下腔静脉重建联合肝叶切除治疗肝癌的初步研究

Anatomical hepatectomy combined with inferior vena cava reconstruction for the treatment of hepatic cancer

目的探讨在全肝血流控制下不采用静脉转流技术行下腔静脉重建的肝叶切除治疗侵犯下腔静脉的肝癌的临床经验和疗效。方法自2004年8月至2005年7月,对3例胆管细胞性肝癌和2例肝细胞性肝癌合并下腔静脉直接侵犯而无癌栓患者,在全肝血流控制而无静脉转流技术下行解剖性肝叶切除联合下腔静脉重建术(局部切除修复2例、局部切除补片2例、人工血管移植1例)。结果5例患者手术均成功。平均手术时间345(300～450)min,平均手术失血量1375 (1200—1800)ml。累计平均肝门阻断时间、全肝血流阻断时间和下腔静脉阻断时间分别为19 min、21．2min、56 min。术后发生胸腔积液1例,胆漏1例,腹水1例,均治愈。患者平均住院时间15．5 (11—19)d。随访4～15个月,1例术后9个月死于肿瘤复发,4例已存活4、8、10、15个月。结论在全肝血流控制而无静脉转流技术下行下腔静脉重建联合解剖性肝叶切除治疗直接侵犯下腔静脉的肝癌不仅可安全施行,而且可延长患者生存时间。

Objective To evaluate concomitant anatomical hepatectomy and inferior vena cava （IVC） reconstruction for hepatic cancer. Methods Between Aug 2004 and Jul 2005, three patients with intrahepatic cholangiocarcinoma and two patients with hepatocellular carcinoma suspected to invade the wall of IVC underwent concomitant hepatectomy, IVC resection and reconstruction under portal triad clamping （PTC）, total vascular exclusion （HVE） without venovenous bypass. The retrohepatic IVC was repaired by primary suture（ n = 2） , a Gore-Tex patch （ n = 2 ） , and a ringed ePTFE graft （ n = 1 ）. Results Surgery was successful in all cases without operative death. The mean operative time was 345 min （ range 300 - 450 min） ,and the mean intraoperative blood loss was 1375 ml（ range 1200 - 1800 ml）. The cumulated mean PTC and HVE times were 19 min and 21.2 min respectively. Postoperative complications included pleural effusion in one needing thoracentesis, bile leakage and ascites in one each. During the follow-up, one patient died at 9 months due to recurrence, and the remaining 4 patients were alive at the follow-up of 4 to 15 months. Conclusions Concomitant hepatectomy with IVC resection offers hope for patients with hepatic tumors involving the IVC, who would otherwise have a dismal prognosis.