原发性肝癌合并脾功能亢进的外科治疗

目的 探讨原发性肝癌合并脾功能亢进的合理治疗方法。方法 1994年1月至2004年12月我院收治67例原发性肝癌合并脾功能亢进患者，17例行肝切除联合脾切除，7例行单纯肝切除，43例行肝动脉栓塞化疗联合脾动脉栓塞。结果 肝切除联合脾切除组术后30d患者脾功能亢进症状消失，外周血细胞恢复正常。单纯肝切除组术后脾功能亢进症状加重，其中6例于术后3～7个月分别行脾动脉栓塞治疗。肝动脉栓塞化疗联合脾动脉栓塞组治疗后30 d 79％（34／43）的病例脾功能亢进症状改善，外周血细胞恢复正常。结论 原发性肝癌合并脾功能亢进的处理应争取行肝切除联合脾切除治疗，如肝癌不能切除，则应争取行肝动脉栓塞化疗联合脾动脉栓塞治疗。     

中晚期肝癌72例外科治疗体会

我院自1970年以来.经外科治疗72例中晚期原发性肝癌(均经手术治疗,病理证实),收到较好的效果,现报告如下。临床资料本组病例均在右上腹部触及包块,最大者达肋下20cm。肝功能正常44例,轻度改变28例。甲胎蛋白阳性56例,占77.7%。同位素肝扫描34例,全部有占位性病变。超声检查有肝癌波型和/或肝癌图像65例,占90.2%。手术方式:单纯剖腹探查17例,肝动脉插管化疗9例。单纯肝动脉结扎2例,肝动脉结扎加插管化疗12例,肝动脉结扎加插管化疗后肝动脉栓塞5例,肝切除27例,其中右半肝切除10例,左半肝切除     

原发性肝癌免疫治疗进展

手术切除、经肝动脉插管栓塞化疗、经皮无水乙醇注射、射频消融、肝移植等是目前治疗原发性肝癌[也称肝细胞肝癌(hepatocellular carcinoma,HCC)]常用的方法,并逐步形成以手术切除为主的综合治疗模式。然而,当前的治疗方法虽然可有效地治疗局部病灶,但不能完全解决复     

合理选择原发性肝癌的治疗方法

由于现代科学技术的进步 ,原发性肝癌 (下称肝癌 )的诊断难题已基本解决 ,而治疗仍在不断的探索中。为提高肝癌的疗效 ,目前已有许多治疗方法在临床应用中。然而 ,从肝癌治疗方法发展的整个历程中可以发现 ,至今没有一种方法能适应每个病人而都能获得理想满意的疗效。肝癌的治疗从 5 0年代的全身化疗 ,60年代初尝试手术切除 ,即规则性肝叶切除 ,到后来的不规则性肝叶切除、局部切除 ,亚段肝切除 ,复发再切除 ,大肝癌治疗缩小后的 期切除 ,不能切除之肝癌行术中肝动脉结扎、栓塞、皮下化疗泵置入 ,还有经肝动脉插管化疗栓塞、经皮无水酒精注…     

中晚期肝癌的综合治疗

目的　评价中晚期原发性肝癌各种疗法的效果。方法　104例中手术治疗51例(行肿瘤切除26例,冷冻治疗15例,肝动脉和门静脉置泵化疗8例,肿瘤无水酒精注射2例)。放射介入行肝动脉插管栓塞53例。结果　手术组手术死亡2例。随访93例(9327%)。各种治疗后1,2年生存率分别为:肿瘤切除者为50%和308%;冷冻治疗者533%和20%;肝动脉和门静脉全埋入式药泵置入者375%和125%;经股动脉肝动脉插管化疗栓塞者为321%和151%;2例行肿瘤无水酒精注射者均在1年死亡。结论　手术切除仍是肝癌首选和最有效的治疗;亦可通过冷冻治疗,其疗效明显优于化疗栓塞术。     

肝动脉、门静脉双栓化疗治疗不能切除的原发性肝癌

目的　探讨肝动脉、门静脉双栓化疗对不能切除的原发性肝癌的治疗作用。方法　对81例不能切除的原发性肝癌进行随机分组 :双栓组 41例 ,术中植入皮下埋藏式投药泵 (CDDS) ,通过药泵经肝动脉行栓塞化疗 门静脉局部灌注化疗 ;术后定期用同法栓塞化疗。肝动脉栓塞化疗(TACE )组 40例按Seldinger法进行 ,用药与术中肝动脉用药量相同。栓塞化疗 3次后 ,记录甲胎蛋白(AFP)、肿瘤大小、肝功能、体重、腹围及生存期 ,并进行比较。结果　栓塞化疗 3次后体重、AFP、肿瘤的缩小双栓组均明显优于TACE组 (P <0 .0 1) ,而肝功能、腹围无明显区别 (P >0 .0 5 )。双栓组与TACE组的中位生存期分别为 18.0个月及 11.1个月 ;6,9,12 ,2 4个月累积生存率分别为87.80 % ,78.0 % ,68.2 9%和 3 1.70 %及 70 .0 % ,5 2 .5 % ,3 0 .0 %和 5 .0 %。影响生存的因素主要是治疗方法、肝功能及肿瘤大小。结论　皮下埋藏式投药泵肝动脉、门静脉双插管栓塞化疗给药途径简单、方便、并发症少、疗效较TACE好 ,是治疗不能切除的肝癌的有效方法之一。     

原发性肝癌并门静脉癌栓的肝动脉化疗栓塞治疗

目的评价经肝动脉化疗栓塞术治疗原发性肝癌并门静脉癌栓的疗效和安全性。方法原发性肝癌并门静脉癌栓患者83例,其中53例行肝动脉化疗栓塞术(栓塞组),30例行肝动脉化学药物灌注(对照组)。对两组的疗效和并发症进行比较。结果经介入治疗后,栓塞组患者 6、12、24、36个月的生存率分别为97．8％、85．2％、45．8％、4．4％,均高于对照组(37．6％、5．3％、0、0． P均<0．01)。两组患者术后并发症的发生率差异无统计学意义。结论原发性肝癌并门静脉癌栓行经肝动脉化疗栓塞术较化疗灌注术的疗效好。     

双介入治疗原发性肝癌

联合应用经股动脉插管肝动脉化疗栓塞术(TAE)和在B超引导下经皮肤肝穿刺瘤内注射无水酒精(PEI)治疗原发性肝癌42例,肿癌面积缩小≥50％26例(61.8％),30％～49％14例(33.3％),<30％或无变化2例(4.9％)。8例经双介入治疗后获Ⅱ期手术切除,占19.0％。半年、1年、2年、3年生存率分别为:92.8％、64.3％、26.2％、7.1％。作者认为:双介入治疗优势互补、疗效增加、是治疗原发性肝癌一种行之有效的方法。     

肝动脉、门静脉双管灌注化疗联合碘油乙醇注射治疗不能切除的原发性肝癌

目的：探讨肝动脉,门静脉双管灌注化疗联合碘油乙醇注射治疗不能手术切除的原发性肝癌的临床疗效。方法：138例经病理证实的不能手术切除的中晚期原发性肝癌患者,分为2组进行治疗：（1）经皮下埋植式药泵经肝动脉和门静脉双插管灌注化疗组（AVPC组,80例）;（2）经皮下埋植式药泵经肝动脉和门静脉双插管灌注化疗联合碘油乙醇注射治疗组（联合治疗组,58例）。结果：治疗后获得二期手术切除率为AVPC组2．5％,。联合治疗组12．1％（P＜0．05）,治疗后0．5,1,2年生存率AVPC组分别为56．3％,45．0％,21．2％。联合治疗线分别为81．0％,61．2％,39．6％,两组间0．1,1,2年生存率均有显著性差异（P＜0．05）,两组并发症率无明显差异,结论：联合治疗是治疗不能手术切除的原发性肝癌的有效方法,效果优于单纯双管灌注化疗。     

原发性肝癌术后复发的再次治疗

目的：探讨原发性肝癌复发后再次手术治疗的可行性及意义。方法：选取2003年1月—2008年12月间就治和随访的58例第一次手术后复发的原发性肝癌患者,分为再手术组和消融栓塞组,比较1,3年生存率。结果：再手术组23例,均行根治性局部切除加肝动脉化疗泵植入术,术后经肝动脉化疗泵行化疗栓塞。消融栓塞组35例,均行局部射频消融治疗加股动脉穿刺肝动脉插管化疗栓塞。再手术者1,3年生存率分别为100%和82.6%,均显著高于消融栓塞组的82.9%和45.7%。结论：原发性肝癌根治性切除术后复发患者,如条件适宜,掌握好手术时机,再次手术治疗是首选方案。     

肝动脉、门静脉栓塞化疗治疗不可切除的原发性肝癌

目的：探讨肝动脉、门静脉双管栓塞化疗对不可切除的原发性肝癌的治疗作用。方法：对19例不可切除的原发性肝癌患者采用手术方法向肝动脉、门静脉植入皮下埋藏式投药泵,术中即开始经肝动脉投药泵栓塞化疗,术后7－10d在X线监测下经门静脉投药泵栓塞化疗,以后定期经两投药泵栓塞化疗,术后观AFP的变化、Bus或CT检查并与同期3次以上的32例HACE进行比较。结果：双栓化疗组17例术后1月AFP均下降、3月下降为正常8例,84．2％的肿瘤缩小,6月、9月、12月、24月生存率分别为89．5％、78．9％、68．4％、31．6％,中位生存期17．1月,其中2例进行了二期手术切除。HACE组术后1月AFP下降10例、3月后下降21例,46．9％的肿瘤缩小,6月、9月、12月、24月生存率分别为71．9％、53．1％、31．3％,中位生存期11．2月、12月、24月生存率组间比较P＜0．01;两组均无异位栓塞。结论：皮下埋藏式投药泵肝动脉、门静脉双插管栓塞化疗术后给药途径简单、方便、疗效好、并发症少,是治疗不可切除的肝癌有效方法之一。     

肝切除及肝动脉化疗栓塞治疗原发性肝癌

作者收集３００例原发性肝癌外科治疗,其中切除１０６例,肝动脉化疗栓塞（ＨＡＣＥ）１９４例,ＨＡＣＥ后二期切除２３例。肝癌患者Ｂ型肝炎带病毒率６９．８％,合并肝硬变８１．６％。临床资料研究显示,肝切除疗效优于ＨＡＣＥ,ＨＡＣＥ后早期局部复发的主要原因是坏死肿瘤周边有癌细胞残留。高供血型肝癌行ＨＡＣＥ有效,低供血型肝癌ＨＡＣＥ效果差。肝癌合并肝硬变时肝切除量的估计,主要依据术前５项生化指标（胆红素、谷丙转氨酶、白蛋白、凝血酶原时间和吲哚氰绿１５分钟潴留率）及术中观察肝脏形态学改变（早、中、晚期肝硬变）来综合判断。     

Hepatic radiofrequency ablation

HYPOTHESIS: Hepatic radiofrequency ablation (RFA) is effective in treating patients with unresectable hepatic malignancies. DESIGN: Case series of 123 patients with unresectable hepatic tumors or tumors with histological findings not traditionally treated by means of hepatic resection were considered for hepatic RFA. Median follow-up was 20 months. SETTING: Tertiary referral center. PATIENTS: The 123 patents underwent 168 RFA sessions from January 1, 1998, through September 30, 2001. Sixty-nine patients were male and 54, female; average age was 65 years (range, 1-89 years). Fifty-two patients had metastatic colorectal cancer; 30, hepatocellular carcinoma; and 41, cancers with other histological findings. INTERVENTIONS: A 200-W, cooled-tip RF probe system was used for all cases. Probe placement and ablation were monitored by means of real-time ultrasonography or fluoroscopic computed tomography. Final tissue temperature of greater than 50 degrees C was achieved in all cases. RESULTS: Initial treatment sessions were percutaneous in 87 patients, open operations in 33, and laparoscopic in 3. Repeated sessions were percutaneous in all but 2 patients. The mean number of lesions treated per session was 2.7 (range, 1-24). Mean tumor size was 5.2 cm (range, 0.5-15.0 cm). One death occurred within 30 days of a procedure. No hepatic bleeds, bile leaks, or adult respiratory distress syndrome occurred. Overall morbidity was 7.1%. Complications included hepatic abscesses in 4 patients, transient liver insufficiency in 3, segmental hepatic infarcts in 2, diaphragm paralysis in 1, hepatic artery-to-portal vein fistula in 1, and systemic hemolysis in 1. CONCLUSIONS: Hepatic RFA is an effective treatment option for patients with unresectable hepatic malignancies. Careful patient selection based on tumor size, location, and number and on patient clinical status should determine the choice of treatment. Further controlled trials are needed to determine the effect of hepatic RFA on long-term survival.     

原发性肝癌经肝动脉栓塞化疗术后再行肝切除的临床观察

１９８７年１月至１９９２年１２月，作者共为４８例经肝动脉栓塞化疗（ＨＡＣＥ）后肿瘤缩小的肝癌患者施行了肝切除术。全组无手术死亡。术后１、２、３年生存率分别为８４．６％、５７．２％和４４．９％。已有２例生存时间超过５年。本文对原发性肝癌（ＰＨＣ）经ＨＡＣＥ后再行切除的临床意义以及ＨＡＣＥ后再作肝切除的手术时机问题进行了讨论。     

累及多肝门的巨大肝肿瘤切除术(附22例报告)

目的 探讨累及多肝门的巨大肝肿瘤切除的安全性、可行性及手术方法。方法 总结1996年4月至2003年4月间我科收治的累及多肝门的巨大肝肿瘤22例，肿瘤平均直径12．9cm（8～23cm）。肿瘤同时累及第1和第3肝门者9例，同时侵及第2、3肝门者8例，累及1、2、3肝门者5例。肝肿瘤包括：原发性肝细胞癌14例，胆管细胞癌1例，肝血管瘤4例，肝母细胞瘤3例。癌灶有完整包膜12例（55．5％），无完整包膜10例（45．5Voo）。对肝肿瘤所施手术方法、并发症防治等进行分析。结果 全部病例均手术切除，无手术死亡，术中平均出血量1480ml（450～4200m1），12例施行第1肝门阻断，10例采用了肝门区域选择性血管阻断，手术时间平均195min。术后无严重并发症，均治愈出院。本组22例病人经1～8年随访，术后存活时间最长已达8年，1年生存率为90．9％（20／22）。结论 对于累及多肝门的巨大肝肿瘤，只要正确把握手术指征，熟练掌握切肝技术，手术切除是安全的、可行的最佳治疗手段。     

Repeated Hepatic Dearterialization for Unresectable Carcinomas of the Liver: Report of a 10-Year Experience

The effectiveness of repeated hepatic dearterialization (RHD) therapy was evaluated in 26 patients with unresectable primary and secondary liver tumors. RHD was performed in 12 patients with hepatocellular carcinoma (HCC), 7 with hepatic metastases from colorectal carcinoma, and 7 with hepatic metastases from gastric carcinoma. It was repeatedly carried out by occluding the hepatic artery for 1 h twice daily. All patients concurrently received an intra-arterial infusion of anticancer drugs. More than 50% remission of the hepatic tumors, defined as a partial response (PR), was demonstrated in 8 patients (31%). A higher PR was seen in hepatic tumors from metastatic gastric cancer (5 out of 7 patients; 71%). Most patients who suffered severe complications had HCC with liver cirrhosis. These preliminary results suggest that RHD with intra-arterial chemotherapy is an acceptable palliative treatment for patients with unresectable liver metastasis from gastric cancer; however, the majority of patients with HCC are not responsive to such treatment, primarily because most have underlying cirrhosis predisposing to the development of postoperative complications at an unacceptably high rate. Received: August 24, 2000 / Accepted: May 15, 2001     

Hepatic Neuroendocrine Metastases: Chemo- or Bland Embolization?

Introduction  Aggressive management of hepatic neuroendocrine (NE) metastases improves symptoms and prolongs survival. Because of the rarity of these tumors, however, the best method for hepatic artery embolization has not been established. We hypothesized that in patients with hepatic NE metastases, hepatic artery chemoembolization (HACE) would result in better symptom improvement and survival compared to bland embolization (HAE). Methods  Retrospective review identified all patients with NE hepatic metastases managed by HACE or HAE at three institutions from January 1996 through December 2007. Results  We identified 100 patients managed by HACE (n = 49) or HAE (n = 51) that were similar with respect to age, gender, and primary tumor type. The percentage of patients experiencing morbidity, 30-day mortality, and symptom improvement were similar between the two groups (HACE vs. HAE: 2.4% vs. 6.6%; 0.8% vs. 1.8%; and 88% vs. 83%, respectively.) No differences in the median overall survival were observed between HACE and HAE from the time of the first embolization procedure (25.5 vs. 25.7 months, p = 0.79). Multivariate analysis revealed that resection of the primary tumor predicted survival (73.8 vs. 19.4 months, p < 0.04). Conclusions  These data suggest that morbidity, mortality, symptom improvement, and overall survival are similar in patients with hepatic neuroendocrine metastases managed by chemo- or bland hepatic artery embolization. Grant Support American College of Surgeons Resident Research Scholarship, National Institutes of Health Grant T32 CA009614 Physician Scientist Training in Cancer Medicine. Presented at Society for Surgery of the Alimentary Tract, May 21, 2008, San Diego, CA, USA.     

Radiofrequency Ablation of Unresectable Primary and Metastatic Hepatic Malignancies: Results in 123 Patients

OBJECTIVE: To describe the safety and efficacy of radiofrequency ablation (RFA) to treat unresectable malignant hepatic tumors in 123 patients. BACKGROUND: The majority of patients with primary or metastatic malignancies confined to the liver are not candidates for resection because of tumor size, location, or multifocality or inadequate functional hepatic reserve. Local application of heat is tumoricidal; therefore, the authors investigated a novel RFA system to treat patients with unresectable hepatic cancer. PATIENTS AND METHODS: Patients with hepatic malignancies were entered into a prospective, nonrandomized trial. The liver tumors were treated percutaneously or during surgery under ultrasound guidance using a novel LeVeen monopolar array needle electrode and an RF 2000 generator. All patients were followed to assess complications, treatment response, and recurrence of malignant disease. RESULTS: RFA was used to treat 169 tumors (median diameter 3.4 cm, range 0.5 to 12 cm) in 123 patients. Primary liver cancer was treated in 48 patients (39.1%), and metastatic liver tumors were treated in 75 patients (60.9%). Percutaneous and intraoperative RFA was performed in 31 patients (35.2%) and 92 patients (74.8%), respectively. There were no treatment-related deaths, and the complication rate after RFA was 2.4%. All treated tumors were completely necrotic on imaging studies after completion of RFA treatments. With a median follow-up of 15 months, tumor has recurred in 3 of 169 treated lesions (1.8%), but metastatic disease has developed at other sites in 34 patients (27.6%). CONCLUSIONS: RFA is a safe, well-tolerated, and effective treatment to achieve tumor destruction in patients with unresectable hepatic malignancies. Because patients are at risk for the development of new metastatic disease after RFA, multimodality treatment approaches that include RFA should be investigated.     

经腹肝动脉门静脉双置泵栓塞灌注化疗治疗中晚期肝癌

目的探讨提高中晚期肝癌外科治疗的有效途径。方法回顾性分析经腹肝动脉门静脉双置泵栓塞灌注化疗治疗不能手术切除的中晚期肝癌３８例的临床资料。结果肿瘤直径５～１８ｃｍ,平均９２ｃｍ,皆为多供血型。巨块型２４例,结节型８例,弥漫型６例。伴门静脉癌栓１８例。肝动脉栓塞采用４０℃的碘油和明胶海绵微粒;化疗药物采用阿霉素（ＡＤＭ）,顺铂（ＤＤＰ）,丝裂霉素Ｃ（ＭＭＣ）和氟脲嘧啶（５Ｆｕ）。３２例甲胎蛋白值升高者治疗后１６例降至正常。肿瘤直径平均缩小４５％。８例行二期手术切除肿瘤,其生存期均在１２个月以上,最长已达３年;未行二期手术者３０例,中位生存期为９６个月。结论经腹肝动脉门静脉双置泵栓塞灌注化疗,附加局部注射无水酒精和热电疗法,是治疗不能手术切除中晚期肝癌首选而有效的方法。