肝脏肿瘤肝切除术前选择性门静脉栓塞的临床应用

目的 探讨选择性门静脉栓塞技术细节及其在残余肝容积不足患者肝切除术前应用的临床意义.方法 2008年1月至2012年7月,6例肝脏肿瘤因残余肝容积不足,二期肝切除术前行选择性门静脉栓塞术.结果 6例选择性门静脉栓塞术均成功.无手术并发症,栓塞对肝功能影响轻微.术前,6例残余肝容积平均(474.33 ±89.19) cm3,术后6周,平均(722.67±151.51) cm3,术前术后残余肝容积比较差异有统计学意义(t=-5.587,P=0.003).术前6例肝脏肿瘤负荷(瘤体总体积)平均(134±181) cm3,栓塞术后6周,肿瘤负荷平均为(270±346) cm3,栓塞前后肿瘤负荷比较差异无统计学意义(t=-1.64,P=0.16).5例二期肝切除术顺利.1例未行肝切除术.随访中位时间为37个月,4例存活(2例无瘤生存),1例死亡.结论 门静脉选择性栓塞是肝切除前增加残余肝容积的有效技术手段;经同侧(患侧)人路并选择弹簧圈作为栓塞材料简单易行、安全、有效.门静脉栓塞前,应以化疗或选择性肝动脉化疗栓塞等手段有效控制肿瘤生长.     

选择性胆管外引流改善梗阻性黄疸大鼠肝功能的研究

目的 探讨选择性胆管外引流(约占30%肝脏体积)对梗阻性黄疸大鼠肝功能的影响.方法 检测梗阻性黄疸大鼠(梗阻10 d)经选择性胆管外引流组及非选择性(全肝)胆管外引流组引流的0、1、4、7、10 d右叶肝质量/体质量的比率,并通过RT-PCR及Western blot法检测两实验组肝组织胆盐输出泵(bile salt export pump,BSEP)、多药抑制相关蛋白2(multidrug resistance-associated protein 2,MRF2)基因及蛋白的表达.结果 选择性胆管外引流组在开放引流后右叶肝质量/体质量的比率继续增加,而非选择性胆管外引流组逐渐恢复正常,两组比较差异有统计学意义(t=15.569,P<0.05);选择性胆管外引流组开放引流后BSEP、MRP2基因及蛋白的表达始终高于非选择性胆管外引流组,两组比较差异有统计学意义(t=4.485,7.143,9.169,5.178,P<0.05).结论 选择性胆管外引流能够改善梗阻性黄疸大鼠肝功能,与预保留侧肝脏体积代偿性增加和开放引流后预保留侧肝脏单位体积的膜转运蛋白表达增高有关.     

肝大部切除术前选择性门静脉栓塞(PVE)的临床应用

肝大部分切除（半肝或三叶肝切除）术后所保存的残余肝脏容积（remnant liver volume，RLV）不足是术后并发肝功能衰竭的主要危险因素。正常成人切除超过70％有功能的肝组织是发生术后肝衰竭的高危因素。术前选择性门静脉栓塞（portal vein embolization，PVE）可使未栓塞侧的肝组织增生肥大，增大肝脏容积；栓塞侧肝组织萎缩，肿瘤可缩小。使原来不能耐受手术切除的部分病例可以耐受手术切除，提高肝切除手术的安全性，并且不会增加使肝切除手术难度。PVE还可减少肿瘤通过门静脉系统发生转移的机会和增加肝动脉栓塞化疗的抗癌作用。本文就肝大部切除术前选择性门静脉栓塞的发展、原理、方法和临床应用作一综述。     

索拉菲尼对大鼠Walker-256移植性肝癌的治疗作用

目的探讨索拉菲尼(Sorafenib)对大鼠Walker-256移植性肝癌的治疗作用及机制。方法 Walker-256移植性肝癌大鼠随机分为4组(n=16):A组(对照组);B组(索拉菲尼低剂量组);C组(索拉菲尼中剂量组);D组(索拉菲尼高剂量组),另设E组(正常组,n=8)。所有大鼠于术后20d取静脉血,检测血清中谷丙转氨酶(ALT)、谷草转氨酶(AST)、胆红素(TB)含量;分离出肝内瘤块,称量其质量、测量其体积,计算出肿瘤的质量抑制率、体积抑制率;采用免疫组织化学方法检测瘤旁组织血管内皮生长因子(VEGF)、微血管密度(MVD)水平,并对VEGF及MVD行双变量相关性分析;对索拉菲尼各组剩余8只大鼠,观察其生存时间。结果索拉菲尼各剂量组大鼠血清ALT、AST、TB普遍低于对照组(P0.05);C、D组大鼠瘤块体积、质量均小于A组,生存时间长于A组(P0.05);索拉菲尼各剂量组大鼠瘤旁组织肿瘤细胞坏死程度较A组明显,癌灶周边肝脏细胞受累坏死程度较A组轻;各剂量组瘤旁组织VEGF阳性率、MVD计数小于A组(P0.01);大鼠瘤旁组织VEGF与MVD高度相关(P0.01),相关系数rp=0.843。结论索拉菲尼通过抑制肝癌大鼠瘤旁组织VEGF合成,降低瘤旁组织微血管密度、抑制瘤旁组织微血管生成,从而抑制肿瘤生长,减轻肿瘤对正常肝细胞的损害作用及肝功损害,延长大鼠生存期限,对大鼠移植性肝癌具有积极的治疗作用。     

选择性门静脉栓塞在肝癌治疗中的作用(文献综述)

肝癌由肝动脉和门静脉双重供血,肝癌细胞容易经门静脉肝内转移,故肝癌经肝动脉栓塞或手术切除后复发率高.选择性门静脉栓塞(SEPV)可扩大肝肿瘤手术切除的指征,有助于预防在肝癌切除术前和术中发生的癌细胞经门静脉肝内转移,与肝动脉栓塞联合应用治疗不能切除的肝癌和门静脉癌栓,可明显提高疗效.SEPV对肝功能有一定的损害,可使门静脉压升高,并有发生异位栓塞的可能.本文还介绍了SEPV的方法和栓塞物质及选择.     

选择性门静脉栓塞在肝叶切除术中的临床应用

手术切除肝脏巨大肿瘤或多发性转移瘤的安全性已大为提高,但半肝或肝三叶切除术后残余肝脏的功能不全仍困扰着外科医师。1986年,日本学者Kinoshita等提出选择性门静脉栓塞（portal vein embolization,PVE）作为扩大肝切除术前准备,并应用于肝癌的治疗。PVE使栓塞侧肝叶萎缩,而非栓塞侧肝叶代偿性增生,     

奥曲肽对肝动脉栓塞治疗大鼠肝癌影响的实验研究

目的　观察奥曲肽(octreotide)降低肝动脉栓塞(HAE)促进肿瘤新生血管生长的作用以及抑瘤作用。方法　采用大鼠肝内种植Walker 256瘤株制作肝癌模型,分为对照组、Octreotide组、HAE组和HAE+octreotide组共四组。定期切取肿瘤标本测量肿瘤体积,检测标本中的血管内皮生长因子(VEGF)的表达及微血管密度(MVD)。结果　各干预组肿瘤体积均小于对照组(P<0.01), HAE+octreotide组肿瘤体积也小于 HAE组(P<0.05); HAE+octrotide组 VEGF表达低于HAE组(P<0.05);Octreotide组、HAE+octreotide组 MVD表达低于对照组(P<0.05)。结论　在对大鼠肝癌的治疗中,行肝动脉栓塞时联用奥曲肽,可降低单纯肝动脉栓塞引起的癌组织 VEGF高表达,减少肿瘤新生血管形成,加强其抑瘤作用。     

选择性肝门阻断联合逆行肝切除治疗巨大肝癌对健侧肝组织的保护作用

目的：探讨选择性肝门阻断联合逆行肝切除治疗巨大肝癌对健侧肝组织再灌注损伤、余肝功能的影响。 方法：45例巨大肝癌（直径≥10 cm）患者按照Zelen设计的临床分组方案分为对照组和观察组,对照组行完全阻断第一肝门的顺行肝癌切除,观察组行选择性阻断第一肝门的逆行肝癌切除,两组均于肿瘤切除后留取少许健侧肝组织。检测两组患者术后1周总胆红素（TBIL）、谷丙转氨酶（ALT）、前白蛋白（PA）水平及健侧肝组织肝细胞凋亡情况、细胞内钙离子浓度（[Ca2+]i）、丙二醛（MDA）含量、超氧化歧化酶（SOD）活性。 结果：与对照组比较,观察组术后1周的ALT明显降低、PA含量明显升高（均P<0.05）,而TBIL水平差异无统计学意义（P>0.05）;健侧肝组织肝细胞凋亡水平、[Ca2+]i、MDA含量均明显下降,SOD活性明显增高（P<0.05）。 结论：与传统方法比较,选择性第一肝门阻断逆行肝切除术治疗巨大肝癌更有利于减少健侧肝组织的再灌注损伤和保护余肝功能。

     

表阿霉素纳米胶束靶向治疗大鼠移植性肝癌

目的 探讨键合表阿霉素纳米胶束(EPI-NPs)在大鼠移植性肝癌模型肝内的分布及药效.方法 制备具有靶向控释作用的EPI-NPs,Walker-256细胞直接注射法制作大鼠移植性肝癌模型,通过肝动脉灌注给药(EPI含量均为2 mg/kg),利用组织荧光和匀浆荧光技术对比分析EPI-NPs和表阿霉素(EPI)在肝内的分布特点,并作药效对比.结果 EPI-NPs组肿瘤组织的EPI荧光强度高于肝组织(P＜0.05),而EPI组则表现为平均分布;EPI-NPs组在肿瘤及肝内的EPI荧光强度均高于EPI组(P＜0.05).EPI-NPs组大鼠肝移植瘤的体积抑瘤率及质量抑瘤率分别为72.96％和68.19％,EPI组的体积抑瘤率及质量抑瘤率分别为39.16％和35.33％,两者差异均有统计学意义(P＜0.05).EPI-NPs组生存率高于EPI组(P＜0.05).结论 EPI-NPs具有良好的肿瘤组织靶向性和抑瘤效果.     

经皮经肝选择性门静脉栓塞化疗术在原发性肝癌合并门静脉癌栓治疗中的应用

目的探讨选择性门静脉栓塞化疗对原发性肝癌的治疗效果。方法对38例合并门静脉瘤栓的原发性肝癌患者在行肝动脉栓塞化疗（TAE）基础上,联合应用经皮经肝选择性门静脉栓塞化疗术（SPVE）。33例为块状型,5例为结节型,其中直径大于10cm24例,5～10cm11例,小于5cm3例,肿瘤位于肝右叶29例,肝左叶6例,左右叶3例。血清AFP检测＞400ug／L21例,在200ug／L～400ug／L之间6例,（一）／＜200ug／L11例。门静脉瘤栓位于右支19例,左支者7例,右支＋主干6例,左支＋主干2例,左右支＋主干4例。结果治疗后门静脉瘤栓消失和缩小率为68．4％,肿瘤缩小率为76．3％,AFP转阴14例,4例呈一过性转阴或下降,总有效率为85．7％。9例获二期手术切除,术后病理证实,门静脉癌栓坏死率100％。术后随访,1年,3年存活率分别为73．7％和18．4％,远比单纯TAE治疗组高。结论选择性门静脉栓塞化疗是治疗肝癌合门静脉癌栓的有效方法。     

胆道大出血的介入造影诊断及栓塞治疗

目的：评价血管造影和栓塞对胆道大出血的诊断及治疗效果。方法８年间收治胆道大出血６例,均采用腹腔动脉和选择性肝右或左动脉造影,随即行肝动脉分支出血点近端栓塞。结果６例患者经这种方法治疗,出血立即停止。其中有一例患者由于再出血而行第２次栓塞,所有患者均存活,随访半年－５年无再出血,结论胆道大出血行选择性肝动脉主栓塞是安全有效的诊断及治疗方法,与手术比较,栓塞治疗具有显著优点。     

EMBOLIZATION OF TRAUMATIC ANEURYSM OF THE MAXILLARY ARTERY

An expanding false aneurysm in the infratemporal fossa followed this patient's complicated jaw fracture. Successful Gelfoam embolization of the maxillary artery has controlled haemorrhage, treated the aneurysm, and avoided the hazards of local operative intervention. The technique of embolization has a place in the management of various difficult vascular problems.     

A CASE OF ARTERIAL PRIAPISM TREATED BY EMBOLIZATION

An 18-year-old unmarried man, who had shown arterial priapism caused by mild perineal trauma sustained during skate-boarding, has been successfully treated by autologous clot embolization at the common penile artery. He was able to have a normal erection and ejaculate 5 d after embolization.     

胆道大出血的导管治疗

目的 探讨运用选择性动脉造影和栓塞术对胆道大出血的诊断和治疗价值。方法 运用Seldinger技术对11例胆道大出血患者进行急诊选择性肝动脉及其分支造影和栓塞术,栓塞材料运用明胶海绵粒或明胶海绵粒加方纱线段。结果 7例胆道术后、1例腹腔镜胆囊摘除术后,1例肝脏外伤后及2例巨块型肝癌破裂后大出血的患者,行选择性肝动脉及其分支造影有9例发现异常,表现为造影剂外溢征（9例）,肿瘤血管和肿瘤染色征（2例）和假性动脉瘤形成（4例）。经导管栓塞术后,11例患者出血均停止,2例导管治疗48小时后复发大出血。结论 胆道大出血的急诊导管治疗是一种快速、安全、有效的方法;导管治疗后保持胆道引流的通畅也很重要。     

PERCUTANEOUS MICROCOIL EMBOLIZATION OF INTRAPERITONEAL INTRAHEPATIC AND EXTRAHEPATIC BILIARY FISTULAS

Background : Persistent intraperitoneal biliary fistulas are associated with significant morbidity and mortality. Percutaneous drainage, stenting, and endoscopic sphincterotomy or embolization of biliary radicals have largely replaced the need for hepatic resection or biliary reconstruction in managing such fistulas. When endoscopy is contraindicated, a previously undescribed technique of percutaneous embolization of intrahepatic and extrahepatic biliary fistula following penetrating liver trauma, and orthotopic liver transplant and its application in three patients, will be discussed. Methods : Embolization procedures were performed by an interventional radiologist. Percutaneous trans-hepatic cholangiography via a standard right-side approach or via tube cholangiography was initially performed and the fistula defined. Coaxial catheter systems were used (5 Fr angiography catheters and Tracker 18 infusion catheters), and were positioned within the biliary tree as close as possible to the origin of the fistula. Embolization was performed using vascular Embolization 28 coils (WA Cook) 2–3 mm × 2 cm coils, straight Hilal 18 embolization coils (WA Cook) 5–7 cm, as well as Gelfoam (Upjohn) 1 mm pellets, and Histoacryl (B. Braun) 0.25–1 mL. Occlusion of the duct was confirmed by a selective intrahepatic cholangiogram. In cases of multiple fistulas several embolizations were performed at subsequent procedures. Follow-up is over 13 months without adverse event. Results : The technique was used in the three cases and was successful in all. A peripheral biliary fistula required embolization twice and two cystic leaks were cured after a single attempt. Conclusions : Percutaneous embolization of biliary fistulas provides a management option in cases where conservative treatment has failed and other techniques are relatively contraindicated. The technique is effective and safe in skilled hands, and avoids major surgery. The long-term effect of microcoils in the biliary tree is unknown.     

PORTAL VEIN EMBOLIZATION USING AN ADAPTED HYSTEROSALPINGOGRAPHY CATHETER

Background

Portal vein embolization is an accepted procedure that provides hypertrophy of the future remnant liver in order to reduce post-hepatectomy complications.

Aim

To present a series submitted to portal vein embolization using an adapted hysterosalpingography catheter via transileocolic route.

Methods

Were performed right portal branch embolization in 19 patients using hysterosalpingography catheter. For embolizing the vessel, was used Gelfoam® powder with absolute alcohol solution. Indications for hepatectomy were colorectal liver metastases in all cases.

Results

An adequate growth of the future remnant liver was achieved in 15 patients (78.9%) and second time hepatectomy could be done in 14 (73.7%). In one patient (5.2%), tumor progression prevented surgery. One patient presented acute renal failure after portal embolization.

Conclusions

The hysterosalpingography catheter is easy to handle and can be introduced into the portal vein with a wire guide. There were no major post-embolization complication. Its use is safe, cheap and effective.     

术前脾动脉栓塞对原位肝移植的影响及临床意义

目的 探讨术前脾动脉栓塞对原位肝移植的应用价值。方法 终末期肝硬化伴脾亢及上消化道出血患者行脾动脉栓塞术，术后一月行原位肝移植术，结果 脾动脉栓塞可有效缓解脾亢症状，并使患者免于手术切脾，保留脾脏的免疫功能，为肝移植创造条件，但脾栓塞并发症则可对肝移植产生不利影响。结论 脾动脉栓塞作为原位肝移植的术前准备措施，具有实用价值，但应严格掌握栓塞范围。