手术切除治疗中央型肝细胞肝癌临床分析

Clinical analysis of surgical resection for centrally located hepatocellular carcinoma

目的探讨中央型肝细胞肝癌(肝癌)手术切除的安全性、可行性和疗效,总结手术治疗经验。方法本组回顾性研究对象为2007年1月至2011年12月在上海交通大学医学院附属新华医院普外科实施手术切除的35例中央型肝癌患者。患者均签署知情同意书,符合医学伦理学规定。男性31例,女性4例,年龄25～69岁,中位年龄46岁。手术方式:肝癌位于肝Ⅳ、Ⅴ段之间者3例,其中2例行左半肝切除术,1例行肿瘤局部切除术;位于Ⅷ段者11例,其中7例行Ⅷ段切除术,4例行右半肝上段(Ⅶ、Ⅷ段)切除术;位于第一肝门者5例,均行中肝叶(Ⅳ、Ⅴ、Ⅷ段)切除术;位于门静脉右前、右后支夹角者7例,其中4例行右肝下段(Ⅴ、Ⅵ段)切除术,另3例行右半肝切除及门静脉取栓术;位于门静脉左、右支、肝右静脉、肝中静脉及下腔静脉之间者2例,2例均行肿瘤局部切除术,其中1例先行左右半肝劈开后再行肿瘤局部切除术;位于下腔静脉背段者7例,其中2例行右后叶(Ⅵ、Ⅶ段)切除术,2例行Ⅶ、Ⅷ段切除术,3例行Ⅴ、Ⅵ段切除术。观察术中出血量、输血量、手术时间、控制出血方法、术中及术后并发症和死亡发生情况。术后随访,应用寿命表法计算患者生存率。结果 35例患者均顺利完成手术,无发生手术相关性死亡,无发生下腔静脉或肝静脉破裂导致的空气栓塞和大出血等严重并发症。术中出血量100～600(280)ml,5例输红细胞悬液2～4 U。手术时间135～265(178)min。术中控制出血方法:行第一肝门阻断22例,阻断时间15～35(24)min,阻断次数1～2次;行左半肝门阻断2例,阻断时间分别为10、15 min,均为一次性阻断;行右半肝门阻断4例,阻断时间20～38(28)min,均为2次阻断;另3例右半肝切除者,切肝前切断肝动脉右支和阻断门静脉右支;行全肝血流阻断4例,下腔静脉阻断时间10～18(13)min,均为一次性阻断。术后并发症包括胆漏1例、膈下积液4例、右侧胸腔积液6例,处理后均治愈,无发生出血和感染。术后1年和3年生存率分别为87.8%和63.0%。结论手术切除治疗中央型肝癌是有效、安全和可行的。术中应选择合适的手术方式和掌握控制肝脏出血方法。

Objective To evaluate the safety, feasibility and therapeutic outcome of surgical resection for centrally located hepatocellular carcinoma（HCC）. Methods A total of 35 cases diagnosed as centrally located HCC were enrolled in this retrospective study, who underwent operations from January 2007 to December 2011 at the Department of General Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University. Local ethical committee approval had been received and that the informed consent of all participating subjects was obtained. The patients included 31 males and 4 females with median age of 64 years old （range： 25-69 years old）. Among three patients with HCC located in Couinaud segments IV and V ,2 cases received left hemihepatoectomy and 1 case received local resection. Among 11 patients with HCC located in Couinaud segments VIII,7 cases underwent hepatic segmentectomy of Ⅷ and the other 4 cases underwent hepatic segmentectomy of Ⅶ and Ⅷ. Among seven patients with HCC located between the fight anterior and posterior branch of portal vein,4 cases received hepatic segmentectomy of V and VI and 3 cases received right hemihepatoectomy plus embolectomy. Two patients had HCC located between the left and right trunk of portal vein, the middle and right hepatic vein, inferior vena cava （IVC）. These two cases received local resection and one of them underwent fight and left liver split following resection. Among seven patients with HCC located in apical segment of IVC,2 cases received hepatic segmentectomy of Ⅵ and Ⅶ,2 cases received hepatic segmentectomy of VII and vm and the other 3 cases received hepatic segmentectomy of V and Ⅵ. The volume of intraoperative blood loss and transfusion, operation time, blood loss control, intraoperative and postoperative complications as well as mortality were observed and recorded. All the patients were followed up and Lift Table method was applied to calculate the survival rate. Results All the 35 HCC patients received successful operations and no operative mortality was observed. No complications were observed such as air embolism and massive haemorrhage caused by IVC or rupture of hepatic vein. The intraoperative blood loss were 100-600 ml with the median volume of 280 ml and 5 cases received 2-4 U blood transfusion. The operating time was 135-265 min with the median time of 178 min. The blood loss control methods included 26 cases undergoing the first hepatic portal control （1-2 times hepatic occlusion with time of 15-35 minutes, median time of 24 minutes）, 2 cases undergoing left hepatic portal control （olny one-time hepatic occlusion with time of 10, 15 minutes respectively）, 4 cases undergoing the right hepatic portal control （2 times of occlusion with time of 20-38 minutes, median time of 28 minutes）. The other 3 cases with right hemihepatoectomy had right branch of hepatic artery cut off and the right branch of portal vein blocked up. Four of the 35 patients received total hepatic vascular exclusion with the inferior vena cava blocking time 10-18 （13） rain for just once. The postoperative complications included 1 ease with bile leakage, 4 eases with subdiaphragmatic effusion and 6 eases with fight pleural effusion. All patients with complications were cured without haemorrhage and infections. The 1- and 3-year survival rates were 87.8% and 63.0% respectively. Conclusions Surgical resection is safe and effective for centrally located HCC. Appropriate techniques and blood loss control should be applied during the operation.