联合肝脏离断和门静脉结扎二步肝切除术治疗巨大原发性肝细胞癌1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）治疗巨大原发性肝细胞癌的安全性及有效性。方法 回顾性分析2014年12月哈尔滨医科大学附属第一医院行ALPPS的１例右肝巨大肝细胞癌并门静脉三个分支病人的临床资料,第一步手术结扎门静脉右支并原位劈离肝左外叶和左内叶,第二步行肝脏右三叶切除术。结果 第一步手术7 d后,剩余肝脏体积由术前281 mL增加至606 mL,术后第7天肝功能恢复正常。第一步术后第8天行第二步手术,术后第5天肝功恢复正常。结论 ALPPS为残余肝脏体积不足的巨大肝癌病人提供了新的治疗选择。     

全腹腔镜联合肝脏离断和门静脉结扎的二步肝切除术治疗肝硬化肝癌

联合肝脏离断和门静脉结扎的二步肝切除术（ALPPS）被誉为肝胆外科领域革命性突破,通过第1步手术刺激剩余肝脏再生,第2步手术行根治性切除,为不能行手术切除的肝癌患者提供了在1次住院期间获得根治性切除的机会.2014年4月第三军医大学西南医院收治1例合并肝硬化的右肝原发性肝癌患者.术前评估行右半肝切除术后剩余肝脏体积占标准肝脏体积的26.9％.采用全腹腔镜ALPPS方案：第1步手术行腹腔镜下右侧Glisson蒂悬吊,门静脉右支结扎,肝后间隙放置绕肝带,正中裂原位肝实质完全离断.第1步手术后13 d再次计算剩余肝脏体积占标准肝脏体积的40.6％.于第1步手术后14 d行第2步手术：腹腔镜下采用直线切割闭合器离断右侧Glisson蒂及肝右静脉,处理右半肝周围韧带,完整切除右半肝及肿瘤,于耻骨上横切口取出标本.切缘距离肿瘤1.5 cm.患者第1步手术后无并发症发生,第2步手术后并发右侧胸腔积液行穿刺引流,于第2步手术后第9天痊愈出院.术后1个月门诊复查肝功能正常,无肝脏占位性病变和胸腔积液.全腹腔镜ALPPS治疗肝硬化肝癌安全可行,手术效果良好.     

联合肝脏离断和门静脉结扎的二步肝切除术

肝癌的完整切除是肝癌患者获得根治性治疗效果的最主要途径,切除术后足够的剩余肝脏体积是避免肝衰竭的必要条件.为了达到上述目的,近年来,一种全新手术方式——联合肝脏离断和门静脉结扎的二步肝切除术(ALPPS)已见报道.本研究回顾性分析2013年4月复旦大学附属中山医院收治的1例传统手术不能切除的巨大肝癌患者行ALPPS的临床资料.第1步手术先结扎门静脉右支,再在镰状韧带的右侧,原位劈离肝左外叶和左内叶.距离第1次手术7d后,剩余肝脏体积由术前291 ml增加至579ml,第8天即行第2步扩大右半肝切除术.ALPPS这一创新技术为不能切除的肝癌患者提供了治愈的希望.     

腹腔镜辅助联合肝脏离断和门静脉结扎的二期肝切除术治疗伴有轻-中度肝硬化的原发性肝细胞癌（附7例报告）

目的 分析腹腔镜辅助联合肝脏离断和门静脉结扎的二期肝切除术（ALPPS）治疗伴有轻-中度肝硬化的较晚期巨大肝癌的安全性、有效性和微创性。方法 回顾性分析2013年8月至2014年10月中山大学孙逸仙纪念医院行腹腔镜辅助下ALPPS治疗伴有轻-中度肝硬化巨大原发性右肝肝癌7例的临床资料。第1期行腹腔镜下门静脉右支结扎＋肝实质离断术,待未来剩余肝脏体积（FLR）增生后行第2期开腹肝脏右三叶切除术,并对围手术期结果和近期肿瘤学疗效进行分析。结果 7例均行全腹腔镜下的第1期肝脏离断和门静脉结扎术,其中4例FLR扩增达标,行第2期开腹肝脏右三叶切除术。第1期平均手术时间（192.9±35.9）min,第2期平均手术时间（210.0±73.9）min,平均FLR增生率35.6%,围手术期无严重并发症及死亡发生。术后随访1年,平均至肿瘤复发时间为178.7 d。结论 在有经验的肝胆外科中心对选择性病人实施腹腔镜辅助ALPPS是可行的,对轻度肝硬化以下的原发性肝细胞癌病人实施腹腔镜下门静脉右支结扎和肝脏离断能有效刺激FLR明显扩增,并具有相对较低的并发症发生率和病死率,围手术期相对安全,为FLR不足的较晚期巨大肝癌病人提供了一个治疗选择。     

联合肝脏离断和门静脉切断二步肝切除术在肝炎后肝硬化肝癌中的应用

目的：探讨联合肝脏离断和门静脉切断二步肝切除术（ALPPS）在肝炎后肝硬化肝癌患者治疗中应用价值。 方法：回顾性分析2014年3月中南大学湘雅医院收治的1例乙型病毒肝炎（HBV）相关性肝癌患者行ALPPS的临床资料。 结果：患者术前评估未来剩余肝脏体积约占标准肝体积的20.2%。患者一期行右侧门静脉离断和左、右半肝原位劈离;患者一期手术后9 d,剩余肝脏体积达标准肝体积的38.8%后,二期行右半肝含肿瘤切除。两次手术时间分别为255 min和297 min,出血量分别为260 mL和350 mL。术后肝功能持续平稳。术后21 d出院。术后2个月随访,未见复发转移,HBV-DNA定量和AFP均在正常范围之内。 结论：对于HBV非活动期合并肝硬化的肝癌可适度扩大ALPPS手术指征,手术仍然安全可行。     

ALPPS治疗巨大肝癌合并肝硬化

目的 探讨联合肝脏离断和门静脉结扎的二步肝切除术（associating liver partition and portal vein ligation for staged hepatectomy,ALPPS）治疗巨大肝癌合并肝硬化的安全性及其有效性。方法 对 2018年11月温州医科大学附属第一医院肝胆外科收治的1例巨大肝癌合并肝硬化患者的临床病理资料进 行回顾分析。结果 术前评估患者右半肝切除后剩余肝脏体积（future liver volume,FLV）不足,约占标准 肝体积35.68%。患者1期手术行右侧门静脉结扎并沿肝正中裂行射频消融术,术后2周,FLV达标准肝体 积的69.35%,吲哚菁绿排泄试验（indocyanine green retention rate at 15 min,ICGR15）为 25.5%,暂缓手术, 术后1个月再次测ICGR15为8.7%,遂行右半肝切除术。两次手术过程顺利,术中无明显出血,术后患者 无手术并发症,但术后出现腹水,经治疗后顺利出院。术后随访1个月,未见复发、转移,甲胎蛋白降至 正常范围。结论 ALPPS治疗巨大肝癌合并肝硬化的是安全有效的,但对2期手术的时机需严格把握,对 合并肝硬化的患者实施ALPPS术时,在2期手术前FLV最好大于40%且ICGR15小于10%。     

门静脉和肝动脉结扎序贯二步法肝切除术治疗巨大肝癌

巨大肝癌切除术后剩余肝脏体积不足是发生肝衰竭的主要原因.通过阻断一侧的门静脉和肝动脉,使肿瘤降低分期,增加对侧术后剩余肝脏体积,成为目前切除巨大肝癌的方法之一.2013年3-4月厦门大学附属第一医院收治的1例原发性右半肝巨大肝癌患者,因肝脏剩余体积不足,术者一期行选择性门静脉及肝动脉结扎术后,序贯二期行肝切除术.患者2次手术均顺利完成,一期行门静脉右支及肝右动脉结扎术,术后肝肿瘤体积缩小,剩余左半肝代偿性增生良好,肝脏体积由术前488 mL增加到术后1个月689 mL.一期手术后33 d顺利实施二期巨大肝癌肝切除术,2次术后均无严重并发症发生.术后随访2个月,患者剩余肝脏未见肿瘤复发,AFP由术前425 mg/L降至26×10^-3mg/L.因此,选择性门静脉及肝动脉结扎后序贯二步法肝切除术可能是传统手术无法切除的巨大肝癌患者有效的治疗方法.     

全腹腔镜前入路经肝后隧道绕肝带结扎并门静脉结扎的分期肝切除术治疗肝硬变肝癌

目的探讨全腹腔镜下前入路经肝后隧道绕肝带结扎和门静脉结扎分期肝切除术(ALTPS)在乙肝肝硬变肝癌患者治疗中的应用价值。方法 2014年9月,笔者所在医院收治1例合并肝硬变的右肝原发性肝癌患者,采用全腹腔镜前入路ALTPS方案:一期手术行腹腔镜下门静脉右支结扎,前入路肝后间隙放置绕肝带结扎肝正中裂,不离断肝实质;一期手术10 d后再行全腹腔镜下右半肝切除术。结果术前评估行右半肝切除术后剩余肝脏体积(FLR)为301.48 m L,占标准肝脏体积的29.1%,占体质量的0.49%。一期手术后4 d,FLR为496.45 m L,占标准肝体积的47.9%,占体质量的0.81%,FLR较术前增加64.67%;术后第8天FLR为510.96 m L,占标准肝脏体积的49.3%,占体质量的0.84%,FLR较术前增加69.48%。术后第10天,二期行全腹腔镜右半肝切除术,二期手术后5 d,测残肝体积为704.53 m L。两次手术时间分别为180 min和220 min,出血量分别为50 m L和400 m L。术后恢复良好,术后7 d出院。结论作为联合肝脏离断和门静脉结扎的二步肝切除术(ALPPS)的一种更简便、安全、微创及更符合肿瘤学原则的改良,前入路全腹腔镜下ALTPS也能使残肝在短期内快速增生,并且对合并肝硬变的肝癌手术仍然安全可行。     

全腹腔镜ALPPS治疗肝脏恶性肿瘤(附三例报告及文献复习)

目的探讨全腹腔镜联合肝脏离断和门静脉结扎的二步肝切除术(associating liver partition and portal vein ligation for staged hepatectomy,ALPPS)治疗肝脏恶性肿瘤的治疗选择。方法回顾性分析2019年中国科学技术大学附属第一医院肝脏外科行全腹腔镜ALPPS治疗的1例直肠癌术后肝脏多发转移和2例巨块型肝癌的临床资料,分析围手术期检查指标和术后随访结果以评价该术式的临床应用价值。结果第一步手术均在腹腔镜下行门静脉右支结扎和原位肝实质离断+胆囊切除术,第一次和第二次术前三维可视化结果显示,3例病例术前两次预估剩余肝脏体积分别为221 ml和364 ml,320 ml和532 ml以及332 ml和422 ml,预留肝脏体积较前增加了65%、66%和27%,在剩余肝脏体积比达到安全标准后第二步手术行解剖性右三叶肝切除术,术后对症治疗肝功能逐渐恢复,围手术期无死亡及其他严重并发症,随访至今未见肿瘤复发、无远处转移。结论全腹腔镜下可以安全地、有效地开展ALPPS,预留肝脏短期内能代偿增生。腹腔镜ALPPS为复杂的肝脏恶性肿瘤创造了手术切除的可能性。     

对“联合肝脏离断和门静脉结扎的二步肝切除术”的述评

联合肝脏离断和门静脉结扎的二步肝切除术(ALPPS)是一个非常新的外科手术.该手术主要针对因未来剩余肝脏体积较小而不能接受大范围肝切除术的T分期较晚的肝癌患者而设计的.ALPPS第1步手术后,患者剩余肝脏对手术的反应非常强烈,使得肝脏体积急剧增生.因而可在第1步手术后1周左右施行第2步手术以切除所有肝内肿瘤(R0切除).本文追溯ALPPS的发展历史,描述该手术的传统步骤和手术的偏离等情况,分析该手术的短期疗效.尽管ALPPS后零死亡已有报道,但初步的研究结果表明:ALPPS的手术死亡率和并发症发生率仍然较高.ALPPS后尚没有明确的长远治疗肿瘤效果的报道.该手术在肝硬化肝癌患者中能否安全施行尚有疑问.     

绕肝提拉法在联合肝脏离断和门静脉切断二步肝切除术中的应用

目的：探讨绕肝提拉法（LHM）在联合肝脏离断和门静脉切断二步肝切除术（ALPPS）中的应用效果。方法：回顾性分析4例原发性肝细胞癌行ALPPS术患者临床资料,其中肝右叶肿瘤3例,肝尾状叶肿瘤1例,均采用LHM法导引的一期左、右肝脏原位劈离,右门静脉切断;二期行肿瘤完整切除。结果：4例均预先游离肝脏,成功安置弹力带,顺利实施二期肝切除术;一期手术时间195~273（232.2±35.3）min,术中失血420~1210（735±344.3）mL,并发胆瘘1例;二期手术时间98~186（139.5±36.6）min,术中失血100~320（197.5±95.3）mL;无手术死亡;术后随访3个月,3例情况良好,1例术后2个月复发死亡。结论：LHM法对于下腔静脉的保护,充分显露左右肝动脉、肝静脉、肝内胆管有较好的效果,可常规适用于肝肿瘤ALPPS二步肝切除术。     

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??Laparoscopic associating liver partition and portal vein ligation for staged hepatectomy for advanced hepatocellular carcinoma with cirrhosis??A report of 7 cases HUANG Ze-jian , CAO Jun, LI Wen-da Li, et al.Department of Hepatopancreatobiliary Surgery, Sun Yat-sen Memorial Hospital,Sun Yat-sen University, Guangzhou 510120, China
HUANG Ze-jian and CAO Jun contributed equally to this work
Corresponding author: CHEN Ya-jin ,E-mail??cyj0509@126.com
Abstract Objective Our aim was to investigate the feasibility and oncological efficacy of laparoscopic “Associating liver partition and portal vein ligation for staged hepatectomy” (ALPPS) in the treatment of advanced hepatocellular carcinoma with cirrhosis. Methods We retrospectively analyzed the clinical data of 7 patients with a huge right-lobe hepatocellular carcinoma lesion who underwent laparoscopic ALPPS in the Sun Yat-sen Memorial Hospital from August 2013 to October 2014. The first-stage surgery was laparoscopic ligation of the right branch of the portal vein and liver partition. When the future liver remnant (FLR) increased, open right hepatic trisegmentectomy was performed as the second-stage surgery. The perioperative indicators and early oncological efficacy were then analyzed. Results The operative time was 192.9±35.9min for the first-stage surgery and 210±73.9min for the second-stage surgery. The future liver remnant volume increased 35.6%, on average, compared to the preoperative volume, The rate of liver failure and mortality were 42.9% and 14.3%,.The tumor recurrence rates were 25% and 75% at 90 days and 1 year post-operation. The average time to tumor recurrence was 178.7days. Conclusion Laparoscopic ALPPS is an additional choice for patients with advanced hepatocellular carcinoma and insufficient volume of the future liver remnant.     

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??Laparoscopic-assisted associating liver partition and portal vein ligation for staged hepatectomy for primary liver cancer CAO Jun??ZHANG Hong-wei??ZHANG Lei??et al. Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China
Corresponding author??CHEN Ya-jin, E-mail:cyj0509@126.com
Abstract Objective Our aim was to investigate the feasibility of laparoscopic “Associating liver partition and portal vein ligation for staged hepatectomy” (ALPPS) in the treatment of advanced hepatocellular carcinoma. We retrospectively analyzed the clinical data of one patient with a huge right-lobe hepatocellular carcinoma lesion and multiple right-lobe metastases who underwent laparoscopic ALPPS in the Sun Yat-sen Memorial Hospital in August 2013. Methods The first-stage surgery was laparoscopic ligation of the right branch of the portal vein and liver partition. Seven days later, open right hepatic trisegmentectomy was performed as the second-stage surgery. The perioperative indicators were then analyzed. Results The operative time was 205 minutes for the first-stage surgery and 160 minutes for the second-stage surgery. Liver function returned to normal six days after the first-stage surgery and left lateral lobe volume increased 115.9% compared to the preoperative volume. The second-stage open right hepatic trisegmentectomy was then performed safely and liver function returned to normal eight days after the second-stage surgery. Conclusion Laparoscopic ALPPS is an excellent choice for patients with advanced hepatocellular carcinoma and insufficient volume of the future liver remnant.     

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??Associating liver partition and portal vein ligation for staged hepatectomy??A report of 2 cases LI Cheng-peng??QIAN Hong-gang??ZHANG Ji??et al. Key Laboratory of Carcinogenesis and Translational Research??Ministry of Education????Department of Hepato-pancreato-biliary Surgery??Peking University Cancer Hospital & Institute??Beijing100142??China
Corresponding author??HAO Chun-yi??E-mail??haochunyi@gmail.com
Abstract Objective To investigate the feasibilities and safeties of associating liver partition and portal vein ligation for staged hepatectomy??ALPPS?? in the treatment of advanced hepatic malignancies. Methods The clinical data of 2 cases of advanced hepatic malignancies which underwent ALPPS between July 2012 and October 2012 at Peking University Cancer Hospital were analyzed retrospectively. The perioperative indicators and follow-up data were evaluated. Results Both patients underwent major hepatectomies without mortality and severe complications. In the first-stage surgeries??the operative time was 360 min and 300 min respectively. Moreover the intraoperative blood loss was 500 mL and 400 mL respectively. In the second-stage surgeries??the operative time was 270 min and 330 min respectively. Moreover the intraoperative blood loss was 600 mL and 400 mL respectively. Comparing to the preoperative remnant liver volume (RLV)??the RLV increased 67.7% and 66.7% respectively in 28 days. After 16 months and 15 months follow-up??both patients were alive without relapse. Conclusion ALPPS extended the indication of ALPPS and is a new choice for the patients of advanced hepatic malignancies without sufficient RLV.     

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??Associating liver partition and portal vein ligation for staged hepatectomy for HCC with liver cirrhosis??A report of 1 case HONG De-fei*??LIU He-chun??PENG Shu-you??et al. *Department of Hepatobiliarypancreatic Surgery??Zhejiang Provincial People’s Hospital??Hangzhou 310014??China
Corresponding author??HONG De-fei??E-mail??hongdefi@163.com
Abstract Objective To discuss the safety and effectiveness of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in hepatocellular carcinoma complicated with liver cirrhosis. Methods ALPPS was performed for 1 cases of huge HCC on right liver complicated with liver cirrhosis on March 7, 2014 in Department of Hepatobiliarypancreatic Surgery, Zhejiang Provincial People’s Hospital. Data of perioperative period were recorded and analyzed. The surgical plan includes??first??S??S?? and S?? segment were dissected with an anterior in situ approach and right portal vein was ligated. After 15 days, a combination of antegrade and retrograde approach were applied in right liver lobectomy. Results The remnant liver volume was 460.8 mL before the first step of operation??which was increased by 65.0% to 760.2 mL before the second step of operation. The standard whole liver volume was 1019.3 mL. The standard remnant liver volume was 320 mL/m2 before the first step of operation??and was 527.9 mL/m2 before the second step of operation??which accounted for 31.4% and 52.0% of the standard whole liver volume respectively. The operative time for the first step and second step of operation was 188 min and 124 min. The intraoperative bleeding was 2000 mL and 400 mL respectivey. The time for restore to normal liver function postoperatively was 6 d and 4 d. Complication of minimal bile leakage??ascites and partial arterial thrombosis in lower lobe of right lung occurred after the first step of operation. No complication occurred after the second step of operation. The patients were discharged 10 d postoperatively. Conclusion The modified ALPPS provides a new strategy for the cases of HCC with cirrhosis who couldn’t tolerate the radical resection due to the insufficient remnant liver volume.     

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??Totally laparoscopic ALPPS for primary liver cancer complicated with cirrhosis----application of round-the-liver ligation to replace parenchymal transection CAI Xiu-Jun*??PENG Shu-You??YU Hong??et al. *Sir Run Run Shaw Hospital??Zhejiang University??Hangzhou310016??China
Corresponding author??CAI Xiu-Jun??E-mail??cxjzu@hotmail.com
Abstract Objective To study the feasibility??effectiveness and safety of totally laparoscopic ALPPS in treating primary liver cancer complicated with cirrhosis and to introduce the experience of using round-the-liver ligation to replace parenchymal transection.Methods Retrospectively analyze the clinical data of a patient with a left-lobe liver cancer who underwent totally laparoscopic ALPPS in the Sir Run Run Shaw Hospital in May 2014.The first-stage surgery was laparoscopic ligation of the left branch of portal vein and execution of round-the-liver ligature.11 days later laparoscopic left lobectomy was carried out as the second-stage surgery.The perioperative indicators were then analyzed.Results The operation time was 290 minutes for the first-stage surgery and 160 minutes for the second-stage surgery.Liver function returned to normal 3 days after the first-stage surgery and right lobe volume increased 94.8% compared to the preoperative volume.The second-stage laparoscopic left lobectomy was then performed uneventfully and liver function gradually returned to normal after the second-stage surgery.Conclusion Both two stage operations can be safely performed laprarscopically.ALPPS also can Results in a marked and rapid hypertrophy of future remnant even in liver cancer complicated with cirrhosis.Round-the-liver ligature can replace liver parenchymal transection to reduce complications with similar therapeutic results.     

联合肝脏离断和门静脉结扎两阶段肝切除术在治疗中晚期肝癌中的应用

联合肝脏离断和门静脉结扎的两阶段肝切除术(associating liver partition and portal vein ligation for staged hepatectomy,ALPPS)是近几年提出的一种全新手术方式,因其能显著促进肝组织增生,明显缩短两次手术时间间隔,所以可用于剩余正常肝脏体积不足,不能接受大范围切除的中晚期肝癌病人。目前该术式仍存在风险和难点,有着较高的并发症发生率和病死率,短期效果尚可,但其所带来的长期存活获益尚无定论,故其发展一直伴随着诸多的争议。本文就ALPPS的相关应用进展等作一综述。     

ALPPS促进剩余肝脏快速增生机制及相关因素研究进展

联合肝脏离断和门静脉结扎的二步肝切除术(ALPSS)是近年来发展起来的一种新型二步肝切除术。ALPPS最大特点是能够在短期内促进剩余肝脏体积(FLR)快速急剧增生,相比传统二步肝切除术,具有更高二期手术完成率和R_0切除率,让因FLR不足而无法行根治性切除的肝癌患者有了治愈的希望。笔者对ALPPS促进FLR快速增生机制及相关因素研究进展进行综述。     

联合肝脏离断和门静脉结扎的二步肝切除术在肝脏肿瘤治疗中的应用

联合肝脏离断和门静脉结扎的二步肝切除术（ALPPS）是近年提出的一种手术方式,分两次完成,第1次手术包括门静脉结扎、在待切除肝和需保留肝之间离断肝实质,待剩余肝脏体积增大后再行第2次手术切除病肝。ALPPS主要目的是使剩余肝脏体积快速增长,为那些原来不能切除的肝脏恶性肿瘤的患者提供可根治性切除的机会。本文综述了近几年ALPPS方面的研究,从演变过程、手术方法、适用范围、存在争论的问题和近几年的研究现状等方面进行了总结和分析,并对以后的发展方向提出了展望。