Hepatic tumors,surgical treatment and its results

During the period from March 1954 to June 1976, 489 cases of hepatic tumors were experienced at the Department of Surgery, National Taiwan University Hospital. The pathological classification are: Hemangioma 5; Cystic hamartoma 2; Hemangioendothelioma 2; Non-parasitic localized cyst 5; Polycystic liver 9; Tuberculoma 1; Actinomycosis 1; Hyperplasia 1; Adenoma 1; Primary liver sarcoma 2; Primary liver cancer 442; and Metastatic liver cancer 18. Of the 489 hepatic tumors, two cases were treated with excision, 148 cases with hepatic lobectomy and nine cases of polycystic liver were treated with fenestration Benign hepatic tumors are all well up to eight years after the operation, 14 cases of primary liver cancer survived five to 17 years after hepatic lobectomy.     

Hepatic resection for incidentaloma

The study goal was to review a single-center experience in hepatic resection for patients who presented with incidental liver tumors. With recent advances in diagnostic imaging techniques, incidental finding of liver tumors, or "incidentalomas," is increasing in asymptomatic and healthy individuals. However, little information is available in the literature regarding the underlying pathology and operative outcomes after hepatic resection. Between January 1989 and December 2002, 1011 patients underwent hepatic resection for liver tumors; of these patients, 107 (11%) were asymptomatic individuals who presented with incidentalomas. Incidentalomas were first detected on percutaneous ultrasonography (n = 83), computed tomography (n = 23), or magnetic resonance imaging (n = 1). Fifteen (14%) patients had preoperative aspiration for cytology or biopsy for histology, and the results correlated with the final pathology in 12 patients. Fifty-six (52%) patients underwent major hepatic resection with resection of three or more Coiunaud’s segments. Median postoperative hospital stay was 8 days (range, 3–66 days). The operative mortality rate was 1%, and the operative morbidity rate was 21%. Histologic examination of the resected specimen revealed malignant liver tumors in 62 (58%) patients, including hepatocellular carcinoma (HCC) (n = 48), cholangiocarcinoma (n = 8), lymphoma (n = 2), cystadenocarcinoma (n = 2), carcinoid tumor (n = 1), and malignant fibrous histiocytoma (n = 1). Benign pathologies were found in 45 (42%) patients, including focal nodular hyperplasia (n = 17), hemangioma (n = 12), angiomyolipoma (n = 5), cirrhotic regenerative nodule (n = 4), hepatic adenoma (n = 2), and others (n = 5). On multivariate analysis, male sex, age of greater than 50 years, and tumor size of greater than 4 cm were the independent predictive factors for malignant diseases. On retrospective analysis, 48 patients with HCC who presented with incidentalomas had signi.cantly better survival outcomes after hepatic resection than did 646 patients with HCC who presented otherwise during the same study period. Hepatic resection for patients with incidentalomas is associated with a low operative mortality and acceptable morbidity. The diagnosis of malignant disease, especially HCC, should be considered in male patients older than 50 years who present with large hepatic lesions. Presented at the Forty-Fifth Annual Meeting of The Society for Surgery of the Alimentary Tract, New Orleans, LA, May 15–19, 2004 (poster of distinction). Supported by the Sun C.Y. Research Foundation for Hepatobiliary and Pancreatic Surgery of the University of Hong Kong.     

肝癌深度冷冻治疗围手术期并发症13例分析

目的 探讨肝癌深度冷冻治疗围手术期并发症。方法 应用LCS－2000型深度冷冻治癌机治疗肝癌患者65例,男性60例,女性5例,年龄26－72岁,中位年龄54．8岁,癌灶直径小于5cm16例,5－10cm24例,大于10cm25例。其中原发性肝癌54例,国际TNM分期Ⅱ期12例,Ⅲ期14例,Ⅳa期22例,Ⅳb期6例。乙肝表面抗原（HBsAg)阳性率94％（51／54）,甲胎球蛋白（AFP）阳性率70％（38／54）。继发性肝癌11例,原发癌为结肠癌4例、直肠癌2例、胆囊癌2例、胰腺癌1例、乳腺癌1例、后腹膜平滑肌肉瘤1例。结果 全组围手术期并发症13例16个,并发症发生率20％（13／65）。包括术后腹内出血3例、肝功能衰竭3例、上消化道出血6例、感染4例。结论 肝癌浓度冷冻治疗为部分不能手术切除的患者提供了有效的治疗手段,但应严格掌握手术适应证。     

肝门区肿瘤切除中肝脏血流阻断方法的探讨

目的 探讨肝脏血流阻断技术在肝门区肿瘤切除中的合理应用.方法 回顾性分析2005年1月至2008年3月采用第一肝门阻断法(Pringle法)和常温下全肝血流阻断技术(NHVE)相结合切除16例肝门区肿瘤的临床资料,分析肿瘤和肝门区血管的毗邻关系、阻断次数、阻断时间、术中出血量、输血量、术后并发症等指标.结果 本组16例患者采用Pringle法与NHVE相结合技术切除肿瘤,Pringle法平均阻断(3.8±1.6)次,平均阻断时间(46.6±28.8)min;NHVE平均阻断(1.6±0.4)次,平均阻断时间(23.5±8.2)min;术中出血量平均(1250±320)ml,输血量平均(860±245)ml;术中修补下腔静脉损伤4例,肝静脉损伤2例,门静脉主干损伤2例;术后均有肝脏酶学指标、胆线素不同程度的升高,经保肝等治疗后恢复正常,未发牛肝功能衰竭等严重并发症.结论 Pringle法与NHVE技术分步结合使用可减少全肝血流阻断时间、增加肝门区肿瘤切除的安全性.     

Rate of perioperative complications in thermal ablation of bone: an animal trial

Introduction While only few data are available yet for radioablation of bone tissue, the occurrence of bone marrow embolisms during cryoablation has been documented. It was the aim of this study to assess perioperative complication rates of thermoablation in animals using state-of-the-art ablation probes.Materials and methods Eight adult sheep were placed under general anaesthesia, and using a radioprobe, thermoablation was performed on the medial side of the head of the right tibia. In addition, freezing was performed with miniature cryoprobes on both femurs and the head of the left tibia. Haemodynamic monitoring and determination of blood gases and electrolytes were done intraoperatively. The animals were killed 1 week after surgery, and the ablation sites and lung tissue examined macroscopically and microscopically.Results None of the animals showed pathological changes in any of these parameters. Blood gases remained unremarkable throughout the operation. All eight animals showed an average drop in haemoglobin of 0.97 g/100 ml. Two animals showed fresh embolisms in the pulmonary vessels.Conclusion Experimental thermoablation of bone tissue in large animals failed to show any significant perioperative complications following surgery. The lung embolisms which did occur were not clinically relevant. The use of mini-cryoprobes or radioprobes as alternative or complementary measures for treating pathologically altered bone tissue seems viable and does not involve any undue risks.     

Ethanol Injection of Hepatic Tumors

To assess the efficacy of intratumoral injections of absolute ethanol in the treatment of hepatic tumors, 18 New Zealand White rabbits underwent implantation of two 1-mm³ fragments of the VX-2 carcinoma. The animals were reexplored 2 weeks postimplant and the tumors measured. One nodule was treated by intratumoral injections of 2.28 ± 0.72 mL of absolute ethanol; the second was injected with an equal amount of normal saline. The animals were sacrificed 4 weeks postimplant, and the tumors were measured and microscopically examined. On gross inspection, tumor size, expressed as the product of the largest and smallest diameters. was 4.59 ± 3.4 cm² fir the ethanol-injected tumors vs 6.73 ± 2.1 cm² for the saline-treated nodules (p =. 01). Histologic sections through the largest tumor diameter were microscopically examined using a computerized image analyzer. The mean cross-sectional area of viable tumor was 0.51 ± 0.3 cm² for the ethanol-treated nodules vs 2.01 f 0.5 cm² for the saline-treated nodules (p <. 001). Contrast-enhanced CT and MRI studies were able to provide valuable information in terms of tissue characterization, which will be useful in differentiating viable tumor from necrotic tumor and infarcted liver. We conclude that intratumoral ethanol injection inhibits growth of liver tumors in this experimental model and deserves further study.     

Single-Incision Laparoscopic Surgery Versus Standard Laparoscopic Surgery for Unroofing of Hepatic Cysts

Background and Objectives:

The aim of this report is to document the feasibility and safety of umbilical single-incision laparoscopic liver cyst unroofing in the treatment of simple hepatic cysts in a retrospective case-control study. We also introduce some operative skills for single-incision laparoscopic surgery.

Methods:

From May 2009 to July 2011, 15 patients underwent umbilical single-incision laparoscopic liver cyst unroofing. All the clinical data were retrospectively analyzed. Another 15 simple liver cyst patients who received standard laparoscopic liver cyst unroofing at our hospital during the same period—with a similar age, nature of the cyst, and position to the single-incision group—were selected to undergo a case-control study. The operative time, blood loss, recovery time of gastrointestinal function, volume of postoperative drainage, postoperative drainage time, postoperative hospitalization time, and postoperative recurrence rate were compared between the two groups.

Results:

There was no significant difference between the single-incision group and standard group in operative time (58.3 ± 7.43 minutes vs 58.7 ± 6.14 minutes), blood loss (17.0 ± 3.19 mL vs 14.7 ± 1.86 mL), recovery time of gastrointestinal function (2.5 ± 0.22 days vs 2.4 ± 0.22 days), volume of postoperative drainage (408.0 ± 119.5 mL vs 450.0 ± 89.5 mL), postoperative drainage time (2.6 ± 0.55 days vs 3.7 ± 0.59 days), or postoperative hospitalization time (4.8 ± 0.44 days vs 5.2 ± 0.56 days) (P > .05). The postoperative follow-up period was 1 to 24 months.

Conclusions:

Compared with standard laparoscopic liver cyst unroofing, single-incision laparoscopic liver cyst unroofing shows no significant difference during the overall treatment process. In addition to the advantages of less trauma, more rapid recovery, and shorter hospital stay, single-incision laparoscopic surgery can reach the effect of “no scar” and can be safely and effectively carried out.     

Local Recurrence After Laparoscopic Radiofrequency Thermal Ablation of Hepatic Tumors

Background: Since we first described laparoscopic radiofrequency ablation (LRFA) of liver tumors, several reports have documented technical and safety aspects of this procedure. Little is known, however, about the long-term follow-up of such patients.Methods: From January 1996 to February 1999, we performed LRFA on 250 liver tumors in 66 patients. Triphasic spiral computed tomographic scanning was obtained preoperatively and at 1 week, and every 3 months postoperatively. Lesion diameter was measured in the x- and y-axes and the volume estimated; 181 lesions in 43 patients for whom computed tomographic scans available were included in the study. The tumor types were as follows: 64 metastatic adenocarcinomas, 79 neuroendocrine metastases, 27 other metastases, and 11 primary liver tumors.Results: One week postoperatively, the ablated zone was larger than the original tumor in 178 of 181 lesions, which suggests ablation of the tumor and a margin of normal liver tissue. A progressive decline in lesion size was seen in 156 (88%) of 178 lesions, followed for at least 3 months (mean, 13.9 months; range, 4.9–37.8 months), which suggests resorption of the ablated tissue. Fourteen definite local treatment failures were apparent by increase in size and change in computed tomographic scan appearance, and eight lesions were scored as failures because of multifocal recurrence that encroached on ablated foci (22 total recurrences). Predictors of failure include lack of increased lesion size at 1 week (2 of 3 such lesions failed), adenocarcinoma or sarcoma (18 of 22 failures; P < .05), larger tumors (failures, M < 18cm³ vs. successes, M < 7cm³; P < .005) and vascular invasion on laparoscopic ultrasonography. By size criteria, 17 of 22 failures were apparent by 6 months. Energy delivered per gram of tissue was not significantly different (P < .45).Conclusions: LRFA has a 12% local failure rate, with larger adenocarcinomas and sarcomas at greatest risk. Failures occur early in follow-up, with most occurring by 6 months. LRFA seems to be a safe and effective treatment technique for patients with primary and metastatic liver malignancies.Presented at the 52nd Annual Meeting of the Society of Surgical Oncology, Orlando, Florida, March 4–7, 1999     

肝三叶切除术11例报告

目的 评价肝三叶切除治疗肝巨大肿瘤的手术技术和经验。 方法 本组肝三叶切除术１１例术前肝功能均为Ｃｈｉｌｄ Ａ级，无肝硬化。瘤体最大横径为１２￣３５ｃｍ，行右三叶切除７例，左三叶切除４例。术中施行全肝血流阻断６例，阻断时间为６￣２２分钟，其中在全肝血流阻断下成功修复损伤的下腔静脉和主肝静脉各２例。 结果 术中输血４００￣１６００ｍｌ，无手术死亡。术后并发症：胆瘘和右侧胸腔积液各２例。切除肿瘤湿重量     

Laparoscopic cryosurgery for hepatic tumors

Background: Hepatic cryosurgery has been shown to be a safe technique that may be well suited to a laparoscopic approach. Methods: The technical feasibility and safety of laparoscopic cryosurgery was explored first in a pig model. Thereafter we performed the first successful case of laparoscopic hepatic cryosurgery at our institution. Results: In the animal model, we found that it is possible to safely identify, target, and cryoablate specific lesions in the liver. Temperature in the peritoneal cavity remained above 35°C, and pathologic examination of the abdominal wall around the cryoprobe site revealed no damage. We also successfully treated a 62-year-old man with a metastatic colorectal carcinoma deep in the right lobe of the liver with laparoscopic cryosurgery using a transpleural approach. Conclusion: We conclude that laparoscopic cryosurgery is feasible for lesions anywhere in the liver. For lesions high on the dome of the liver, a transpleural approach may provide better access.     

良性肝脏肿瘤肝移植相关进展

肝脏肿瘤分为良性和恶性,其中良性肝脏肿瘤较为常见,治疗以随访观察、介入治疗为主,仅少数情况下需要进行外科手术切除治疗。肝移植可有效治疗终末期肝病,但通常不作为良性肝脏肿瘤的治疗手段,仅存在巨大占位压迫、合并肝衰竭、肿瘤破裂出血风险或恶变风险的良性肝脏肿瘤才考虑进行肝移植治疗。与恶性肿瘤及慢性肝衰竭肝移植相比,良性肝脏肿瘤肝移植手术风险相当,预后及远期生存较为理想。但良性肝脏肿瘤肝移植术前应充分谨慎评估,同时注意新形势下供肝匹配难度。本文对良性肝脏肿瘤包括肝血管瘤、多囊肝、肝细胞腺瘤、肝脏间叶错构瘤等肝移植相关研究进展进行总结,旨在为肝移植治疗良性肝脏肿瘤提供参考。     

Surgical treatment of hepatic tumors in children: lessons learned from liver transplantation

Purpose

Hepatectomy remains a complex operation even in experienced hands. The objective of the present study was to describe our experience in liver resections, in the light of liver transplantation, emphasizing the indications for surgery, surgical techniques, complications, and results.

Methods

The medical records of 53 children who underwent liver resection for primary or metastatic hepatic tumors were reviewed. Ultrasonography, computed tomographic (CT) scan, and needle biopsy were the initial methods used to diagnose malignant tumors. After neoadjuvant chemotherapy, tumor resectability was evaluated by another CT scan. Surgery was performed by surgeons competent in liver transplantation. As in liver living donor operation, vascular anomalies were investigated. The main arterial anomalies found were the right hepatic artery emerging from the superior mesenteric artery and left hepatic artery from left gastric artery. Hilar structures were dissected very close to liver parenchyma. The hepatic artery and portal vein were dissected and ligated near their entrance to the liver parenchyma to avoid damaging the hilar vessels of the other lobe. During dissection of the suprahepatic veins, the venous infusion was decreased to reduce central venous pressure and potential bleeding from hepatic veins and the vena cava.

Results

Fifty-three children with hepatic tumors underwent surgical treatment, 47 patients underwent liver resections, and in 6 cases, liver transplantation was performed because the tumor was considered unresectable. There were 31 cases of hepatoblastoma, with a 9.6% mortality rate. Ten children presented with other malignant tumors—3 undifferentiated sarcomas, 2 hepatocellular carcinomas, 2 fibrolamellar hepatocellular carcinomas, a rhabdomyosarcoma, an immature ovarian teratoma, and a single neuroblastoma. These cases had a 50% mortality rate. Six children had benign tumors—4 mesenchymal hamartoma, 1 focal nodular hyperplasia, and a mucinous cystadenoma. All of these children had a favorable outcome. Hepatic resections included 22 right lobectomies, 9 right trisegmentectomies, 8 left lobectomies, 5 left trisegmentectomies, 2 left segmentectomies, and 1 case of monosegment (segment IV) resection. The overall mortality rate was 14.9%, and all deaths were related to recurrence of malignant disease. The mortality rate of hepatoblastoma patients was less than other malignant tumors (P = .04).

Conclusion

The resection of hepatic tumors in children requires expertise in pediatric surgical practice, and many lessons learned from liver transplantation can be applied to hepatectomies. The present series showed no mortality directly related to the surgery and a low complication rate.     

肝移植术后肝动脉血栓形成的预防

目的 探讨肝移植术后肝动脉血栓形成(hepatic artery thrombosis,HAT)的预防.方法 2004年1月至2007年12月我院器官移植科共实施596例成人尸肝移植,自2005年开始采取综合措施预防HAT形成,包括术中重建变异肝动脉,受体肝动脉条件不好的患者采取供体肝动脉与受体腹主动脉搭桥,动脉吻合全部采用显微缝合技术,术后常规监测移植肝血流,对肝动脉峰值流速低于40 cm/s的患者行抗凝治疗.比较2004年实施的181例肝移植患者(A组)与2005-2007年实施的415例肝移植患者(B组)HAT发生情况.结果 A组共有8例患者出现HAT,发生的中位时间为术后11 d(3～41 d),3例表现为急性肝功能恶化,3例表现为胆漏,1例表现为肝脓肿,1例无明显临床症状.B组共有6例患者出现HAT,发生时间为术后8 d(1～21 d),3例表现为急性肝功能恶化,1例表现为胆漏,2例无明显临床症状.B组患者HAT发生率明显低于A组(1.44%vs4.42%,X~2=4.86,P=0.027).A组3例行再次肝移植,共死亡5例,B组3例行肝动脉重建联合肝动脉局部溶栓治疗,2例患者康复出院,1例患者因严重感染、肾功能衰竭死亡.3例患者接受再次肝移植.结论 肝动脉血栓形成是肝移植术后的严重并发症,术中采用显微缝合方式,注意重建变异肝动脉,术后严密监测,及时抗凝治疗可以有效预防肝动脉血栓形成.     

Hepatic artery ligation for metastastic leiomyosarcoma of the liver

A case is presented of metastatic leiomyosarcoma of the liver in which the right and left hepatic arteries were ligated in two stages. Although a moderate disturbance in liver functions was found postoperatively, the patient tolerated them well. The postoperative roentogenological examinations showed an apparent regression of the tumor indicating that hepatic artery ligation can be useful as a palliative therapy for diffuse metastatic liver tumors.     

Hepatic resections for bilobar liver metastases from colorectal cancer

The present study was performed to assess survival benefits in patients who underwent a hepatic resection for isolated bilobar liver metastases from colorectal cancer. Thirty-eight patients underwent a curative hepatic resection for isolated colorectal liver metastasis. Among them, 11 patients had bilobar liver metastases and 19 had a solitary metastasis. The remaining 8 patients had unilobar multiple lesions. We investigated survival in two groups those with bilobar and those with solitary metastatic tumors. Survival and disease-free survival were 36% and 18% at 5 years, respectively, in the patients with bilobar liver metastases, while these survivals were 43% and 34% in the patients with solitary liver metastasis. In the 38 patients, repeated hepatic resections were performed in 15 patients with recurrent liver disease. The 5-year survival and disease-free survival rates for these patients were 38% and 27%, respectively, after the second hepatic resections. Of the 11 patients with bilobar liver metastases, 5 underwent a repeated hepatic resection, and they all survived for over 42 months. Based on our observations, a hepatic resection was thus found to be effective even in selected patients with either bilobar nodules or recurrence in the remnant liver. Received: February 7, 2000 / Accepted: April 26, 2000     

Radiofrequency ablation of primary and metastatic liver tumors: a critical review of the literature

BACKGROUND: Surgical resection is the treatment of choice for hepatic tumors; however, for various reasons, the vast majority of patients are not operative candidates. As a result, several local ablative therapies have emerged as alternatives to resection or as adjuncts in total oncologic care. Presently, the most widely employed liver-directed treatment is radiofrequency thermal ablation. METHODS: To define the current status of radiofrequency ablation (RFA), the authors reviewed available safety and efficacy data from select studies on RFA. A MEDLINE search was performed using the keywords "tumor type" + "radiofrequency ablation" + "survival." Only those studies containing long-term survival data on greater than 50 patients were included in this analysis. CONCLUSIONS: Although RFA has been readily adopted into treatment paradigms, more rigorous trials are needed to solidify its place in the armamentarium of therapeutic strategies for hepatic malignancy.     

腹腔镜手术治疗胃间质瘤32例报告

目的 研究胃间质瘤腹腔镜手术的临床疗效,探讨腹腔镜技术在胃间质瘤（GST）治疗中的应用价值。 方法 对2009年1月至2010年11月中国医科大学附属盛京医院32例GST行腹腔镜手术治疗的临床资料进行分析,探讨腹腔镜手术的手术时间、术中出血量、术后排气时间、进食时间、住院时间。 结果 腹腔镜 GST 手术平均时间（65.5±9.8）min,术中出血量（49.7±7.5）mL,排气时间（24.8±3.7）h,进食时间（26.8±3.4）h,住院时间（6.3±1.1）d,随访1~25个月,无复发病例。结论 GST行腹腔镜手术安全有效,具有可行性。     

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。     

Anaesthetic experience with laparoscopic cryotherapy

Background: Laparoscopic cryotherapy is a new technique for treating hepatic tumors that obviates the need for a laparotomy and may reduce the amount of surgical trauma and heat loss associated with the open technique. Liquid nitrogen is applied to the tumor via a cryoneedle probe introduced through a laparoscopic port. The aim of this study was to assess the effect on body temperature and the hematological and biochemical changes associated with this technique. Methods: Five patients who underwent this procedure were studied prospectively under a standardized general anaesthetic. Core and peripheral temperature were measured during the procedure, and blood samples were taken for hematological and biochemical analysis. Results: Freezing time ranged 19–57 min and measured blood loss 0–1000 ml. In one case, bleeding resulted from hepatic surface cracking. Three patients required a blood transfusion. The mean fall in both nasopharyngeal and right atrial temperature was 0.4°C. Postoperatively, all patients showed a large rise in alanine aminotransferase (ALT) and a fall in platelet count. A systemic inflammatory response syndrome was seen in some cases, but all patients survived to hospital discharge. Conclusions: Laparoscopic hepatic cryotherapy can be performed without significant temperature changes, but it entails significant morbidity. Received: 3 March 1997/Accepted: 28 April 1997