肝癌术前门静脉栓塞的临床应用

肝癌术前门静脉栓塞(PVE)是通过栓塞患侧门静脉使同侧肝叶萎缩,对侧肝细胞增生,诱导预留肝体积增大。目前临床主要应用于剩余肝脏体积太小而无法耐受肝叶切除术的肝癌患者。从而扩大肝癌肝切除手术的适应证,提高了手术的安全性。现就PVE的应用现状及进展等做一概述。     

门静脉栓塞术在肝癌治疗中临床应用的现状与进展

近年,虽然肝癌(原发性、继发性)切除技术有较大提高,但由于术后剩余肝脏组织(future liver remnant,FLR)太少,将会导致肝功能衰竭、感染、出血、甚至死亡,因此,肝癌的切除率仍维持在很低的水平。1986年,Kinoshita等首先在肝细胞性肝癌切除前行门静脉栓塞(portal vein embolization,PVE),二期手术切除肝癌,取得满意效果,认为PVE安全、有效、实用、不增加肝切除难度,术后肝功能衰竭的发生率较低。     

经皮门静脉栓塞治疗肝癌的临床应用

目的探讨经皮选择性门静脉右支栓塞(PVE)在肝癌治疗中的应用价值。方法12例无手术切除指征的中晚期肝癌患者,在电视透视引导下经导管行经皮穿肝或穿脾行PVE。栓塞前、后用CT测量左侧肝叶的体积,并测量栓塞前后的门静脉压力、肝功能。结果12例患者均成功行经皮PVE,栓塞术后左肝叶代偿增生明显,其中3例PVE后顺利实行右肝切除术。PVE后未出现门静脉高压,肝功能损害轻,均未发现并发症。结论经皮选择性PVE能诱导非栓塞侧肝叶代偿性增生及栓塞侧肝叶萎缩,增加肿瘤手术切除机会,提高手术切除的安全性,对于无法手术切除的肝癌患者重新获得手术切除的机会,具有潜在的临床应用价值。     

肝门部胆管癌门静脉栓塞后剩余肝脏体积增生速度预测因素分析北大核心CSCD

目的分析肝门部胆管癌术前门静脉栓塞(PVE)后剩余肝脏体积(FLR)增生速度的影响因素及其简单预估模型。方法回顾性分析2017年1月至2022年1月在海军军医大学附属东方肝胆外科医院完成PVE治疗的63例肝门部胆管癌患者临床资料。重线性回归分析PVE后FLR增生速度的影响因素,并建立简单预测增生速度模型。配对t检验分析PVE前后患者各项指标。分析PVE及胆管癌根治术后并发症发生率。结果63例患者PVE后(25.43±11.01)d,FLR由PVE前(581.44±159.42)mL增加至PVE后(762.86±184.18)mL(P=0.01)。每日FLR增生速度为(0.47±0.29)%。多重线性回归分析结果显示,术前胆道感染(t=-2.07,P=0.04)、碱性磷酸酶(ALP)升高(t=-2.99,P=0.004)是FLR增生速度的影响因素。每日FLR/全肝体积(TLV)增生的简单预测公式为Y=0.61-0.001X_(1)-0.22X_(2)。PVE前后总胆红素、白蛋白、丙氨酸转氨酶、天冬氨酸转氨酶、ALP、国际标准化比值、血小板计数比较,差异无统计学意义(均P>0.05)。PVE、肝门部胆管癌术后3~4级并发症分别为9例次、30例次。结论PVE可有效促进肝门部胆管癌患者FLR增生,胆道感染和ALP升高会减缓FLR增生速度。     

肝动脉与门静脉双重栓塞治疗肝恶性肿瘤

经导管肝动脉栓塞(TAE)是广泛应用于临床的治疗肝脏恶性肿瘤的有效方法。随着栓塞方法的不断改进,已向重复、联合和双重栓塞方向发展,进一步提高了疗效,目前已公认为肝脏恶性肿瘤非手术治疗的首选方法。     

选择性门静脉栓塞术联合肝动脉化疗栓塞术治疗肝转移癌的对照研究

目的探讨选择性门静脉栓塞术(PVE)联合肝动脉化疗栓塞术(TACE)治疗肝转移癌的疗效和安全性。方法将49例无法或拒绝接受手术切除肝转移癌的患者分为对照组和治疗组。对照组(26例)单纯行TACE,治疗组(23例)在此基础上联合选择性门静脉栓塞术,观察比较2种疗法对患者术后肝功能、肝脏体积、不良反应、并发症及近期疗效和累积生存率的影响。结果①术后6个月治疗组有效率65.2%(15/23)高于对照组30.8%(8/26)(P=0.04);治疗组肿瘤最长径总和由术前(9.92±2.63)cm下降为术后(7.32±2.61)cm,对照组由术前(10.34±3.12)cm下降为术后(9.13±3.42)cm,治疗组优于对照组;治疗组和对照组中位生存时间分别为21个月及13个月,累积生存率比较P<0.05。②肝脏体积变化比较:对照组术后肝脏体积无明显变化;治疗组术前非栓塞叶体积为(481±251)cm3,术后2,4,8周分别为(523±250)cm3,(548±249)cm3,(552±249)cm3,分别比术前增加(10.1±7.6)%,(16.1±10.9)%,(17.2±11.5)%。③术后肝功能:两组患者术后血浆白蛋白水平变化均不明显,治疗组术后第1,3天,ALT、AST、TB等指标较术前明显升高,至术后第7天下降(P>0.05)。两组相比,术后第1天、第3天ALT、AST、TB治疗组高于对照组,第7、14天差异无统计学意义。结论选择性PVE联合TACE能够有效的控制和缩小肝转移癌,改善患者累积生存率,是治疗无法手术切除肝转移癌安全有效的选择,值得进一步研究应用。     

经皮经肝钢圈选择性门静脉栓塞术在肝门部胆管癌术前的应用

目的 探讨肝门部胆管癌扩大肝切除术前使用经皮经肝钢圈选择性门静脉栓塞术(PVE)的应用和疗效.方法 2007年4月至2009年1月收治肝门部胆管癌28例,分为两组,将预保留肝占全肝体积<50%、接受PVE者设为PVE组12例,其中10例最终接受联合扩大肝切除者设为PVE肝切除组;同期未行PVE而接受扩大肝切除术者为非P...     

32 P-玻璃微球经肝动脉门静脉栓塞治疗中晚期肝癌

中晚期原发性肝癌 (以下称肝癌 )大多采用经肝动脉插管栓塞化疗药物治疗 ,但患者常无法耐受化疗药物的毒副反应。笔者应用32 Ｐ 玻璃微球 (ＧＭＳ)治疗中晚期肝癌 2 1例 ,取得了较好的疗效 ,现报道如下。一、资料与方法1.临床资料。 2 1例原发性肝癌患者 ,均经临床、生化、Ｂ超、ＣＴ或病理学检查确诊 ,其中男 16例 ,女 5例 ,年龄 33～6 8岁 ,平均 5 4岁。肿瘤直径 6 .5～ 18ｃｍ ,5例伴门静脉癌栓 ,19例合并有不同程度的肝硬变。 2 1例患者甲胎蛋白(ＡＦＰ)为 (2 99.4 3± 16 5 .79) μｇ Ｌ ,其中 15例ＡＦＰ >4 0 0 μｇ Ｌ ,1例 15 0 μ…     

白芨微球与无水乙醇行兔门静脉栓塞的实验研究

目的　探讨门静脉栓塞的安全范围及白芨微球作为门静脉栓塞剂的可行性与有效性。材料与方法　新西兰大白兔 30只 ,随机分为两组 ,分别以白芨微球和无水乙醇行兔门静脉不同分支栓塞治疗 ;栓塞后行连续随访2 8d ,定期复查肝功能、CT、门静脉造影及动物处死后组织病理检查等 ,并将所获的数据行统计学处理。结果　术后丙氨酸转氨酶 (ALT)、天冬氨酸转氨酶 (AST)变化较明显 ,术后第 1d开始增高 ,术后 5d达到最高峰 ,白芨微球组显著高于无水乙醇组 (P <0 .0 5 ) ,但两组均于栓塞后 14d逐步恢复正常。栓塞部位比较 :两组均以右上支加左内支栓塞小组增高最为明显 ,且均有 1只兔于术后 14d死亡。 2种栓塞剂均可导致门静脉段及段以下分支完全性、急性闭塞 ,邻近的门静脉分支未见异位栓塞 ;无水乙醇栓塞后 2 8d ,肝实质呈不规则散在液化坏死 ,部分栓塞的门静脉出现再通现象 ;而白芨微球栓塞后 ,肝实质呈大片状气化坏死 ,未见栓塞区门静脉再通 ;两组术后再通率与不全坏死率有显著性差异 (P <0 .0 5 )。结论　门静脉栓塞的安全性与栓塞范围密切相关 ,其安全范围应小于或等于 3个段 ;白芨微球可作为一种末梢性门静脉栓塞剂 ,其安全性与无水乙醇相似 ,但栓塞效果佳 ,值得进一步临床应用与推广。     

无水酒精-碘化油乳剂门静脉栓塞的实验研究

目的：研究无水酒精－碘化油乳剂的最佳配比及其在门静脉栓塞中的有效性和安全性。方法：健康的Sprague-Dawley(SD)大鼠90只,随机数字表完全随机化分成9组,每组10只,剖腹细针穿刺门静脉主干。每组以0．5ml/kg的剂量分别缓慢注入：单纯无水酒精,4∶1、3∶1、2∶1、1∶1、1∶2、1∶3、1∶4无水酒精－碘化油乳剂,单纯碘化油（以下按顺序称为第1～9组）。分别于栓塞后第3、7、21天处死大鼠,观察栓塞效果,根据栓塞灶占肝脏表面积分成无、轻度、中度、重度4级,记录各等级大鼠只数,行Ridit分析。同时测定肝功能的变化。结果：栓塞效果第1～5诸组与第7～9诸组比较,P＜0．05;第1～3组与第6组比较,P＜0．05;第1、2组与第6组比较,P＜0．05。结论：以3∶1的无水酒精－碘化乳剂作门静脉栓塞,能达到与单纯无水酒精同样的栓塞效果,且更安全。     

Preoperative portal vein embolization: indications and technical considerations

Preoperative portal vein embolization (PVE) has become an important tool in the management of select patients before major hepatic resection. PVE redirects portal flow to the intended future remnant liver (FRL) to induce hypertrophy of the nondiseased portion of the liver and thereby may reduce complications and shorten hospital stays after surgery. This article reviews the technical considerations for performing PVE including the use of the ipsilateral or contralateral approaches, how to choose a particular embolic agent for PVE, the importance of liver volumetric measurements to estimate functional hepatic reserve, the pathophysiology of PVE, and some of the results showing the benefit of the procedure. In addition, the indications and contraindications for performing PVE in patients with and without chronic liver disease, the use of combination therapies, and the concern for tumor growth after PVE will be discussed.     

Preoperative portal vein embolization with a mixture of gelatin sponge and iodized oil: efficacy and safety

Purpose: To evaluate whether portal vein embolization (PVE) using a mixture of gelatin sponge (GS) pieces and iodized oil is safe and effective in inducing hypertrophy of the future liver remnants (FLR).

Material and Methods: PVE was performed in 14 patients (eight male and six female, mean age 65 years, range 35-81 years) diagnosed with malignant liver tumor before surgery, whose FLR volumes were judged too small to allow for safe resection. Liver volume change, biochemical data change, complications related to PVE, and postoperative complications were retrospectively evaluated.

Results: PVE was successful in all patients, and there were no procedural complications. Absolute FLR volume and FLR/total liver volume (TLV) ratio increased by 102 cm³ and 8% (mean values), respectively. Planned hepatectomies were cancelled in three patients due to extrahepatic metastasis or bile duct infection. Five of the 11 patients (45%) who underwent hepatectomies had major postoperative complications. However, complications due to hepatic failure were not seen. In 10 patients, except one whose outcome was fatal outcome, the mean hospitalization days with and without major complications were 73 and 33 days, respectively.

Conclusion: PVE using a mixture of GS and iodized oil seems to be effective and safe in inducing hypertrophy of the FLR.     

Preoperative portal vein embolization using an amplatzer vascular plug

The purpose was to evaluate the safety and efficacy of preoperative portal vein embolization (PVE) using an Amplatzer vascular plug (AVP). Forty-one patients who underwent PVE using gelatin sponge particles and the AVP were enrolled. The right portal branches were embolized using gelatin sponges (1–8 mm³) through a 5-F catheter, and the AVP was deployed at the first- or second-order right portal vein. Technical success and complications, recanalization, and changes of total estimated liver volumes (TELV), future liver remnant (FLR), and FLR/TELV were evaluated. Follow-up CT performed 6–43 days (median, 16 days) after PVE was used to evaluate volume parameters. PVE was technically successful in 40 of 41 patients. Major complications occurred in two patients, with one each having extensive portal vein thrombosis and liver abscess. Partial recanalization of the occluded portal vein was seen in one patient. The mean FLR volume (653 ± 174 ml vs. 532 ± 154 ml, p < 0.001) and mean FLR/TELV ratio (43 ± 8% vs 36 ± 7%, p < 0.001) were significantly higher after than before PVE. PVE using the AVP seems to be a relatively safe and effective technique for inducing hypertrophy of the FLR with minimal risk of recanalization.     

31P MR spectroscopic imaging detects regenerative changes in human liver stimulated by portal vein embolization

Purpose:

First, to evaluate hepatocyte phospholipid metabolism and energetics during liver regeneration stimulated by portal vein embolization (PVE) using proton‐decoupled ³¹P MR spectroscopic imaging (³¹P‐MRSI). Second, to compare the biophysiologic differences between hepatic regeneration stimulated by PVE and by partial hepatectomy (PH).

Materials and Methods:

Subjects included six patients with hepatic metastases from colorectal cancer who were scheduled to undergo right PVE before definitive resection of right‐sided tumor.³¹P‐MRSI was performed on the left liver lobe before PVE and 48 h following PVE. Normalized quantities of phosphorus‐containing hepatic metabolites were analyzed from both visits. In addition, MRSI data at 48 h following partial hepatectomy were compared with the data from the PVE patients.

Results:

At 48 h after PVE, the ratio of phosphomonoesters to phosphodiesters in the nonembolized lobe was significantly elevated. No significant changes were found in nucleoside triphosphates (NTP) and Pi values. The phosphomonoester (PME) to phosphodiester (PDE) ratio in regenerating liver 48 h after partial hepatectomy was significantly greater than PME/PDE 48 h after PVE.

Conclusion:

³¹P‐MRSI is a valid technique to noninvasively evaluate cell membrane metabolism following PVE. The different degree of biochemical change between partial hepatectomy and PVE indicates that hepatic growth following these two procedures does not follow the same course. J. Magn. Reson. Imaging 2011;. © 2011 Wiley‐Liss, Inc.     

Acceleration of primary liver tumor growth rate in embolized hepatic lobe after portal vein embolization

Background: Portal vein embolization (PVE) is now widely accepted as a useful preoperative procedure in selected patients undergoing extended hepatectomy. However, the effect of PVE on the growth of liver tumors has not been fully elucidated.

Purpose: To retrospectively evaluate the effects of PVE on the growth of liver tumors in the embolized lobes.

Material and Methods: Eight patients with a primary liver tumor, six hepatocellular carcinomas (HCC) and two cholangiocellular carcinomas (CCC), were studied. The growth rates of the tumors in the embolized lobes and non-embolized liver parenchyma were calculated using the computed tomography (CT) volume values at the time of tumor identification, and before and after PVE.

Result: The median tumor growth rate was 0.59 cm³/day (range 0.22-6.01 cm³/day) before PVE and 2.37 cm³/day (range 0.29-13.97 cm³/day) after PVE (P = 0.018). The tumor growth acceleration ratios ranged from 1.50 to 7.46 (median 2.65) in the six HCCs, and were 1.00 and 1.32 in the two CCCs. There was no apparent correlation between the tumor growth rate after PVE and the growth rate of non-embolized liver parenchyma (median 6.00 cm³/day, range 1.24-11.0 cm³/day).

Conclusion: Liver tumor growth in an embolized lobe accelerates after PVE, in patients with HCC.     

Comparison of four embolic materials for portal vein embolization: experimental study in pigs

Different embolic materials for portal vein embolization (PVE) were evaluated. Twenty pigs received left and median PVE. Hydrophilic phosphorylcholine, N-butyl cyanoacrylate, hydrophilic gel, and polyvinyl alcohol (PVA) particles measuring either 50–150 μm or 700–900 μm were used in five pigs each. Portography and portal vein pressure measurement were performed before, immediately after PVE, and before being euthanized at day 7. Tissue wedges from embolized, and non-embolized liver were obtained for pathology. After complete embolization, recanalization occurred at 7 days in one gel and one 700–900 PVA embolization. Post-PVE increase in portal pressure was found in all groups (p = 0.01). The area of the hepatic lobules in non-embolized liver was larger than in the embolized liver in all groups (p = 0.001). The ratios of the areas between non-embolized/embolized livers were 1.65, 2.19, 1.57, and 1.32 for gel, NBCA, 50–150 PVA and 700–900 PVA, respectively; the ratios of fibrosis between the embolized and non-embolized livers were 1.37, 3.01, 3.49, and 2.11 for gel, NBCA, 50–150 PVA and 700–900 PVA, respectively. Hepatic lobules in non-embolized liver were significantly larger with NBCA than in other groups (p = 0.01). Fibrosis in embolized liver was significantly higher for NBCA and 50–150 PVA (p = 0.002). The most severe changes in embolized and non-embolized liver were induced by 50–150 PVA and NCBA PVE.     

Percutaneous transhepatic portal vein embolization: effectiveness of absolute ethanol infusion with balloon catheter in a pig model

Purpose: To evaluate the effectiveness of portal vein embolization (PVE) with absolute ethanol using multidetector-row computed tomography (CT) angiography in a pig model.

Material and Methods: Percutaneous transhepatic PVE with 10 ml absolute ethanol was performed in liver segments (n = 5) or subsegments (n = 5) in 10 pigs. CT images and volumetric data were qualitatively and quantitatively assessed to determine future liver remnant (FLR) hypertrophy and to correlate with histopathologic changes 2-6 weeks after PVE. Effectiveness evaluation was based on changes in absolute FLR size and ratio of FLR to total estimated liver volume (TELV).

Results: Occlusion of the embolized vessel was achieved immediately after injecting absolute ethanol within a range of 0.25-0.33 ml/kg. The TELV prior to PVE was 660.49±103.66 cm³ (range 527.22 to 833.70 cm³) and after PVE 769.51±29.36 cm³ (range 685.95 to 887.34 cm³). The mean FLR/TELV ratio increase after PVE was 14.2%. No statistically significant difference was found in the increase of TELV between segmental or subsegmental PVE. On microscopic observation, atrophy of the embolized liver was noted in all animals and was seen distinctly at 3 weeks after PVE in 2 animals.

Conclusion: Both regenerative response and histopathologic changes of the liver were seen after PVE with absolute ethanol with a mean FLR/TELV ratio of 14.2%.     

门静脉化疗配合肝切除治疗原发性肝癌临床研究

目的：探讨门静脉化疗配合肝切除治疗原发性肝癌的治疗效果及临床意义。方法：2001年1月-2006年1月收治76例原发性肝癌行根治性切除，其中，术后联合门静脉化疗（治疗组）38例，单纯根治性切除38例（对照组），全部患者随访2年以上。将两组患者术中情况、术后并发症、复发率、生存率进行对比研究。结果：两组患者术中情况、术后并发症情况无显著差异，治疗组与对照组之间的术后复发率与生存率均有明显差异。结论：肝癌根治性切除后，联合门静脉化疗明显降低术后复发率，提高术后生存率。     

肝细胞癌肝大部分切除术前序贯TACE和门静脉栓塞与单独门静脉栓塞的比较：系统评价和荟萃分析

目的比较序贯经导管动脉化疗栓塞（TACE）和门静脉栓塞（PVE）与单独PVE在肝细胞癌（HCC）患者肝大部分切除术前的有效性和安全性。 方法对PubMed、Cochrane图书馆进行检索。主要终点包括总生存率（OSR）、无复发生存率（RFSR）、残肝体积百分比（FLR）的增加;次要终点包括肝切除率、术后并发症、术后肝功能衰竭率和术后死亡率。 结果共纳入了五项回顾性研究。结果显示,TACE + PVE组与PVE组相比,具有较高的1年OSR、3年OSR、5年OSR以及10年OSR。结果还表明,TACE + PVE组与PVE组相比,具有较高的1年RFSR、3年RFSR、5年RFSR以及10年RFSR。此外,TACE + PVE组与PVE组相比,具有更高的FLR体积、更高的肝切除率以及较低的术后并发症。 结论在肝大部分切除术前,对于HCC患者来说,序贯TACE和PVE似乎是比单独PVE更有效的治疗方法,具有更好的生存率和安全性。