肝动脉栓塞加手术切除治疗大肝癌37例

作者报告３７例大肝癌采用肝动脉栓塞（ＴＡＥ）加手术切除的疗效及临床病理研究结果。３７例肝癌直径５～２４ｃｍ（平均１１．２Ｃｍ）。ＴＡＥ与动脉灌注化疗同时进行。化疗药物括氟尿嘧啶（５－ＦＵ）、阿霉素（ＡＤＭ）或表阿霉素（Ｅ－ＡＤＭ）、丝裂霉素（ＭＭＣ）和顺铂（ＣＤＤＰ）。多采用三种药物联合方案。肝动脉末梢栓塞剂采用国产或进口碘化油,用明胶海绵颗粒作近端栓塞。手术切除前进行１～４次ＴＡＥ,每次相隔４～６周。１７例ＡＦＰ值增高者ＴＡＥ后１０例降至正常水平。肿瘤直径由平均１１．２ｃｍ降至８．５ｃｍ（缩小２６％）。栓塞后手术切除病理标本显示９２％有肿瘤组织坏死,范围达４０％～１００％。１、２、３年生存率分别为８０％、６６．７％和５３．３％。作者认为ＴＡＥ加手术切除是大肝癌的有效治疗方法。     

双吻合器吻合法在直肠癌保肛手术中的应用

目的评估双吻合器吻合法在直肠癌保肛手术应用中的安全性和实用性。方法回顾总结４年中采用该技术行直肠癌手术９７例。癌灶下缘距肛缘平均距离８２ｃｍ,其中３～７ｃｍ４２例（４３３％,４２／９７）,大于８ｃｍ５５例（５６７％,５５／９７）。结果所有患者吻合器切除圈完整。术后吻合口漏９例（９３％,９／９７）,肿瘤距肛缘小于７ｃｍ患者的吻合口漏发生率显著高于距离大于７ｃｍ的患者（Ｐ＜０．０５）,神经性膀胱排空障碍５例（５２％,５／９７）,切口感染７例（７２％,７／９７）,吻合口出血４例（４１％,４／９７）,术后肛门部疼痛１例（１０％,１／９７）。结论双吻合器吻合法可作为低位直肠癌保肛手术的一种安全可靠的术式选择。     

手术前肝动脉插管化疗栓塞对肝癌术后复发的影响

本文报道了３２例经肝动脉插管栓塞化疗（ＴｒａｎｓｈｅｐａｔｌｉａｒｔｅｒｉａｌＣｈｅｍｏｔｈｅｒａｐｙａｎｄＥｍｂｏｌｉｚａｔｉｏｎ，ＴＡＣＥ）后二步手术的肝癌患者（二步手术组）的临床资料和手术后的随访情况。ＴＡＣＥ后肿瘤最大直径平均下降３．５６ｃｍ（３６．６％），４例降至５ｃｍ以下，ＡＦＰ平均下降７７．３％，５例转为正常，无一例出现严重并发症。二步手术组随访２年，１１例（３４．４％）复发，与同期３５例一步手术组（１４例４０．０％复发）比较、无明显差异。但二步手术组的平均复发时间为７．０９±３．２７个月，较一步手术组的４．２９±３．２９个月显著延长．以上结果表明，术前ＴＡＣＥ能杀死肿瘤细胞，缩小肿瘤体积，延长手术后无瘤生存时间，是治疗原发性肝癌的一种有效手段。     

术前肝动脉化疗栓塞对肝细胞癌切除术疗效影响的探讨

为了探讨术前肝动脉栓塞（ＴＡＥ）能否改善肝癌切除术预后，作者分析了肿瘤直径３ｃｍ以上，无门静脉癌栓的７７例患者，术前进否行肝动脉化疗栓塞对肝癌切除术后疗效影响，７７例患者按术前是否接受ＴＡＥ分为栓塞组（Ａ组，ｎ＝２６）和非栓塞组（Ｂ组，ｎ＝５１），每组按肿瘤直径再分Ａ１，Ｂ１（３～８ｃｍ），Ａ２，Ｂ２（〉８．０ｃｍ）两个亚组，结果术后１，２，３年无瘤存活率各组分别为Ａ１组（ｎ＝１４）的５０．０％，     

小肝癌手术切除82例临床分析

目的探讨影响小肝癌手术疗效的相关问题。方法回顾性分析８年间手术切除的８２例瘤径≤５０ｃｍ的小肝癌。其中ＨＢｓＡｇ（＋）６０例,合并肝硬变７１例。７８例肝细胞癌的高、中、低分化分别为１５、５３和１０例。行联合肝段切除１３例,肝段切除１４例,局部肝切除５５例。结果手术病死率为１２％,术后１、３、５年生存率分别为９２７％、７２５％、５４３％。高、中、低分化组术后５年生存率分别为７９６％、４９９％和４１１％。术后１、３、５年复发率分别为１２８％、４０７％、７１５％。结论小肝癌具有与大肝癌相同的肝病史,早期发现和限量肝切除是减少术后并发症、提高术后生存率的重要途径。     

经括约肌或尾骨入路的直肠肿瘤局部切除术

本文报道９例低恶性或良性的直肠肿瘤行局部切除术的结果。其中广基无蒂绒毛状腺瘤６例，距肛缘４～９ｃｍ，肿瘤直径２．０～３．５ｃｍ；类癌２例．肿瘤距肛缘７ｃｍ，直径０．５～０．８ｃｍ；血管瘤１例，肿瘤距肛缘４ｃｍ，大小为２．５ｃｍ×５ｃｍ。经肛门前括约肌局部切除４例，经尾骨局部切除４例，经尾骨及括约肌局部切除１例。术后无肛门失禁及复发。作者认为经肛门括约肌或尾骨入路的肿瘤局部切除术对于距肛缘１０ｃｍ以下的直肠低恶性或良性肿瘤是较理想的手术方式。     

胫后动脉逆行皮瓣修复足跟部肿瘤性软组织缺损

我院自１９９５年４月。采用胫后动脉逆行皮瓣修复３例足跟部肿瘤性软组织缺损。临床资料本组３例患者均为男性,年龄分别为３７、３９和５９岁,病程为１～１．５年。部位：足跟２例,足跟后侧１例。肿瘤大小：６ｃｍ×５ｃｍ～７ｃｍ×５ｃｍ。所有诊断均经术后病理组织学证实,恶性黑色素瘤。横纹肌肉瘤、鳞状细胞癌各１例,均行肿瘤扩大切除、腔后动脉逆行皮瓣修复术,皮瓣大小９ｃｍ×７ｃｍ～１０ｃｍ×８ｃｍ,术后皮瓣血运良好,切口一期愈合。２例术后行放疗及定期化疗（ＣＶＡＤＩＣ）,另１例行非定期化疗（ＣＶＡＤＩＣ）。随访…     

肝动脉栓塞加手术切除治疗大肝癌37例

作者报告３７例大肝癌采用肝动脉栓塞（ＴＡＥ）加手术切除的疗效及临床病理研究结果。３７例肝癌直径５￣２４ｃｍ（平均１１．２ｃｍ），ＴＡＥ与动脉灌注化疗同时进行，化疗药物包括氟尿嘧啶（５－ＦＵ），阿霉素（ＡＤＭ）或表阿霉素（Ｅ－ＡＤＭ），丝裂霉素（ＭＭＣ）和顺铂（ＣＤＤＰ），多采用三种药物联合方案，肝动脉末梢栓塞剂采用国产或进口碘化油，用明胶海绵颗粒作近端栓塞。手术切除前进行１￣４次ＴＡＥ，每次相隔４     

巨大无功能胰岛细胞瘤手术问题探讨

巨大无功能胰岛细胞瘤的生长部位特殊，肿瘤切除困难较大。我院１９８０．１～１９９７．１月共收治１３例，男４例，女９例，年龄１８～６４岁，病程１个月至９年。定位检查：１３例中胃肠钡透共５例，十二指肠窗无变化２例、开大１例，胃受压移位并十二指肠窗开大２例。经内窥镜逆行性胰胆管造影术（ＥＲＣＰ）检查１例，见主胰管受压移位。同时做Ｂ型超声和ＣＴ检查７例，除１例外，６例可确定与周围脏器的关系。本组肿瘤位于胰头部和体部各５例，体尾部２例，单纯胰尾部１例。直径６～２０ｃｍ。结果：１３例中２例曾在外院探查未切除，…     

肝叶切除治疗特大肝癌

对于直径＞１０ｃｒｎ的原发性肝癌（简称肝癌）的治疗,目前认为手术切除仍然是最有效的手段之一。１９８５年１月至１９９６年６月我院共手术切除治疗直径＞１５ｃｍ以上的特大肝癌８６例,效果良好。临床资料８６例中男性７７例,女性９例。年龄最小２２岁,最大６７岁,平均４６．１岁。肿瘤直径：１５～２０ｃｒｎ者７７例,２０～２５ｃｍ者７例,＞２５ｃｒｎ者２例,其中最大肿瘤为３６．０。Ｘ１９．５ｃｒｕＸ１６．０ｃｍ。全组行规则性肝叶切除４６例（５３．４９％）,包括右三叶１例,左三叶１例,中肝叶２例;不规则性肝叶切…     

不同治疗模式对不能切除的肝癌二期手术预后的影响

目的探讨不能切除的肝细胞癌(HCC)经皮穿刺肝动脉化疗栓塞(TACE)及经手术肝动脉结扎、置管化疗栓塞(HALCE)缩小后二期切除的疗效,并比较不同治疗模式对预后的影响.方法204例HCC二期切除患者,分成TACE组及HALCE组.TACE组112例,行TACE1～7次(中位2.4).HALCE组92例,其中49例行HALCE,7例行HALCE+肝脏外放射治疗,36例行HALCE+导向内放射治疗.肿瘤缩小后予以切除.选择7个可能对HCC二期切除术后预后产生影响的临床因素通过单因素、多因素Cox模型对预后进行分析.结果随访至1999年6月,首次TACE及HALCE后1、3、5、7年生存率分别为95.7%、69.3%、56.5%及44.5%,切除肿瘤后1、3、5、7年生存率分别为88.5%、64.9%、51.9%及38.3%.TACE组及HALCE组1、3、5、7年生存率分别为94.1%、64.7%、51.2%、40.8%和96.3%、73.9%、61.6%、45.2%,2组差异无显著性意义(P＞0.05).影响预后的主要因素是肝硬化程度和肿瘤坏死程度(P＜0.05).TACE组中肝硬化程度、缩小后肿瘤有无包膜及肿瘤坏死程度是影响预后的主要因素(P＜0.05),而HALCE组各因素对预后影响差异无显著性意义(P＞0.05).结论不能一期切除的HCC缩小后应进行二期切除,且可获得满意疗效.而肝硬化程度、肿瘤坏死程度是影响肝癌二期切除预后的主要因素.     

经皮微波凝固治疗不能切除肝癌及其疗效分析(附108例报告)

目的 探讨经皮微波凝固治疗不能切除肝癌的方法并观察其疗效。方法 1999年10月至2001年4月运用UMC—1型超声引导微波凝固治疗仪治疗108例不能切除肝癌，肿瘤直径3—18cm，其中≤5cm者7例，1个肿瘤者56例，2个以上肿瘤者52例，伴门静脉主支癌栓23例。在B超引导下，穿刺至肿瘤部位，每次输出功率60W，作用时间300s，每100s间歇20s。肿瘤直径＜3cm者经行1—2次微波治疗，≥3cm以上者行多点多次(＞2次)治疗。结果 68例AFP阳性病人中32例(42％)降至正常，14例(20．6％)AFP有不同程度下降；治疗后3个月肿瘤直径平均缩小3．0cm；术后6个月、1年、2年生存率分别为80．7％、62．9％及35．1％，108例中18例因肿瘤缩小获二期切除。结论 不能切除的中晚期肝癌可用经皮微波凝固治疗，其安全、方便、易行，疗效佳。     

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。     

术前经动脉化疗栓塞在肝母细胞瘤治疗中的应用

目的 探讨肝母细胞瘤术前介入性肝动脉化疗栓塞(transarterial chemoembolization，TACE)的临床可行性、疗效及适应证及在综合治疗中的地位。方法 对常规估计不能切除的13例肝母细胞瘤先行经动脉化疗栓塞，再行Ⅱ期外科手术切除，观察分析患儿临床症状的变化反应、术中情况和远期疗效。结果 TACE术后数天至1个月复查，肿瘤体积明显缩小7．5％～66．3％(平均38．0％)，AFP水平显著降低11％～61．2％(平均52．3％)，无明显的化疗毒性反应，TACE后其中11例患儿都安全地施行外科手术，手术切除标本的病理改变肿瘤明显坏死，平均坏死区域面积达70．9％。介入后2年死于肺转移1例，介入后3年死于肺、脑转移的1例，肝移植后死亡1例，3个月后肝衰竭者1例，3例复发，无瘤存活6例，其平均生存期22．3个月，平均随访时间为30个月。结论 TACE能有效杀死肿瘤细胞，控制肿瘤生长，使部分不能Ⅰ期手术的患儿重新获得手术机会，改善预后，无严重并发症，是一种安全、有效、实用的肝母细胞瘤的辅助治疗方法，而且对防止术中肿瘤细胞的扩散也有一定的作用。     

Management of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most common tumors globally, with varying prevalence based on endemic risk factors. In high-risk populations, including those with hepatitis B or C or with cirrhosis, serum α-fetoprotein (AFP) and screening ultrasound have improved detection of resectable HCC. Treatment options, including surgical resection, for patients with HCC must be selected based on the number and size of hepatic tumors, underlying hepatic function, patient condition, and available resources. An approach, which has been summarized shows the corresponding treatment choices under given clinical circumstances. For cirrhotic patients with less than three tumor nodules of a size less than 3 cm or a solitary HCC less than 5 cm, liver transplantation offers long-term survival similar to that observed in patients transplanted for nonmalignant disease. Ablative treatment using either chemical or thermal techniques provides locally effective tumor destruction. Transcatheter arterial chemoembolization (TACE) is commonly used for palliation of unresectable tumors as well as an adjunct to surgical resection, treatment of tumors before transplant, and in conjunction with other ablative therapies in a multimodality approach. Regional approaches to chemotherapy have produced more encouraging results than systemic chemotherapy, although both remain ineffective for long-term tumor control. Several newer treatment modalities are under investigation, including gene therapy, tagged antibodies, isolated perfusion, and novel radiotherapy techniques.     

Influence of preoperative transarterial lipiodol chemoembolization on resection and transplantation for hepatocellular carcinoma in patients with cirrhosis.

OBJECTIVE: To investigate the impact of preoperative transarterial lipiodol chemoembolization (TACE) in the management of patients undergoing liver resection or liver transplantation for hepatocellular carcinoma. PATIENTS AND METHODS: TACE was performed before surgery in 49 of 76 patients undergoing resection and in 54 of 111 patients undergoing liver transplantation. Results were retrospectively analyzed with regard to the response to treatment, the type of procedure performed, the incidence of complications, the incidence and pattern of recurrence, and survival. RESULTS: In liver resection, downstaging of the tumor by TACE (21 of 49 patients [42%]) and total necrosis (24 of 49 patients [50%]) were associated with a better disease-free survival than either no response to TACE or no TACE (downstaging, 29% vs. 10% and 11 % at 5 years, p = 0.08 and 0.10; necrosis, 22% vs. 13% and 11% at 5 years, p = 0.1 and 0.3). Five patients (10%) with previously unresectable tumors could be resected after downstaging. In liver transplantation, downstaging of tumors >3 cm (19 of 35 patients [54%]) and total necrosis (15 of 54 patients [28%]) were associated with better disease-free survival than either incomplete response to TACE or no TACE (downstaging, 71 % vs. 29% and 49% at 5 years, p = 0.01 and 0.09; necrosis, 87% vs. 47% and 60% at 5 years, p = 0.03 and 0.14). Multivariate analysis of the factors associated with response to TACE showed that downstaging occurred more frequently for tumors >5 cm. CONCLUSIONS: Downstaging or total necrosis of the tumor induced by TACE occurred in 62% of the cases and was associated with improved disease-free survival both after liver resection and transplantation. In liver resection, TACE was also useful to improve the resectability of primarily unresectable tumors. In liver transplantation, downstaging in patients with tumors >3 cm was associated with survival similar to that in patients with less extensive disease.     

Current role of portal vein embolization/hepatic artery chemoembolization

This article has reviewed indications, methods, and results of PVE and TACE for hepatobiliary tumors. PVE is applied mainly to increase the safety of major hepatic resection in patients with hilar cholangiocarcinoma, HCC, or metastatic liver tumors. Hepatic arterial embolization causes selective ischemia of the liver tumor and enhances the cytotoxicity of the chemotherapeutic agent administered concomitantly. A survival benefit of TACE in patients with unresectable or recurrent HCC has been demonstrated. The significance of preoperative TACE is still controversial. TACE is routinely performed before PVE in HCC patients.     

Comparison of transarterial chemoembolization in patients with unresectable,diffuse vs focal hepatocellular carcinoma

HYPOTHESIS: Transarterial chemoembolization (TACE) is beneficial for selected patients with unresectable hepatocellular carcinoma (HCC). DESIGN AND SETTING: A prospective comparison study in a tertiary hospital. STUDY PERIOD: November 21, 1995, to May 2, 2001, with a mean follow-up of 939 days. PATIENTS: A total of 157 TACE treatments were performed in 88 patients with unresectable HCC: 132 treatments in 69 patients with focal HCC (F-HCC) and 25 treatments in 19 patients with diffuse HCC (D-HCC). INTERVENTIONS: Transarterial chemoembolization consisted of selective catheterization and intra-arterial infusion of a mixture of doxorubicin hydrochloride, cisplatin, and mitomycin followed by embolization. Sequential treatments were performed for bilobar HCC. MAIN OUTCOME MEASURES: Child-Pugh classification and clinical outcomes, including alpha-fetoprotein (AFP) response, length of hospital stay, readmission rate, and survival, were compared between patients with F-HCC and D-HCC following TACE using the chi(2) test, Fisher exact test, or t test (2-tailed, unpaired). RESULTS: Fifty-eight patients (84%) in the F-HCC group and 18 patients (95%) in the D-HCC group had cirrhosis. For those patients with cirrhosis, 58 (100%) in the F-HCC group and 14 (78%) in the D-HCC group had a Child-Pugh score of A or B (P =.002). The mean baseline AFP was higher in the D-HCC group: 55 577 vs 7815 ng/mL in the F-HCC group (P =.001). Of the patients secreting AFP, 4 (29%) of 14 in the D-HCC group and 30 (68%) of 44 in the F-HCC group had a significant decrease in AFP 1 month following TACE (P =.01). The mean hospital stay was longer (3 vs 1.9 days; P =.001), and readmissions occurred more frequently (44% vs 9%; P<.001) in the D-HCC group. The mean survival rate was significantly higher in the F-HCC group: 425 vs 103 days (P<.001). CONCLUSIONS: In patients with F-HCC, TACE is well tolerated and provides a survival benefit. However, there is no apparent benefit for patients with D-HCC. Importantly, tumor characteristics and hepatic reserve are essential criteria for successful TACE.     

Liver resection for hepatocellular carcinoma in cirrhotic patients

The incidence of hepatocellular carcinoma (HCC) in cirrhotic patients is increasing. Despite advances in imaging and laboratory screening which allow earlier diagnosis, the surgeon is all too often confronted with an HCC of advanced stage or arising in the setting of severe cirrhosis. Hepatic resection is still considered the treatment of choice for hepatocellular carcinoma in patients with liver cirrhosis. From 1998 to 2005, 6 patients (5 males, 1 female, age 52-70 years, mean age 64.1 years) with HCC associated severe, but well compensated liver cirrhosis (Child A-- 4 patients, Child B--2 patients) underwent 9 hepatic resection in our department. Mean tumor size was 56 mm (range 23-86 mm). Two of these lesions were in the left liver and four in the right lobe. Doppler ultrasonography was performed in all cases and CT in 3 cases to confirm the extension of the lesions. Laparoscopy was performed in 3 patients under CO2 pneumoperitoneum. The Pringle maneuver was not used. The transection of the liver parenchyma was obtained by the use of Ligasure and harmonic scalpel. Nine hepatic resections were performed: 7 segmentectomy and 2 non-anatomical resections. The resection margin was 1 cm. The mean operative time was 90 minutes (range 60-120). Mean blood loss was 250 ml and 2 patients required blood transfusion. One patient died on the tenth postoperative day from a severe respiratory distress syndrome and hepatic failure. Major morbidities occurred in three patients who developed moderate postoperative ascites, which resolved successfully with conservative treatment in two patients. Limited liver resection in cirrhotic patients with HCC is feasible with a low complication rate when careful selection criteria are followed (tumor size smaller than 8 cm, Child-Pugh A class and the good general conditions of the patients). Other medical and interventional treatments (chemoembolization, chemotherapy) can only slow the progress of HCC.     

可切除肝细胞癌合并门静脉癌栓的外科治疗

背景与目的 对于肝细胞癌（HCC）合并门静脉癌栓（PVTT）患者而言,手术切除率低,复发率高,预后较差,其治疗方式目前仍有很多争议。笔者总结可切除HCC合并PVTT的外科治疗经验,比较手术与肝动脉化疗栓塞术（TACE）对此类患者的近远期疗效。方法 回顾性分析云南省临沧市人民医院2016年3月—2021年3月收治的39例可切除HCC合并PVTT患者的临床资料,其中23例患者施行手术治疗（手术组）,16例行TACE治疗（TACE组）。比较两组患者的相关临床资料与预后,并分析影响患者预后的因素。结果 手术组除1例肿瘤广泛侵犯仅取材活检,其余均完成手术,无手术死亡;19例示切缘阴性;2例术后肝功能不全,经人工肝及其他支持治疗痊愈出院。TACE组16例肝动脉超选、灌注、栓塞顺利;1例因肝动脉完全栓塞,术后3 d因急性肝衰竭救治无效死亡。手术组8例术后辅助TACE治疗,5例靶向治疗,其中1例I型PVTT患者手术后联合TACE等治疗后仍生存47个月。TACE组13例多次治疗,4例给靶向药物,其中1例II型PVTT患者TACE术后经过7次灌注化疗及栓塞仍然生存25个月。与TACE组比较,手术组住院时间延长、医疗成本增加、术后行TACE的例数更少、术后未做其他治疗的例数以及术后AFP恢复正常的例数更多（均P<0.05）。手术组与TACE组的中位生存期分别为16.2个月与9.5个月;0.5、1、2、3年生存率分别为65.2%、43.5%、34.8%、17.4%与46.7%、33.3.0%、13.3%、0。两组患者中位生存期与累积生存率差异均有统计学意义（均P<0.05）。单因素分析结果显示,PVTT分型、甲胎蛋白（AFP）水平、肿瘤大小、肿瘤数目与患者术后生存时间有关（均P<0.05）;多因素分析结果显示,治疗方式、PVTT分型、肿瘤直径、AFP水平是患者术后生存时间的独立影响因素（均P<0.05）。结论 PVTT分型、肿瘤直径、AFP水平直接影响HCC合并PVTT患者的术后生存,外科手术切除治疗效果明显好于TACE治疗,尤其是对于可切除HCC合并I/II型PVTT的患者,但治疗选择可能受患者意愿、经济因素等的限制。