超声引导下人工腹水辅助肝癌微波消融治疗研究

Artificial ascites assisted microwave ablation of hepatocellular carcinoma

目的探讨人工腹水在辅助肝癌微波消融中的应用价值。方法采用超声引导下直接穿刺或通过腹腔镜向腹腔内注入生理盐水的方法,在超声显示肝脏周围出现无回声区及肺脏遮盖病灶完整显示后对33例患者(35个肝癌病灶,27个距肝边缘<5mm,8个因肺脏遮盖超声无法完整显示)行经皮微波消融治疗。术后1周内行超声检查,观察肝脏治疗区声像图变化及评价有无腹腔出血、感染等并发症发生。术后1个月时行增强CT或MR,并定期临床随访检查,以评价治疗效果。结果采用两种方法注入生理盐水400～2000ml后,33例均成功形成人工腹水,肝脏周围均出现无回声区,8个肺脏遮盖的病灶均能完整显示。人工腹水灌注成功后对超声显示的35个肝癌病灶完成了经皮超声引导下穿刺消融治疗。术后1周内复查,超声提示原病灶处均变为边界不清的混合回声区,4例患者出现少量右侧胸腔积液,均自行缓解,余31例无腹腔内出血、周围脏器损伤等并发症发生。术后1个月复查CT或MR显示34个肝癌病灶完全消融(34/35,97.1%);1个肝癌病灶残留,经再次人工腹水辅助消融治疗后肝癌病灶完全消融。随访期间13例肝内出现肝癌病灶复发,经再次消融治疗后随访1年,20例患者无瘤生存(20/33,60.6%)。结论人工腹水可安全有效辅助邻近肝边缘或受肺脏遮盖肝癌病灶的微波消融治疗,有较好的临床应用价值。

Objective To evaluate the safety and effectiveness of artificial ascites assisted microwave ablation for hepatocellular carcinoma abutting liver edge or shadowed by lung. Methods Artificial ascites was achieved in thirty-three patients（35 lesions, including 27 lesions located less than 5 mm from hepatic edge and 8 lesions shadowed by lung）by injecting normal saline percutaneously or laparoscopically. When the liver was separated from the surrounding structure by ascites and the tumor became completely visible by sonography, percutanoeus microwave ablation was performed. Baseline ultrasound was performed within 1week after RFA to observe the sonographic changes of the liver and complications such as intraabdominal bleeding and infection. All the patients received CT/MR 1 month after RFA to evaluate the treatment and regular follow-up was also required. Results After introduction of normal saline（400-2000 ml）percutaneously or laparoscopically, artificial ascites was successfully achieved in all of the 33 patients. Liver was separated from the surrounding structures by ascites and the sonic window was improved in all the cases, so that all the 35 lesions had percutaneous microwave ablation. Patients received ultrasound examination within 1 week after the ablation and all the lesions changed into inhomogeneous area. Four patients had asymptomatic pleural effusion and showed complete absorption 1 month after the ablation. No bleeding or thermal injury of the adjacent organs was observed. Complete tumor necrosis was achieved in 97.1%（34/35）of the lesions, and one incompletely ablated lesion received the second artificial ascites assisted microwave ablation and was completely ablated. During the follow-up, 13 cases relapsed and 60.6%（20/33） of the patients were free from tumor during 12 months. Conclusions Artificial ascites was an effective and safe method in assistance of microwave ablation for hepatocellular carcinoma abutting liver edge or shadowed by lung.