精准肝脏外科理念在原发性肝癌治疗中的临床价值

目的 探讨精准肝脏外科理念在原发性肝癌治疗中的临床价值.方法 回顾性分析2009年1月至201 1年10月解放军第八十一医院收治的141例原发性肝癌患者的临床资料.术前对患者行CT等检查收集二维影像学数据进行三维重建,根据患者情况选择性行肝脏储备功能评估,模拟手术操作以制订手术方案.术中结合彩色多普勒超声探查,选择性阻断肝血流,根据患者情况选择行解剖性肝切除术或非解剖性局部肝切除术.采用电话和门诊进行随访,随访时间截至2014年1月.采用Kaplan-Meier法计算生存率.结果 77例患者术前完成三维重建,39例患者行ICG R15检查,95例患者在术中行彩色多普勒超声探查.141例患者均成功完成手术,采用Pringle法行入肝血流全阻断4例、肝蒂部分阻断48例、未行肝门阻断89例.其中行解剖性肝切除术者占85.11％（120/141）.手术时间为（188±56）min,术中出血量为（230±100） mL,围手术期输血者12例,术后当日腹腔引流量为（147 ±58）mL.术后ALT、AST和TBil峰值分别为（219±121）U/L、（214±104） U/L和（32±14） μmol/L.术后8例患者发生胸腔积液、膈下感染、腹腔积液、胆汁漏等并发症,5例发生肺部感染、切口感染等,并发症发生率为9.22％（13/141）.所有并发症经对症治疗后痊愈,尢肝衰竭和围手术期死亡发生.术后住院时间为（11.0 ±2.6）d.术后病理检查结果示肝细胞癌130例、胆管细胞癌11例,切除肿瘤直径为（5.8 ±1.7）cm,其中1例患者切缘阳性.138例患者获得随访,随访时间为（40±10）个月,患者术后1、2、3年生存率分别为91.5％、75.9％和65.2％,生存时间为（43±5）个月.结论 精准肝脏外科理念运用于原发性肝癌的治疗,术后并发症少,近、远期疗效好.

Clinical value of precision liver surgery concept in the treatment of primary liver cancer

Objective To investigate the clinical value of precision liver surgery concept in the treatment of primary liver cancer. Methods The clinical data of 141 patients with primary liver cancer who were admitted to the No. 81 Hospital of PLA from January 2009 to October 2011 were retrospectively analyzed. The three-dimensional reconstruction, preoperative evaluation and virtual surgery were done based on the data of imaging examination. Hepatic functional reserve evaluation was done based on the condition of patients. The blood flow was occluded in selected patients according to the results of ultrasonography, and the tumor was anatomically resected. Patients were followed up via phone call or out-patient examination till January 2014. The survival rate was calculated by Kaplan-Meier method. Results Three-dimensional reconstruction was done in 77 patients preoperatively. Thirty-nine patients received ICG R15 test to detect the liver functional reserve and 95 received intraoperative color Doppler ultrasonography. The operation was successfully done on 141 patients. Four patients underwent total inflow occlusion, 48 underwent partial inflow occlusion in the hepatic pedicle by Pringle maneuver. Eighty-nine patients did not receive inflow occlusion. The proportion of patients who received anatomical hepatectomy was 85.11% （120/141）. The operation time, volume of intraoperative blood loss, number of patients who received blood transfusion, volume of peritoneal drainage at postoperative day 0 were （188 ± 56）minutes, （230 ± 100）mL, 12 and （147 ±58）mL, respectively. The peak levels of postoperative alanine transaminase, aspartate transami- nase and total bilirubin were （219 ± 121 ） U/L, （214 ±104） U/L and （32 ± 14） μmol/L, respectively. Eight patients were complicated with thoracic effusion, subphrenic infection, peritoneal effusion and bile leakage,and 5 patients were complicated with pulmonary infection and incisional infection, with the complication rate of 9.22% （13/141） after the operation. All the patients were cured after symptomatic treatment, without occurrence of hepatic failure or perioperative death. The duration of postoperative hospital stay was （ 11.0 ± 2.6） days. There were 130 patients with hepatocellular carcinoma and 11 patients with cholangiocarcinoma. The mean diameter of tumors resected was （5.8 ±1.7） cm, and the resection margin of 1 patient was positive. One hundred and thirty eight patients were followed up for （40 ± 10）months, and the 1-, 2-, 3-year survival rates were 91.5 %, 75.9% and 65.2%, and the survival time was （43 ± 5） months. Conclusion Precision liver surgery has advantages of few postoperative complications and better short- and long-term efficacy.