巨大肝癌的外科治疗分析（附86例报告）

目的：探讨外科治疗巨大肝癌的可行性及其方法。方法：回顾性分析86例巨大肝癌的临床资料,并对外科治疗中遇到的主要困难和相应的对策进行分析总结。结果：86例肝癌患者中合并乙肝肝硬化76例,丙肝肝硬化2例。合并门静脉、肝下腔静脉（IVC）癌栓分别为10例和5例。86例中行Ⅰ期和Ⅱ期肝切除术分别为60例和26例;其中规则性右半肝和左半肝切除术分别为9例和8例、联合肝段切除术69例。术前门静脉栓塞（PVE）6例;全肝、患侧半肝、第一肝门、无血流阻断切肝术分别为10例、例、606例、例。术中行门静脉和IVC癌栓取出术分别为10例和5例。86例中治愈81例（占94.2%）;围手术10期死亡5例（占5.8%）。术后1年生存率达77.9%（67/86）。结论：巨大肝癌的手术治疗是安全可行的。术前充分评估,术中仔细探查以及手术者的技术水平起关键作用。     

如何做好肝切除术

近 1 0余年来 ,肝癌手术切除技术有较大提高。难切部位肝癌一期切除报道日益增多 ,肝门部肝癌切除和单独尾叶切除也不再是手术“禁区”;对侵及下腔静脉及肝静脉肝癌 ,也有用体外静脉转流离体或半离体状态下冷却灌注切除肿瘤和受累血管 ;对合并门静脉癌栓积极的手术治疗 ,如切开取栓术、气囊导管取栓术、门静脉吻合搭桥术、门静脉切除吻合术等 ;对合并下腔静脉癌栓的肝癌在切除肿瘤同时有人采用体外静脉转流技术切开下腔静脉取癌栓 ;对肝癌合并胆管癌栓或肿瘤压迫所致梗阻性黄疸 ,亦可考虑作肝癌切除和手术取癌栓 ;对肝癌合并门静脉高压、食…     

16 肝细胞癌合并脉管系统癌栓的外科治疗

目的:探讨肝细胞癌（HCC）合并脉管系统癌栓的外科治疗效果。方法:回顾性分析1993年1月—2002年1月采用肝切除和癌栓取出术治疗HCC合并脉管系统癌栓68例的临床资料，其中门静脉癌栓63例，肝左静脉癌栓1例，肝中静脉癌栓合并门静脉左支癌栓1例，肝右静脉、下腔静脉合并门静脉右支癌栓1例，下腔静脉癌栓2例。HCC合并门静脉癌栓患者中6例术后行门静脉化疗。结果:6例术后3个月内死于肝肾功能衰竭， HCC合并脉管系统癌栓患者术后1，3，5年生存率分别为41.7%，20.8%，4.1%。结论:肝切除并癌栓取出术是HCC合并脉管系统癌栓有效的治疗方法，术后辅助治疗能提高治疗的效果。     

巨大肝癌的外科治疗：附146例报告

目的　探讨巨大肝癌外科治疗的效果。方法　回顾性分析近 11年间收治的 14 6例原发性巨大肝癌的外科治疗情况。 14 6例均经手术治疗 ,其中行不规则肝切除 99例 ,半肝切除 2 8例 ,右三叶切除 4例 ,包括术前行TACE后获得二期切除 19例 ;6例同时行门静脉切开取栓术。另 15例仅行活检 DDS ,术中行DDS治疗者 10 5例。结果　手术并发症发生率 10 .3 % ,术后 1个月内病死率1.4% ,术后 1,3 ,5年和 10年的生存率分别为 5 6.6% ,3 0 .2 % ,14 .4%和 2 .1%。结论　巨大肝癌仍以手术切除为主 ,疗效满意。结合TACE、门静脉取栓和DDS能提高患者的远期生存率。     

原发性肝癌合并胆管癌栓的诊断和外科治疗：附16例报告

目的：探讨原发性肝癌合并胆管癌栓的诊断、外科治疗及疗效。
方法：回顾性分析河南省肿瘤医院2006年6月—2008年12月期间收治16例原发性肝癌合并胆管癌栓患者的临床资料。
结果：16例患者均接受外科手术治疗,其中左半肝切除+胆总管切开取栓2例,右半肝切除+胆总管取栓3例,肝段切除+胆总管取栓4例,左半肝及肝门部胆管切除+胆肠吻合1例,肝中叶切除+胆总管取栓+门静脉取栓1例,扩大左半肝+左肝管取栓1例,右半肝切除+右肝管切除取栓1例,肝Ⅴ,Ⅵ段切除+断面取栓术1例,胆总管取栓2例。术后发生胆瘘1例,持续引流34d后拔出引流管治愈;无其他严重并发症,无围手术期死亡。全组均得到随访,平均生存时间23.6（4~63）个月,现存活6例,最长的存活时间为5年余。
结论：原发性肝癌合并胆管癌栓的患者明确诊断后行积极的外科治疗,可获得较好的治疗效果。

     

原发性肝癌伴胆管癌栓的诊治

目的　探讨原发性肝癌伴胆管癌栓的诊治方法。方法　回顾性分析 8年间收治的 2 1例原发性肝癌伴胆管癌栓的临床资料。结果　临床表现为肝癌及梗阻性黄疸症状 ;术前正确诊断率76.2 %,B超 ,CT ,MRI ,ERCP和PTC的正确诊断率分别为 14 .3 %,9.5 %,14 . 3 %,71.4%和10 0 %。行肝癌切除加胆管癌栓清除术 10例 ,肝癌切除加肝外胆管切除术 5例 ,单纯胆总管切开取栓加肝动脉化疗栓塞 (TACE ) 3例 ,胆管癌栓清除加肝动脉灌注 (HIA ) 3例。术后 3年生存率 44 .4%,5年生存率 2 8.6%。结论　原发性肝癌伴胆道癌栓的诊断应选择多种检查手段 ,综合分析 ;以外科为主的综合治疗是积极有效的治疗方法。     

巨大肝癌外科治疗探讨

目的：探讨巨大原发性肝癌的外科治疗。
方法：回顾性分析109例行手术切除治疗的巨大肝癌患者的临床资料。
结果：肿瘤最大径10.5~30(14.46±3.84)cm;病灶单发92例,多发17例;肿瘤位于左肝41例,右肝63例,超过半肝5例;83例合并肝炎后肝硬化,5 例肝癌破裂出血,19例合并门静脉癌栓(4例并有胆道癌栓),15例有肝门或肝周腹腔淋巴结转移;术前肝功能Child A级101例, B级8例;98例AFP>500 μg/L,11例<20 μg/L;临床分期IIa期2例,IIb 期92例,IIIa期15例;规则切除42例,局限性肝切除67例,手术失血量400~2 200 mL;全组住院期无死亡,术后并发症82例次(75.23%);68例获随访2~72个月,肝癌破裂出血5例切除术后生存8~13个月,63例非破裂肝癌择期手术切除后1,3,5年生存率分别为44.07%,13.06%和7.84%
结论：巨大肝癌切除近期效果优良,远期效果仍待提高;具备条件的巨大肝癌破裂出血可行一期切除。     

联合肝脏离断和门静脉结扎的二步肝切除术治疗肝硬化巨大肝癌2例报告并文献复习

目的:探讨联合肝脏离断和门静脉结扎的二步肝切除术(ALPPS)治疗肝硬化巨大肝癌的安全性及有效性。方法:回顾性分析2014年8月和2015年1月东南大学附属中大医院行ALPPS治疗的2例合并肝硬化的右肝巨大肝癌患者的临床资料,通过围手术期指标和术后随访资料评价疗效。结果:2例患者第一步手术行门静脉右支结扎和左右半肝原位劈离,第一步手术后2例患者的剩余肝体积均迅速增大,患者1术后6 d,剩余肝体积达到704.8 m L,占标准肝体积的60.3%;患者2术后11 d,剩余肝体积达到771.3 m L,占标准肝体积的63.6%。2例患者第二步手术行扩大右半肝切除术。第一步手术时间分别为240 min和210 min,术中出血均为600 m L;第二步手术时间为300 min和325 min,术中出血为1000 m L和800 m L。围手术期无死亡及术后严重并发症发生。术后随访6个月,均无新发肝内外转移。结论:ALPPS治疗肝硬化巨大肝癌是安全可行的。     

原发性肝癌的手术治疗：附408例分析

目的　探讨原发性肝癌的手术治疗效果及影响疗效的因素。方法　回顾性分析近 8年外科手术治疗的原发性肝癌 40 8例患者的临床资料。结果　 40 8例占同期原发性肝癌住院之 43 .9% ,大肝癌占 81.9% ,伴门静脉癌栓者占 8.5 % ,伴胆管癌栓者 4.8%。 40 8例中行左外叶切除 118例 ,左半肝切除 97例 ,右半肝切除 112例 ,右肝肿瘤所在区段切除 73例 ,左、右叶肿瘤同时切除 8例。同时行门静脉癌栓 (左、右支或主支 )取栓术 3 5例 ,同时行肝内外胆管癌栓取栓术 2 0例 ;加行全植入或药泵置入 (DDS) 48例 (3 5例有门静脉癌栓者均经门静脉置入 )。术后发生并发症共 3 0 2例次。包括膈下脓肿、肺部感染 ,上消化道出血 ,胸腔积液、腹水、伤口裂开等。手术死亡率 2 .7% ,残癌率为18.4% ,术后复发或转移率为 73 .0 %。 1,3 ,5年生存率分别为 73 .9% ,5 1.3 % ,3 5 .5 %。结论　原发性肝癌接受手术治疗者的病期均较晚 ,术后复发和 /或转移是影响远期疗效的主要因素。     

肝癌合并下腔静脉癌栓再手术一例

患者男性,77岁.因"肝癌合并下腔静脉(IVC)癌栓术后40个月,腹痛、腹胀1周"于2007年11月入院.患者于2004年6月经检查诊断为原发性肝癌,伴门静脉左支、肝左静脉、IVC癌栓形成,乙型肝炎后肝硬化.     

肝细胞癌合并下腔静脉癌栓的手术治疗

目的 探讨肝细胞癌(简称肝癌)合并下腔静脉癌栓的手术治疗方法。方法 采用肝切除 腔静脉取栓治疗4例肝癌合并下腔静脉癌栓患者,取栓方法包括经荷栓肝静脉取栓(1例)和下腔静脉切开取栓(3例),后者又分在全肝血流阻断下取栓(2例)和在萨氏钳局部血管阻断下取栓(1例)。结果 4例肝癌及下腔静脉癌栓均得到成功切除,术中无明显并发症发生;术后除l例发生中等量胸水外,无其他并发症发生;随访中3例已死亡,分别生存30、10和14个月;1例尚存活,已生存7个月。结论 肝癌合并下腔静脉癌栓的手术治疗安全可行,其基本术式为肝切除 下腔静脉切开取栓。     

布加综合征病因的临床和实验研究初探

目的 初步探讨布加综合征(BCS)的病因.方法 分析2001年3月至2009年5月109例BCS根治术中所见.对11例隔膜型BCS患者下腔静脉和(或)肝静脉隔膜和8例下肢深静脉血栓形成(DVT)的血栓成分进行比较.免疫组化方法研究两者组织中B型转化生长因子受体(TGFβR)、血小板衍化生长因子受体(PDGFR)、内皮素-1(ET-1)、Ⅷ因子相关抗原(FⅧ-rAg)、α1-抗胰蛋白酶、铁蛋白的表达情况.结果 本组除4例为下腔静脉肿瘤和1例为下腔静脉外纤维条索压迫所致BCS外,其余104例均为下腔静脉和(或)肝静脉隔膜或血栓形成所致.2例原为下腔静脉血栓,根治清除血栓1年和7年后复发,再次手术发现为下腔静脉新生隔膜.3例下腔静脉节段性闭塞者术中可见陈旧血栓向隔膜演变的过程.8例下腔静脉隔膜在肝静脉开口下方.隔膜和血栓组织均含纤维母细胞、中性粒细胞,均有肉芽组织及新生血管等病理改变.相关的细胞因子TGF-βR、PDGFR、ET-1、FⅧ-rAg、铁蛋白在两者组织中的表达率分别为72.3%和50.0%(P＞0.05),45.5%和100%(P＜0.05),100%和0(P＜0.05),90.9%和12.5%(P＜0.05),72.3%和100%(P＞0.05).结论 BCS患者的隔膜和血栓有着相似的组织细胞成分和细胞因子表达,隔膜和血栓或为病变的不同阶段.     

Left Renal Vein Graft for Vascular Reconstruction in Abdominal Malignancy

Background Advanced abdominal malignancies are occasionally invasive for the major blood vessels, such as the portal vein (PV), inferior vena cava (IVC), and major hepatic veins (HVs), and complete removal of the tumors is required for patients undergoing vascular resection and reconstruction. We used left renal vein (LRV) grafts for vascular reconstruction in patients with these malignancies and evaluated their clinical relevance. Methods A total of 113 patients underwent vascular resection including the PV (42 patients), IVC (68 patients), and HV (3 patients) for hepatobiliary-pancreatic or abdominal tumor resection. Of these, 11 patients underwent vascular reconstruction with a LRV graft of the PV, superior mesenteric vein (SMV), and HVs in 3 patients each, and the IVC in 2 patients. The HVs were resected with segmentectomy involving Couinaud’s segments VII, VIII, and IV; VII, VIII, and II; or III, IV, VIII in each patient. The PV and SMV were resected in 5 patients undergoing pancreaticoduodenectomy for pancreatic carcinoma, and in 1 patient being treated with extended right hepatectomy and pancreaticoduodenectomy for hepatic hilar carcinoma. The IVC was partially resected in 1 patient with advanced colon cancer and 1 with malignant schwannoma. Results The mean graft length of LRV obtained was 3.6 (3.5–4.0) cm. The graft was used as a tube in 9 patients, and as a patch in 2 patients. The mean duration of clamping time was 41.9 (35–60) min. Portal vein thrombosis was encountered in 2 patients, and anastomotic stenosis in 1 patient. Other morbidity was not related to vascular reconstruction. One patient who underwent extended right hepatectomy and pancreaticoduodenectomy died of liver failure in the hospital. The serum creatinine level after surgery did not deteriorate except in the one patient who died in the hospital. Graft patency was maintained during the follow-up period in all patients. Conclusions A LRV graft may enhance the possibility of vascular reconstruction without deteriorating serum creatinine level, and it provides sound graft patency.     

Portal vein tumor thrombus from colorectal cancer with no definite metastatic nodules in liver parenchyma

Portal vein tumor thrombus (PVTT) in hepatocellular carcinoma (HCC) is a common entity. In colorectal liver metastasis, microscopic tumor invasion into the intrahepatic portal vein is also usually observed, but the incidence of macroscopic tumor thrombus in the first branch and trunk of the portal vein is rare. Most reported cases of PVTT from colorectal cancer had concomitant metastatic nodules in liver parenchyma, and the PVTT was continuous with the liver nodule, like PVTT in HCC. We present a case of PVTT from colorectal cancer with no definite metastatic nodules in liver parenchyma. A 58-year old man underwent laparoscopic high anterior resection for rectosigmoid carcinoma accompanied by bulky tumor thrombus in the branch of the inferior mesenteric vein. Six months later, he received left lobectomy and left caudate resection for liver metastasis. The resected specimen demonstrated there was no metastatic nodule in liver parenchyma and that the left portal system was filled with the tumor thrombus. The patient is alive with no sign of recurrence 66 months after hepatectomy. Even if there is a macroscopic PVTT from colorectal cancer, a better prognosis may be expected when the tumor can be completely resected en-bloc by anatomic hepatectomy including PVTT.     

Precaution against postoperative venous complications after major hepatectomy using the pedicled omental transposition flap: Report of two cases

INTRODUCTION

Vascular complications following hepato-pancreatic biliary surgery can be devastating, and therefore precaution of them must be critical. We report two cases in which the pedicled omental transposition flap might be effective to avoid postoperative venous complications following major hepatectomy.

PRESENTATION OF CASE

Case 1 is a 80-year-old male who required to perform re-laparotomy at postoperative day 1 following major hepatectomy due to acute portal venous thrombosis (PVT). In the second surgery, the main trunk of PV was occluded by thrombus resulted from its redundancy and kinking. PV was resected with an adequate length and reconstructed. The omental flap was placed between PV and inferior vena cava (IVC) to fill in the dead space, resulting in favorable intrahepatic portal blood flow. Case 2 is a 64-year-old male who underwent left trisectionectomy because of giant hepatocellular carcinoma located close to the trunk of right hepatic vein (RHV) and IVC. After removal of the specimens, the dead space developed between the RHV and IVC. In order to prevent outflow block caused by kinking of the RHV, the omental flap was placed between the RHV and IVC, and the right triangle ligament of the liver was fixed to the diaphragm. RHV patency was confirmed by postoperative imaging.

DISCUSSION

The omental flap is a simple procedure and useful to fill the dead space developed in the area surrounding major vessels.

CONCLUSIONS

We experienced two cases in which vascular complications might be avoided by filling the dead space surrounding major vessels using the omental flap.     

Budd-Chiari综合征与直视根治术

Budd-Chiari综合征行直视根治术观察其病变并作分析。方法:在常温下血管阻断或置管转流下,经右胸作下腔静脉(IVC)切开行膜切除、血栓摘除、癌栓摘除、自体心包片腔静脉成形、心包管代血管移植等手术共70例。结果:手术死亡3例,术后67例随访5～84个月(平均45个月),B超和IVC造影显示IVC-HV通畅者64例,术后4个月IVC血栓形成1例,术后1～1.5年示IVC狭窄2例。结论:Budd-Chiari综合征用直视根治术是一种较理想的疗法。     

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??Analysis of risk factors for early recurrence of primary hepatocellular carcinoma after radical hepatectomy HUANG Jin-qiu*, PENG Min-hao, ZOU Quan-qing, et al. *Department of Hepatobiliary Pancreatic Surgery, Nanhua Hospital Attached to University of South China, Hengyang421002,China Corresponding author: PENG Min-hao, E-mail: minhaopeng@yahoo.com.cn Abstract Objective To explore the risk factors for early recurrence of primary hepatocellular carcinoma after radical hepatectomy. Methods The clinical data of 145 cases of hepatocellular carcinoma performed radical hepatectomy from June 2000 to December 2002 at the First Affiliated Hospital of Guangxi Medical University were analyzed retrospectively. Sixteen factors involved in clinic, pathology and treatment were analyzed to determine their impact upon early recurrence of hepatocellular carcinoma. Results Fifty-seven cases underwent early recurrence within one year after hepatectomy. The survival rate of 1 and 3 years in early recurrence group was 36.8% and 3.5%, respectively. The survival rate of 1 and 3 years in control group (relapse one year after hepatectomy or relapse-free during follow-up) was 100% and 63.6%, respectively. The significant difference of survival rate exist between the two groups (χ2=139.9, P<0.001).The univariate analysis showed that age, liver cirrhosis, tumor diameter, multiple tumor, tumor capsule formation, tumor capsule invasion, portal vein tumor thrombus, hepatic vein tumor thrombus, microvessel invasion and tumor Edmond-Steiner grade were high risk factors for early recurrence of hepatocellular carcinoma after hepatectomy. Meanwhile, multivariate analysis indicated that tumor diameter, portal vein tumor thrombus, microvessel invasion and tumor capsule invasion were independent factors for early recurrence. Conclusion Recurrence after hepatectomy is one of main biology properties of hepatocellular carcinoma. Tumor diameter, portal vein tumor thrombus, microvessel invasion and tumor capsule invasion are main high risk factors for early recurrence. Identifing the high risk factors associated with early recurrence contributes to the grasp of operation indication and guidance of adjunctive therapy.     

原发性肝癌切除术后早期复发高危因素分析

目的 探讨影响原发性肝癌根治性切除术后早期复发的高危因素。方法 回顾性分析2000年6月至2002年12月广西医科大学第一附属医院经根治性手术切除的145例原发性肝癌的临床病理资料,选择16项临床、病理和治疗等指标分析其对早期复发的影响。结果 全组1年内早期复发57例,早期复发组的1年存活率为36.8％,3年存活率为3.5％,而对照组（1年后复发或随访期间无复发）1年和3年存活率分别为100％和63.6%,两组存活率差异有统计学意义（χ2=139.9, P<0.001）。单因素分析表明,年龄、肝硬化、肿瘤直径、多发肿瘤、肿瘤包膜形成、肿瘤包膜浸润、门静脉癌栓、肝静脉癌栓、微血管浸润和肿瘤Edmond-Steiner分级是影响肝癌早期复发的高危因素。多因素分析提示,肿瘤直径、门静脉癌栓、肿瘤微血管浸润和肿瘤包膜浸润是影响肝癌早期复发的独立因素。结论 术后复发是肝癌的一大生物学特性,肿瘤直径、门静脉癌栓、微血管浸润和肿瘤包膜浸润是影响肝癌早期复发的最主要危险因素。甄别肝癌切除术后早期复发的高危因素对于手术适应证的把握和术后的辅助治疗有指导性意义。