联合肝脏离断和门静脉结扎二步肝切除术治疗巨大原发性肝细胞癌1例报告并文献复习

目的 探讨联合肝脏离断和门静脉结扎的二步肝切除术（ALPPS）治疗巨大原发性肝细胞癌的安全性及有效性。方法 回顾性分析2014年12月哈尔滨医科大学附属第一医院行ALPPS的１例右肝巨大肝细胞癌并门静脉三个分支病人的临床资料,第一步手术结扎门静脉右支并原位劈离肝左外叶和左内叶,第二步行肝脏右三叶切除术。结果 第一步手术7 d后,剩余肝脏体积由术前281 mL增加至606 mL,术后第7天肝功能恢复正常。第一步术后第8天行第二步手术,术后第5天肝功恢复正常。结论 ALPPS为残余肝脏体积不足的巨大肝癌病人提供了新的治疗选择。     

大鼠实验性肝硬化门脉高压形成过程中内皮素及其转化酶的动态变化

目的 观察大鼠实验性肝硬化门脉高压形成过程中,外周血内皮素(ET-1)含量和肝脏前内皮素原(ppET-1)和内皮素转化酶(ECE)mRNA表达的动态变化,以期对其在门脉高压中动态变化的特点有进一步的了解。方法 通过四氯化碳(CCl4)介导大鼠实验性肝硬化门脉高压模型,放免法检测ET-1,半定量RT-PCR法观察不同时期肝组织中ppET-1和ECEmRNA的表达差异。结果 与对照组相比,模型组中外周血ET-1含量和肝脏ppET-1的表达分别从第8周和第6周开始显著升高,且ET-1的升高与门脉高压形成呈显著相关,而肝脏中ECE的表达无明显差异。结论 外周血中ET-1含量的增高和肝脏中ppET-1表达的增加可能是形成肝硬化门脉高压的重要原因之一。     

Associating liver partition and portal vein ligation for staged hepatectomy in the treatment of colorectal cancer liver metastases

Colorectal cancer (CRC) is a common malignancy of the digestive system. Colorectal liver cancer metastasis (CRLM) occurs in approximately 50% of the patients and is the main cause of CRC mortality. Surgical resection is currently the most effective treatment for CRLM. However, given that the remnant liver volume after resection should be adequate, only a few patients are suitable for radical resection. Since Dr. Hans Schlitt first performed the associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) for CRLM in 2012, ALPPS has received considerable attention and has continually evolved in recent years. This review explains the technical origin of the ALPPS procedure for CRLM and evaluates its efficacy, pointing to its favorable postoperative outcomes. We also discuss the patient screening strategies and optimization of ALPPS to ensure long-term survival of patients with CRLM in whom surgery cannot be performed. Finally, further directions in both basic and clinical research regarding ALPPS have been proposed. Although ALPPS surgery is a difficult and high-risk technique, it is still worth exploration by experienced surgeons.     

活体右半肝供者肝脏血管和胆道解剖变异分析

目的:探讨活体肝移植右半肝供者血管、胆道解剖学特点。方法:依据门静脉分型、肝静脉解剖分型、胆道分型及肝动脉解剖分型,观察90例右半肝活体肝移植供者的肝静脉、门静脉、肝动脉及胆道的解剖学特点。结果:正常门静脉的比例为94.4%(85/90),三叉型门静脉的比例为5.6%(5/90);肝动脉变异率较高;正常胆道的比例为66.7%(60/90),三叉型胆道占20%(18/90),3型胆道的比例为12.2%(11/90),4型胆道占1.1%(1/90);肝中静脉和肝左静脉共干的比例为70.0%(63/90),大于5mm的肝右下静脉出现概率为26.6%(24/90),左内叶上段静脉汇入肝左静脉的比例为68.8%(62/90),共同汇入肝左静脉和肝中静脉的比例为21.1%(19/90),汇入肝中静脉的比例为10.0%(9/90)。结论:肝脏血管和胆道的解剖变异很常见,准确的术前评估对于活体肝移植至关重要。     

Creating a place for caregivers in personal health: the iHealthSpace copilot program and diabetes care

Background

As America’s baby boom generation reaches retirement, the number of elders, and, in turn, the number of lay individuals who support them, will continue to increase. With the important services caregivers provide, it is critical that we recognize and provide assistance to the informal caregivers who play this important role in our society. The network of support provisioned by relatives, partners, friends, and neighbors suggests that the dyadic, unidirectional caregiver–care recipient relationship assumed by caregiver research so far and by resources deployed to assist caregivers may be insufficient to ascertain and meet the needs of the care community.

Methods

In this article, we describe the extension of a Web-based personal health record system, iHealthSpace, for explicitly and openly incorporating caregivers into the care community.

Results

Using this portal, a set of business rules was implemented to support the creation of custodial accounts. These business rules will be used to create modules that support diabetes care in an adult population.

Conclusions

We successfully extended an existing patient portal to accommodate the creation of custodial accounts. We will use this portal to assess the impact of custodial access in the care of older patients with diabetes.     

The optimal cut-off for predicting large oesophageal varices using transient elastography is disease specific

The diagnosis of cirrhosis requires screening for oesophageal varices by upper gastrointestinal endoscopy. In many countries, serological tests and elastography are replacing liver biopsy for diagnosing cirrhosis. The aims of this study were to see whether there was an optimal cut-off of liver stiffness that could predict the presence of large (>F2) oesophageal varices and whether this was disease specific. A total of two hundred and twenty-two patients with all cause cirrhosis (Child class A) were screened, and 211 had successful elastography and are included in the analysis. Of the patients studied, one hundred and thirty-two patients had no or small F1 varices and 79 had large varices. Liver stiffness of 19.8 kPa had a negative predictive value of 91% and a positive predictive value of 55% with an area under the curve (AUC) on receiver operating characteristics (ROC) of 0.73 in differentiating between small and large varices. Seven patients with large varices would have been incorrectly classified. In the 157 patients with hepatitis C as the aetiology of cirrhosis, the negative predictive value was 98% and only one patient was misclassified. Liver stiffness was superior in diagnostic accuracy to platelet count in all patients. A liver stiffness of >19.8 kPa could be utilized as a cut-off for endoscopy and beta blocker utilization, particularly in patients with hepatitis C.     

Hepatocellular carcinoma with portal vein tumor thrombosis: Improved treatment outcomes with external beam radiation therapy

The treatment of advanced hepatocellular carcinoma (HCC) associated with portal vein tumor thrombosis (PVTT) is very challenging because of HCC's grave prognosis. Despite many efforts to improve the treatment results, patient survival has been limited to several months. In this situation, radiotherapy has been considered as an alternative treatment modality because of the growth of knowledge about the radiotolerance of normal tissue and the advances of radiotherapy techniques such as three dimensional conformal radiotherapy, intensity modulated radiotherapy, stereotactic body radiotherapy and proton therapy. More restoration of the liver function and longer survival of the patients can be achieved by the better response after radiotherapy. However, considering the high risk of intrahepatic advanced tumor or extrahepatic dissemination by PVTT at disease presentation, a combination of radiation therapy and systemic agents will be desirable. Therefore, performing prospective randomized clinical trials is important to assess the benefits of radiotherapy and to develop combination treatment strategies.     

Portal blood supply to locally progressed hepatocellular carcinoma after transcatheter arterial chemoembolization: Observation on CT during arterial portography

Aim: To analyze the clinical features of locally progressed hepatocellular carcinoma (HCC) supplied by portal blood (PB) after transcatheter arterial chemoembolization (TACE). Methods: This cohort included 12 tumors (mean diameter ± SD, 1.8 ± 0.8 cm) in 10 patients. PB supply to tumors was judged by CT during arterial portography (CTAP). Imaging data and the clinical course were retrospectively evaluated. Results: Six tumors initially had a small tumor portion supplied by PB. In four tumors, TACE was incomplete because of technical problems. PB supply to recurrent tumors was demonstrated 7.3 ± 3.7 months after TACE. On follow‐up arteriography, all embolized branches were occluded or severely attenuated. Four tumors showing a partial stain were treated by additional TACE (n = 3) or TACE plus radiofrequency (RF) ablation (n = 1), one without staining was treated by RF ablation, and seven were followed‐up. All tumors progressed except for one treated by RF ablation. On serial CTAP images, relatively large‐diameter portal veins directly entered 11 tumors (91.7%) and connected with intratumoral vessels in nine (75%). During follow‐up, partial arterial supply was demonstrated in two tumors and additional TACE was performed. Nine patients died after 31.4 ± 16.2 months due to tumor progression (n = 8), or hepatic failure (n = 1). One patient has survived for 53 months despite multiple tumors. Conclusions: PB supply to locally progressed tumor after TACE became apparent on CTAP. Arterial damage by TACE, incomplete TACE, and preexisting tumor tissues supplied by PB may be the main causes.     

Predictive factors for long‐term survival in patients with clinically significant portal hypertension following resection of hepatocellular carcinoma

Background: Hepatic resection for hepatocellular carcinoma (HCC) is not currently recommended for patients with clinically significant portal hypertension (PHT); however, recent studies have shown similar post‐operative outcomes between patients with and without clinically significant PHT. Aim: To clarify the post‐operative prognostic relevance of clinically significant PHT in Child–Pugh A cirrhotic patients. Methods: A total of 100 Child–Pugh A cirrhotic patients who underwent curative resection of HCC were eligible for this analysis. Patients were divided into two groups: PHT group (n=47) and non‐PHT group (n=53). Results: Clinicopathological variables showed no significant differences except for prothrombine time. Liver‐related complications were significantly higher in the PHT group (P=0.015), and the 5‐year overall survival rate was significantly higher in the non‐PHT group (78.7 vs. 37.9%, P<0.001). The proportion of patients who died because of complications of cirrhosis was significantly higher in the PHT group (P=0.001). Multivariate analysis indicated that the presence of clinically significant PHT was the most powerful adverse prognostic factor for overall survival. Multivariate analysis of the 47 patients with clinically significant PHT indicated that gross vascular invasion and non‐single nodular type were poor prognostic factors. The 5‐year survival rate of patients with single nodular type and without gross vascular invasion (n=17) was 78.4%. Conclusions: In Child–Pugh A cirrhotic patients, the presence of clinically significant PHT was significantly associated with post‐operative hepatic decompensation and poor prognosis after resection of HCC. However, in patients with clinically significant PHT, those with single nodular tumours lacking gross vascular invasion may be good surgical candidates.