肝癌侵犯右膈肌的外科处理

Surgical therapy for hepatocellular carcinoma with right diaphragmatic invasion

目的探讨肝癌合并右膈肌部分切除的适应证、手术方法、术中应注意的问题，总结肝癌侵犯右膈肌的外科处理经验。方法对广东省东莞市人民医院1998年9月至2008年9月收治的27例肝癌合并右膈肌部分切除患者的临床资料进行回顾性分析。结果全部病例手术均获得成功。切除肿瘤直径5．0～15．0（平均8．5）cm，合并切除右膈肌面积9．0～50（平均28．5）cm2，手术时间110～250（平均165）min，失血量450～2600（平均870）ml。术后病理证实膈肌侵犯者9例（33．3％）。术后全部病例均见少量右胸积液。其他并发症包括慢性肝功能不全4例及术后早期出血、上消化道出血、胆汁瘘、膈下感染各1例。所有患者经相应处理后均康复出院，无围手术期死亡病例。术后19例接受综合治疗，6例拒治，2例失访。术后6个月、1年、2年、3年生存率分别为92．6％、81．5％、51．9％、33．3％。结论右膈肌侵犯不是肝癌切除禁忌证。合并右膈肌部分切除安全可行，而且远期疗效比较满意。

Objective To review the indications, surgical methods, and matters which need at- tention in partial right diaphragmatic resection, and to summarize our experience of surgical therapy for hepatocellular carcinoma with right diaphragmatic invasion. Methods The clinical data of 27 pa- tients with hepatocellular carcinoma which had invaded the diaphragm and had received partial right di- aphragmatic resection and partial hepatectomy in our hospital from September 2008 to September 2012 were retrospectively analyzed. Results The operations were all performed successfully. The tumor di- ameter ranged from 5.0 to 15.0 cm （average 8.5 cm）. The area of right diaphragm which was resec ted ranged from 9.0 to 50.0 cm2 （average 28.5 cm2）. The operation time was 110-250 min （average 165 min）, and blood loss was 450-2600 ml （average 870 ml）. Diaphragmatic invasion was confirmed by postoperative histopathology in 9 patients （33.3%）. A small quantity of right thoracic effusion was detected in all the cases postoperatively. Other complications included hepatic insufficiency in 4 pa- tients and early postoperative bleeding, upper gastrointestinal bleeding, biliary fistula, and infection under the diaphragm in 1 case each. All patients recovered after conservative treatment. There was no perioperative death. 19 patients received other postoperative adjuvant treatment while 6 patients re- fused further treatment and 2 patients were lost to follow-up. The 0.5-, 1-, 2-, and 3-year survival rates after operation were 92.6%, 81.5%, 51.9% and 33.3% respectively. Conclusions Right dia- phragmatic invasion is not a contraindication to surgery. Right diaphragmatic resection was safe and feasible, and postoperative long-term survival was satisfactory.