰值血流速度（PS）及搏动指数（PI）．结果在慢性肝病组，左、右肝动脉分支峰值血流速度及搏动指数无显著差异，而3cm以上肝癌，供癌肝动脉分支与非供癌肝动脉分支相比，峰值血流速度明显升高，搏动指数明显降低，其血流动力学变化程度与肝癌大小及门静脉内有无癌栓有关．结论供应肝癌的肝动脉分支较非供应肝癌的肝动脉分支阻力降低     

动脉化疗栓塞术治疗126例原发性肝细胞肝癌的疗效观察

目的探讨原发性肝细胞肝癌(HCC)的非肝动脉供血规律及介入治疗技术。方法对解放军第305医院2000—2006年收集的126例HCC患者,常规行腹腔动脉、肝总动脉、肠系膜上动脉、胃左动脉和膈动脉造影,并行超选择性插管,同时进行肝动脉、非肝动脉双动脉化疗栓塞术。结果126例HCC患者中,111例为肝脏本身固有的寄生性供血,其余15例由肝动脉闭塞引起侧支动脉供血。非肝动脉供血与肝脏肿瘤的部位、大小密切相关。用肝动脉导管或Cobra导管配合SP导管行非肝动脉超选择性插管成功率达92%。随访74例,1年及2年存活率分别为61%和25%。结论在HCC介入治疗中,除了肝动脉以外,还要积极寻找非肝动脉供血支。对具有非肝动脉供血的HCC采取双动脉内化疗栓塞是治疗成功的关键。在介入治疗操作过程中,要尽量预防肝动脉闭塞,减少侧支供血形成。     

Portal vein embolization induces compensatory hypertrophy of remnant liver

AIM:To evaluate the effectiveness and safety ofdifferent portal vein branch embolization agents ininducing compensatory hypertrophy of the remnantliver and to offer a theoretic basis for clinical portal veinbranch embolization.METHODS:Forty-one adult dogs were included in theexperiment and divided into four groups.Five dogsserved as a control group,12 as a gelfoam group,12as a coil-gelfoam group and 12 as an absolute ethanolgroup.Left portal vein embolization was performed ineach group.The results from the embolization in eachgroup using different embolic agents were compared.The safety of portal vein embolization(PVE)wasevaluated by liver function test,computed tomography(CT)and digital subtraction angiography(DSA)ofliver and portal veins.Statistical test of variance wasperformed to analyze the results.RESULTS:Gelfoam used for PVE was inefficient inrecanalization of portal vein branch 4 wk after theprocedure.The liver volume in groups of coil-gelfoamand absolute ethanol increased 25.1% and 33.18%,respectively.There was no evidence of recanalization ofembolized portal vein,hepatic dysfunction,and portalhypertension in coil-gelfoam group and absolute ethanolgroup.CONCOUSION:Portal vein branch embolization usingabsolute ethanol and coil-gelfoam could induce atrophyof the embolized lobes and compensatory hypertrophy ofthe remnant liver.Gelfoam is an inefficient agent.     

Measurement of portal shunting in dogs

A new method for measuring the quantity of portal blood bypassing the liver (shunted) has been developed and tested in the dog. Shunts were mimicked by the simultaneous infusion of glycocholic acid into a small peripheral portal venule and a peripheral vein. The total infused amount was kept constant, but the ratio at the two infusion sites varied. Determination of the extraction efficiency of the liver by simultaneously measuring the hepatic vein and arterial blood for systemically infused [14C]glycocholic acid permitted the calculation of shunted blood from information provided by the concentration of glycocholic acid in the hepatic vein, artery, and portal vein blood. This method was tested for various proportion of shunting from none to complete. The total hepatic flow was determined with single injection of indocyanine green and the individual arterial and portal vein flows determined with flowmeters. The input ratios of shunting related quite closely to that calculated from the flowmeters or the hepatic extraction ratio.     

A case of hepatic artery embolization and partial arterialization of the portal vein for intraperitoneal, hemorrhage after a pancreaticoduodenectomy

We report a case of hepatic artery embolization and partial portal vein arterialization for the treatment of a delayed massive hemorrhage after a pancreaticoduodenectomy. A 70-year-old male underwent a pancreaticoduodenectomy for the treatment of lower bile duct cancer. A slight discharge of pancreatic juice was recognized early during the postoperative period. A delayed massive hemorrhage occurred on postoperative day 34, resulting in hypotensive shock. Angiography and computed tomography examinations revealed bleeding from a pseudoaneurysm at the stump of the gastroduodenal artery and portal vein compression by the hematoma. Embolization of the stump of the gastroduodenal artery resulted in the total occlusion of the hepatic artery. We performed a partial portal vein arterialization via side-to-side anastomosis of a branch of the ileal artery and vein. The partial portal oxygen pressure increased from 70 mmHg to 90 mmHg. A liver abscess was recognized two weeks after the arterialization, but was successfully treated by percutaneous transhepatic drainage. The patient was discharged from hospital in good condition on postoperative day 69. Whether the partial portal vein arterialization was effective is unclear, but partial portal vein arterialization should be considered as an option in cases of total hepatic artery occlusion with impairment of portal blood flow.     

Experimental studies of new embolizing material for portal vein embolization

BACKGROUND/AIMS: Preoperative portal vein embolization induces hypertrophy of the future remnant liver and atrophy of the liver to be resected. This procedure has been used recently to avoid hepatic failure in extensive hepatic resection, but an adequate embolizing material has not been developed. This experimental study investigated the embolization effect of a newly devised embolizing material in dogs. METHODOLOGY: The left branch of the portal vein was embolized with an emulsion of polidocanol and gelatin sponge. We studied the changes in liver weight and biochemical data up to 8 weeks after embolization. Pathological examination of the embolized portal vein and radiological study of the embolizing effect were performed. RESULTS: Complete obstruction of the portal vein was maintained until 8 weeks after embolization. Sufficient hypertrophy of the non-embolized liver and atrophy of the embolized liver were obtained during this examination. No serious complication was observed. CONCLUSIONS: The mixture of polidocanol and gelatin sponge seems to ensure perfect portal embolization without recanalization. This embolizing material is suitable for portal embolization.     

Changes in distribution spaces and cell permeability caused by ATP in the rat liver

AIMS/BACKGROUND: Cellular and extracellular volume changes caused by ATP were investigated in the liver as well as the possible formation of diffusion barriers, which could be responsible for some of its metabolic effects. METHODS: The experimental system was the bivascularly perfused rat liver. [(14)C]Sucrose and [(3)H]water were simultaneously injected into either the portal vein or the hepatic artery. Mean transit times, distribution spaces, variances and linear superimpositions were calculated. RESULTS: In the portal system, ATP reduced the transit time in the great vessels, had little or no effect on sinusoidal and cellular spaces, but impaired the flow-limited distribution of both [(14)C]sucrose and [(3)H]water. In the arterial bed ATP infused into either the portal vein or the hepatic artery produced vasodilation and increased the aqueous extra-sucrose space. These effects were inhibited by Nomega-nitro-L-arginine methyl ester infused into the hepatic artery. CONCLUSIONS: Sucrose and extra-sucrose space changes caused in the arterial bed by portally infused ATP are most probably analogous to the transhepatic vasodilation effect already described for the rabbit liver. Impairment of flow-limited distribution of tracers in the sinusoidal bed indicates that ATP induces the formation of permeability barriers, which could be responsible for some of its metabolic effects.     

Partial portal arterialization in complete en bloc resection of the hepatoduodenal ligament and left lobe of the liver for hepatic hilar cancer

The complete resection of the hepatoduodenal ligament is associated with enormous surgical invasion, which frequently results in postoperative hepatic dysfunction secondary to interruption of the reconstructed artery. We administered partial portal arterialization by anastomosis of the gastroduodenal artery to the portal vein without reconstruction of the hepatic artery in the complete resection of the hepatoduodenal ligament with resection of the left lobe of the liver in a patient with hilar bile duct carcinoma. After division of the proper hepatic artery, the gastroduodenal artery was anastomosed in an end-to-side fashion to the trunk of the portal vein. After division of the portal vein, to prevent ischemia, a single catheter bypass was inserted into a branch of the mesenteric vein and the another side of the catheter was attached to the hepatic end, of the portal vein. The portal vein was reconstructed with the superficial femoral vein graft. The blood supply to the remaining liver was interrupted for only 15 min during which the proximal end of the superficial femoral graft was anastomosed to the hepatic end of the portal vein. Postoperative liver function has been stabilized and his postoperative course is uneventful without portal hypertension. One month postoperatively, angiography through the vessels nourishing the raised jejunum visualized intrahepatic arteries.     

Anomalous intrahepatic portal system in a patient with hilar bile duct cancer

We report a case of anomaly of the intrahepatic portal system in a 65-year-old man with hilar bile duct cancer. Preoperatively, percutaneous transhepatic portography demonstrated that there was a right posterior portal vein arising from the main portal vein. In addition, a large portal branch originated from the left portal vein and coursed toward the right hepatic lobe. Following portal embolization of the right posterior branch, the patient underwent an extended right hepatectomy with a caudate lobectomy. Intraoperatively, to the left at the porta hepatis and then it first gave off the right anterior portal vein originated from the left portal vein and coursed toward the right hepatic lobe horizontally behind the gallbladder and then separated into superior and inferior segmental branches to supply the right anterior segment of the liver. The ramification of some major branches without malposition of the gallbladder or round ligament was the important clinical feature of this anomaly.     

Technical dilemma in living-donor or split-liver transplant

In partial liver transplantation for adults criteria for the extent of reconstruction of middle hepatic vein tributaries have not been clarified. After hepatic venous and portal anastomoses in living-donor liver transplantation using left liver graft without middle hepatic vein, color Doppler ultrasonography was applied to check venous and portal blood flow. Color Doppler ultrasonography demonstrated absent hepatic venous flow and reversed portal venous flow in the congested area of the left paramedian sector which had been drained by the divided branch of the middle hepatic vein. The area was darkly discolored before arterial reperfusion and under clamping of the artery. Reconstruction of the venous branch was added after arterial anastomosis. Color Doppler ultrasonography revealed restored normal venous outflow and portal inflow after venous reconstruction. Postoperative course of the recipient was uneventful with rapid recovery of liver function. We propose that middle hepatic vein tributaries should be reconstructed if color Doppler ultrasonography demonstrates absent venous flow and reversed portal flow, and if the liver volume excluding the discolored area under occlusion of the hepatic artery is estimated to be insufficient for postoperative metabolic demand.     

Evaluation of liver function for the application of preoperative portal vein embolization on major hepatic resection

BACKGROUND/AIMS: Although preoperative portal vein embolization has been employed for hepatectomy to increase the safety of the surgery, patient selection criteria for hepatectomy following portal vein embolization have still not been established. In this study liver functional tests before and after portal vein embolization were evaluated in order to determine their influence on the outcome of subsequent hepatectomy and the prognostic potential of this approach. METHODOLOGY: Forty-five patients, who had undergone major hepatic resection after embolizing the right portal branch, were divided into the following 3 groups according to their postoperative course: complication(-), complication(+), and liver failure group. Clinical, analytical, and hemodynamic parameters obtained before and after portal vein embolization were compared between the three groups. RESULTS: Significant differences were found between the complication(-) group and the liver failure group for 8 factors, and statistically significant cut-off points distinguishing the liver failure group could be determined. Based upon values measured before PVE these were: 1) portal pressure > 16 cmH2O; 2) pre-PVE serum cholinesterase < 160 U/L; 3) pre-PVE serum hyaluronate > 130 ng/mL. Based on values measured after PVE they were: 1) a hypertrophic ratio of the left lobe < 1.21; 2) post-PVE ICGR15 (%) > 16%; 3) a portal pressure measured immediately after PVE > 25 cmH2O; 4) post-PVE serum cholinesterase < 160 U/L; 5) post-PVE serum hyaluronate > 160 ng/mL. Discriminant function analysis in a stepwise manner showed that the portal pressure and serum levels of hyaluronate measured before and after portal vein embolization were the most useful in prediction of the outcome of the following hepatectomy. CONCLUSIONS: Patients whose data match the above criteria before portal vein embolization should be excluded as candidates for major hepatic resection with portal vein embolization. Even after portal vein embolization in patients whose data match post-portal vein embolization criteria major hepatic resection may have to be abandoned, or the extent of the hepatic resection reconsidered.