经皮射频治疗肝肿瘤中肠穿孔预防措施探讨

Strategy to prevent intestinal perforation in radiofrequency ablation of hepatic tumors

目的探讨经皮射频治疗近消化管肝肿瘤时肠灼伤、肠穿孔发生的原因及预防策略,评价临床应用效果。方法对有手术切除史或其他治疗等原因不宜接受再手术的邻近消化道肿瘤55例59个病灶,制定相应的附加方法及治疗后预防措施进行治疗,并进行超声、CT随访。结果经皮射频治疗后3～72h内持续不同程度腹痛者占38.2%(21/55例),其中48例治疗后7天内行超声或CT检查,右上腹显著疼痛、肠壁增厚水肿者占25%(12/48例),12.5%(6/48例)肠壁增厚显著,并在肝肠之间有少量积液;12例有右上腹手术或邻近肠管区域肿瘤的2～3次射频治疗病史,其中2例为胆肠吻合术后。2～3周后10例疼痛症状缓解,2例持续性右上腹不适隐痛达4～6个月。3个月后超声或CT检查,8例(14.5%)显示肠粘连,无1例发生肠穿孔。本组病例肿瘤1次射频消融成功率达89.8%(53/59灶),治疗后复发率达15.3%(9/59灶),其后有11例(11/55,20.0%)采用手术切除或术中RF等方法再治疗。结论右上腹手术及邻近肠管区域局部反复射频治疗是RF易发生肠壁灼伤的危险因素;重视预防策略,可有效减少肠穿孔并发症的发生。

Objective To explore the reasons of intestinal injury or perforation in radiofrequency (RF) ablation of hepatic tumors adjacent to intestines, to establish a preventive strategy and investigate its clinical efficacy. Methods To prevent colon perforation, a preventive strategy was established and applied to 55 cases with 59 tumors which were adjacent to colon or small intestines. They were closely followed up with CT or ultrasound. Results Twenty-one cases (38.2%, 21/55) complained persisted abdominal pain at various degrees 3-72 hours after the procedure. Of the 48 cases which were examined with ultrasound or CT within 7 days after treatment, 12 (25.0%) were found to have thickened or edematous bowel walls in the right upper abdomen. Small amount of fluid was found between the liver and bowels in 6 cases (12.5%) with significant bowel wall edema, of which 2 had undergone prior cholangioenterostomy. All the 12 cases had prior right upper quandrant surgery or 2 to 3 sessions of RF treatment for tumors adjacent to the bowels. After adopting the corresponding measures during and after the procedure, the pain in 10 cases was obviously relieved, while in 2 cases the discomfort persisted for 4 to 6 months. On the 3 month follow-up ultrasound or CT, 8 cases demonstrated bowels adhension and no intestinal perforation occurred. The success rate of single session of RF treatment was 89.8% (53/59 tumors) with a recurrence rate of 15.3% (9/59 tumors) in this study. Eleven cases (20.0%) were subsequently converted to surgery or intraoprative RF ablation and other methods. Conclusion Prior right upper quandrant surgery and repeated RF ablation of tumors adjacent to bowels are high risk factors of bowel injury in RF treatment. Adopting the preventive strategy during and after the procedure can effectively reduce the possibility of bowels perforation and broaden the indications of percutaneous RF treatment.