肝癌肝切除手术方式的理论基础及临床价值

治愈性肝切除治疗肝癌的主要目的是切除有足够切缘的肿瘤,同时亦保留足够的余肝体积和功能以支持病人快速康复。近年来,肝脏外科发展迅速,新的切肝技术涌现。概括而言,肝切除手术仅有5个操作步骤,即：（1）分离韧带和游离肝脏。（2）阻断第一肝门的有关分支,即阻断有关切除肝脏部分的入肝血流及胆管。（3）阻断第三肝门的肝短静脉。（4）阻断第二肝门的有关肝静脉。（3）+（4）等同于阻断有关切除肝脏部分的出肝血流。（5）离断肝实质。此外,在关腹前须彻底止血清洗。不同肝切除方法以不同的顺序联合上述5个步骤。部分肝切除可分为解剖性与非解剖性肝切除。理论上,解剖性肝切除比非解剖性肝切除的优点多。因此,非解剖性肝切除只应施行在肿瘤位于数个肝段的交界处,或肿瘤较小并且位于肝脏周边的病人。解剖性肝切除是基于肝内解剖,将肝脏分为两个半肝,4个肝区（或扇区）和8个肝段。解剖性肝切除是根据肝内解剖平面进行,故出血较少且余肝功能较好。手术可在术前或术中计划,而且手术可遵循肿瘤学的原则进行。解剖性肝切除可采取以下方法进行：（1）基于肝脏表面解剖学标志和使用术中超声引导。（2）首先控制Glisson肝蒂供应准备切除的肝段。（3）术中超声引导穿刺供应将要切除肝段的门静脉分支,并注入染料。（4）使用球囊导管通过肠系膜上静脉的属支进行性阻断门静脉或注入染料。最新的三维可视化技术在肝脏领域的应用,使解剖性肝切除手术在术前可进行更好地规划。     

Management of colorectal liver metastases

Hepatic metastases occur in 60% of patients following resection for colorectal cancer. Liver resection is the only curative option, with one third of resected patients alive at five years. In those developing recurrence in the liver following resection, further liver surgery may be curative, with similar 5 years survival rates of about 30%. Until recently surgery was feasible in only 15–25% of patients with colorectal liver metastases. New strategies, such as downstaging chemotherapy, portal vein embolization and two‐stage hepatectomy, may increase the resectability rate by 15%. Earlier detection of liver metastases would increase resectability, although good follow‐up trials are lacking. Once suspected, colorectal liver metastases are staged by spiral CT, CT portography and MRI, which have similar overall accuracies. Mortality following liver resection is less than 5% in major centres, with a morbidity rate of 20% to 50%. Prognostic scoring systems can be used to predict the likely cure rate with resection. Pulmonary metastases occur in 10–25% of patients with resected colorectal cancer, but are limited to the lung in only 2% of cases. In these selected cases surgery provides long‐term survival in 20–40%, and repeat lung resection has shown similar rates. For patients with unresectable disease, chemotherapy and ablation techniques have been demonstrated to prolong survival, although chemotherapy alone has been shown to improve quality of life.     

Perioperative nutritional support and fluid therapy in patients with liver diseases

The prevalence of liver dysfunction and malnutrition is common among patients with obstructive jaundice or cirrhosis, the poor nutrition status in patients with indications for hepatic resection increases the risk of postoperative complications and/or mortality. Hepatic surgery significantly affects body’s metabolism and environment. Therefore, it is very important for patients with liver diseases undergoing hepatic surgery to receive essential nutritional support and fluid therapy during perioperative period. There are several principles in nutritional support and fluid therapy that surgeons need to pay attention to, for example, time, nutritional approach, fluid volume, choice of fat emulsions and amino acids. Some issues, such as albumin and plasma application, choice of crystalloid and colloid, liver protective therapy, also need further attention.     

Optimization of the future remnant liver: review of the current strategies in Europe

Liver resection still represent the treatment of choice for liver malignancies, but in some cases inadequate future remnant liver (FRL) can lead to post hepatectomy liver failure (PHLF) that still represents the most common cause of death after hepatectomy. Several strategies in recent era have been developed in order to generate a compensatory hypertrophy of the FRL, reducing the risk of post hepatectomy liver failure. Portal vein embolization, portal vein ligation, and ALLPS are the most popular techniques historically adopted up to now. The liver venous deprivation and the radio-embolization are the most recent promising techniques. Despite even more precise tools to calculate the relationship among volume and function, such as scintigraphy with ^99mTc-mebrofenin (HBS), no consensus is still available to define which of the above mentioned augmentation strategy is more adequate in terms of kind of surgery, complexity of the pathology and quality of liver parenchyma. The aim of this article is to analyse these different strategies to achieve sufficient FRL.     

术前肝储备功能评估的研究进展

肝切除是原发性或继发性肝脏肿瘤的首选治疗方法.尽管在过去的10年里,肝切除技术已经得到了相当大的改进,而肝功能衰竭仍然是最令人担心的并发症,尤其是合并肝硬化的患者.近年来,外科医生为了提高切除率还在不断地尝试着攻克解剖和肿瘤体积的束缚.因此,准确的术前肝脏储备功能评估对于肝胆外科技术的提高非常重要.     

复杂肝切除术安全性及有效性今日观

随着外科技术及设备的进步,越来越多复杂的肝切除术被实施,越来越多的肝切除病人从中受益。活体肝移植手术的成功施行使供者安全无恙,使受者接受了高质量的供肝,是复杂肝切除手术的精彩体现。作为病人的肝切除术难度随着疾病的复杂性增加也逐日被克服。与此同时,也发现有的病人经历了复杂的手术是否安全度过围手术期？即使安全度过围手术期,术后效果是否满意？这些都提示外科医生要认真掌握手术适应证,认真地术前评估及准备。术中精细操作达到今日提倡的精准肝切除术的水平,是至关重要的。     

微创技术治疗肝细胞癌的进展

Minimally invasive therapy is gaining increasing attention as an important part of therapies in hepatocellular carcinoma (HCC). It includes laparoseopic liver resection, transarterial therapy, local ablative therapy and some new extraeorporeal energy therapies. The theoretical advantages of laparoscopic liver resection are those of minimally invasive surgery in general, such as early recovery, shorter hospital stay, and better cosmetic outcome. However, laparoseopie liver resection for HCC is still considered as controversial because of the uncertainty of the long-term results, and fear of compromising the principles of oncologic resection. Transarterial chemoembolization is the most promising palliative medality for uuresectable HCC, but other techniques, such as transarterial radioembolization and local ablative therapy, have also shown promising results. Recent evidence suggests that local ablative therapy may offer comparable survival outcomes in patients with small HCC and preserved liver function when compared with partial hepatectomy. This article focuses on the development in minimally invasire therapy of HCC.     

Liver resection for neoplasm

Major hepatic resections can now be performed with much greater safety than formerly. This is largely a consequence of improved surgical and anesthetic techniques, which have in turn resulted from better understanding of the anatomy, physiology and biochemistry of the liver. The treatment of liver tumours by resection must be reappraised in the light of these advances. This paper reports twelve patients who have undergone major hepatic resection for neoplasm at the Royal Prince Alfred Hospital over a ten-year period. The current indications for such surgery in the treatment of benign and malignant liver tumours are reviewed, and the results discussed.     

LIVER RESECTION FOR NEOPLASM

Major hepatic resections can now be performed with much greater safety than formerly. This is largely a consequence of improved surgical and anaesthetic techniques, which have in turn resulted from better understanding of the anatomy, physiology and biochemistry of the liver. The treatment of liver tumours by resection must be reappraised in the light of these advances. This paper reports twelve patients who have undergone major hepatic resection for neoplasm at the Royal Prince Alfred Hospital over a ten-year period. The current indications for such surgery in the treatment of benign and malignant liver tumours are reviewed, and the results discussed.     

肝切除治疗结直肠癌肝转移预后影响因素研究进展

结直肠癌是我国最常见的恶性肿瘤之一。临床上，结直肠癌病人首次确诊时已有15%～25%发生肝脏转移，中位生存期约为6个月，然而行手术切除肝转移灶后5年存活率可达60%。近年来，虽然在新辅助化疗和外科技术等方面取得迅速发展，使得病人获得较长的生存时间，但肝切除仍是治愈结直肠癌肝转移（CRLM）病人的主要治疗方式。肝切除术能够改善病人预后，手术应做到R0切除或者达到无疾病证据状态（NED）；若有复发应积极施行二次手术；原发病灶部位以及淋巴结转移情况对预后影响尚有待研究；结直肠癌确诊至发生肝转移时间间隔越长预后较好（＞2年）。然而，肝转移灶的大小、数目、部位情况等，并不是影响手术预后的主要因素。总之，肝切除对CRLM病人具有良好的预后，同时需要结合病人的切缘状态、残余肝体积、原发病灶及淋巴结转移等因素综合考虑。     

The detection and management of complications following the treatment of liver metastases

Whilst once considered as incurable systemic disease, treatment options for liver metastases have increased over the last 30 years and safety has improved dramatically, such that for a selected group of patients the hope of cure can now be offered with radical treatment and low morbidity interventions can be offered which prolong survival, even in patients with more widely disseminated disease. Advances have been made in selection and surgical technique for liver resection and several adjuncts to resection now exist in the form of portal vein embolization, thermal ablation and targeted drug or radiotherapy delivery options. A natural consequence of these developments has been the delivery of services within fewer specialist units, with the result that later complications of therapy may present to local hospitals, rather than directly to the specialist centres. This article will describe the current common liver directed therapies and outline the presentation and management of their complications.     

Intrahepatic Glissonian access for segmental liver resection in cirrhotic patients

The main goal of segmental technique is to preserve the maximum amount of liver parenchyma. Liver-preserving techniques are especially important for patients with hepatocellular carcinoma and cirrhosis. We report the technique for segmental liver resection in cirrhotic patients and detail technical difficulties and immediate surgical outcome. For right segmental liver resections the intrahepatic access is performed through small incisions around the hilar plate. Left segmental resection technique also consists of small incisions following specific anatomic landmarks. Nineteen cirrhotic patients underwent segmental liver resections. A blood transfusion was required in 2 patients. No patient experienced major bleeding from the liver incisions made for intrahepatic access. The median hospital stay was 5 days. No surgical mortality occurred. The intrahepatic access technique allows individual resections of liver segments and is feasible even in cirrhotic patients. Knowledge of segmental liver resection techniques is an essential armamentarium in the modern era of liver surgery.     

Beurteilung der Resektabilität kolorektaler Lebermetastasen und erweiterte Resektionen

Most patients with colorectal liver metastases are treated within a multimodal therapy regime whereby liver resection is a key point in the curative treatment concept. The achievement of an R0 situation is of vital importance for long-term survival. Besides general operability and the assessment of comorbidities, resection depends on the quality of liver parenchyma (functional resectability) and the anatomical position of the tumor (oncological resectability). The improvement of operation techniques and perioperative medicine nowadays allow complex surgical procedures for metastasis surgery. This article presents the methods for the assessment of resectability and modern strategies of preoperative conditioning as well as approaches for extended liver resection.     

Volumetric analysis predicts hepatic dysfunction in patients undergoing major liver resection

Liver-enhancing modalities, such as portal vein embolization, are increasingly employed prior to major liver resection to prevent postoperative liver dysfunction. Selection criteria for such techniques are not well described. This study uses CT-based volumetric analysis as a tool to identify patients at highest risk for postoperative hepatic dysfunction. Between July 1999 and December 2000, a total of 126 consecutive patients who were undergoing liver resection for colorectal metastasis and had CT scans at our institution were included in the analysis. Volume of resection was determined by semiautomated contouring of the liver on preoperative volumetrically (helical) acquired CT scans. Hepatic dysfunction was defined as prothrombin time greater than 18 seconds or serum bilirubin level greater than 3 mg/dl. Marginal regression was used to compare the predictive ability of volumetric analysis and the extent of resection. The percentage of liver remaining was closely correlated with increasing prothrombin time and bilirubin level (P < 0.001). After trisegmentectomy, 90% of patients with ≤s25% of liver remaining developed hepatic dysfunction, compared with none of the patients with more than 25% of liver remaining after trisegmentectomy (P < 0.0001). The percentage of liver remaining was more specific in predicting hepatic dysfunction than was the anatomic extent of resection (P = 0.003). Male sex nearly doubled the risk of hepatic dysfunction (odds ratio = 1.89, P = 0.027), and having ≤25% of liver remaining more than tripled the risk (odds ratio = 3.09, P < 0.0001). Hepatic dysfunction and ≤25% of liver remaining were associated with increased complications and length of hospital stay (P < 0.0001 and P = 0.0003, respectively). Preoperative assessment of future liver volume remaining distinguishes which patients undergoing liver resection will most likely benefit from preoperative liver enhancement techniques such as portal vein embolization. Presented at the Forty-Third Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, California, May 19–22, 2002 (oral presentation).     

肝癌肝切除术中损伤控制和无瘤操作策略

行肝切除手术病人存在发生出血、胆漏、肝功能衰竭及感染等损伤的风险,术中出血和围手术期输血、切肝方式、手术切缘、手术入路、淋巴结清扫等均影响术后肿瘤复发和转移。术者在肝癌肝切除术中应遵循损伤控制理念和无瘤操作原则,综合运用肝血流阻断技术、断肝器械和合理的肝断面处理方法,预防和控制术中出血和围手术期输血,采用解剖性肝切除、保证足够手术切缘、前入路肝切除,必要的淋巴结清扫和血管切除以及腹腔镜肝切除为代表的微创技术,使手术本身所带来的创伤降到最低,从而提高病人术后生活质量和延长术后生存时间。     

Resection of rectal cancer: A historical review

Local control of rectal cancer and patient survival have improved remarkably with advances in surgical techniques and adjuvant therapy. By applying advanced surgical principles, surgeons can now excise most rectal cancers completely, often preserving the anal sphincter and leaving the patient with relatively normal bowel and pelvic function. Historically, the earliest surgical approaches to rectal cancer were via the perineum. As surgical techniques and general anesthesia improved, other approaches such as a posterior approach were undertaken to improve access to the whole rectum. Consequently, abdominoperineal resection became the standard treatment until anterior resection was introduced for proximal rectal cancers. The most important surgical breakthrough in recent years has been the advent of total mesorectal excision (TME). The emphasis in rectal cancer surgery is on preservation of function, with dissection being done in appropriate anatomical planes. Thus, mobilization of the rectum has a long history, and is seen in modern procedures including TME and intersphincter resection. This article reviews the progression of the surgical management of rectal cancer with reference to historical perspectives. We discuss the major surgical considerations for mobilization of the rectum in several surgical procedures, from conventional operations to modern standardized TME.     

原发性肝癌手术方式选择与原则

手术切除仍是原发性肝癌首选的治疗方法,兼顾肿瘤根治与手术安全是肝癌手术治疗的基本原则。作为肝胆外科医生,术者需结合自身经验与患者具体情况,选用简单有效、安全合理的切除方法、阻断技术和断肝设备,并按照规范化的手术方案进行个体化的肝癌切除。     

Malignant tumours of the liver

Malignant tumours of the liver can either be primary (arising from the liver) or secondary (metastasis from a distant primary tumour). Clinical symptoms are non-specific and tumours are diagnosed incidentally or during surveillance imaging. Contrast-enhanced CT and MRI with hepatobiliary contrast are both excellent imaging modalities used for evaluation of these tumours. Hepatocellular carcinoma (HCC) is the most common primary tumour and often presents on a background of liver cirrhosis. Tumour size, degree of liver cirrhosis and patient performance status dictate management pathways. Surgical resection, ablation and liver transplantation are curative options in selected patients. However, noncurative management such as transarterial chemoembolization (TACE) can prolong survival in patients not suited to curative management. Cholangiocarcinoma is a less common malignancy of the biliary epithelium but unfortunately has poorer outcomes. Extended liver resections with biliary reconstructions are usually required for cure but postoperative morbidity is high and long-term survival is often short. Colorectal liver metastases are the most common liver tumours. Curative resection with good long-term outcomes are often achieved with improvements in preoperative chemotherapy, surgical techniques, newer radiological interventions such as portal vein embolization (PVE) and two-stage resections. The role of liver transplantation in management of malignant liver tumours is promising and under investigation.     

The detection and management of complications following the treatment of liver metastases

While once considered as incurable systemic disease, treatment options for liver metastases have increased over the last 30 years and safety has improved dramatically, such that for a selected group of patients the hope of cure can now be offered with radical treatment, and low morbidity interventions can be offered which prolong survival, even in patients with more widely disseminated disease. Advances have been made in selection and surgical technique for liver resection and several adjuncts to resection now exist in the form of portal vein embolization, thermal ablation and targeted drug or radiotherapy delivery options. A natural consequence of these developments has been the delivery of services within fewer specialist units, with the result that later complications of therapy may present to local hospitals, rather than directly to the specialist centres. This article will describe the current common liver-directed therapies and outline the presentation and management of their complications.