体外肝切除自体肝移植在复杂肝切除中的应用

Application of ex-vivo liver resection combined liver autotransplantation in complex liver resection

目的评估体外肝切除自体肝移植在巨大肝癌患者复杂肝切除中的临床价值。方法回顾性分析2008年1月至2010年5月首都医科大学附属北京朝阳医院收治的4例巨大原发性肝癌患者的临床资料。肿瘤最大直径10—18cm，病灶不同程度地累及了第一、二、三肝门。患者难以耐受常规肝切除，均行体外肝切除自体肝移植。结果4例患者顺利完成手术，手术时间690～840rnin，无肝期250～300min，术中出血量400—1400ml，术中无肝期未行门、腔静脉转流术。4例患者在体外肝切除后行下腔静脉或肝静脉及门静脉修复成型，均应用成型异体血管来延长剩余肝脏肝上腔静脉以利于腔静脉吻合及第一肝门的重建。本组患者1例术后肝功能正常，l例出现腹腔出血再次手术止血，1例发生肝功能不全，1例出现肝肾功能不全于术后5d放弃治疗而死亡。3例术后生存的患者术后1～2个月间剩余肝脏均发生不同程度的代偿增生。术后生存的3例患者中2例分别于术后8、9个月发现肺部多发转移瘤，分别于术后13个月及15个月死亡。随访截至2012年4月，1例患者无瘤生存37个月。结论体外肝切除自体肝移植为复杂肝切除的巨大肝癌患者提供了技术上的可行性，术后肝功能代偿不全及近期肿瘤的复发是限制该手术发展的主要问题。

Objective To evaluate the feasibility and efficacy of ex-vivo liver resection combined liver autotransplantation for patients with massive primary liver cancer who underwent complex liver resection. Methods The clinical data of 4 patients suffering from massive primary liver cancer who were admitted to the Beijing Chaoyang Hospital from January 2008 to May 2010 were retrospectively analyzed. Regular liver resection could not be carried out because the first, second and third hepatic hilum of the 4 patients were invaded by the tumors, so ex-vivo liver resection combined liver autotransplantation were performed. Results The operation was successfully carried out for the 4 patients. The operation time, the duration of anhepatic phase and the volume of operative blood loss were 690-840 minutes, 250-300 minutes and 400-1400 ml, respectively. Portacaval bypass operation was not performed. After ex-vivo liver resection, the inferior vena cava or hepatic vein and portal vein of the 4 patients were repaired, and the allogenous blood vessels were kept to extend the superior vena cava of the remnant liver so as to facilitate the anastomosis of blood vessels and reconstruction of the first hepatic hilum. After operation, the hepatic function of 1 patient was back to normal; 1 patient who suffered from abdominal hemorrhage received reoperation for hemostasia; 1 patient was found with hepatic dysfunction; 1 patient died of hepatorenal dysfunction at postoperative day 5. Compensatory hypertrophy was observed in the 3 patients who survived at postoperative months 1-2. Of the 3 patients, 2 were found with multiple pulmonary metastases at postoperative months 8 and 9, and they died at postoperative months 13 and 15. Until April 2012, 1 patient survived for 37 months with no tumor recurrence or metastasis. Conclusions Ex-vivo liver resection combined liver autotransplantation provides the technical feasibility for performing complex liver resection for patients. The incomplete compensation of liver function and the short-term recurrence of tumors after operation are still the main issues which hinder the development of this technique.