晚期妊娠合并肝细胞癌的外科治疗

Surgical treatment for hepatocellular carcinoma in late pregnancy

目的探讨晚期妊娠合并肝细胞癌(肝癌)患者的外科治疗及疗效。方法回顾性分析2011年11月至2011年12月佛山市第一人民医院肝胆外科先后收治的3例晚期妊娠合并肝癌患者临床资料。患者年龄分别为23、33、26岁。例1因孕35周,剖宫产术后进行性皮肤、巩膜黄染3周余入院,AFP 49 096μg/L;例2因孕29周+4,发现肝右叶巨大占位性病变1周入院,AFP 973μg/L;例3因孕30周+6,右上腹隐痛1个月,发现肝右叶巨大占位性病变2 d入院,AFP>1 210μg/L。3例患者均孕3+个月开始产检,未行上腹部超声检查,均有乙型病毒性肝炎(乙肝)病史。患者行超声、CT或MRI检查诊断为肝癌。3例患者均签署知情同意书,符合医学伦理学规定。例1先行经皮经肝胆道引流术(PTCD)减黄,后行前入路右半肝切除+胆总管切开取癌栓术+肝左管-空肠端侧吻合术。例2入院后保守治疗2周,行剖宫产术分娩1健康女婴,遂行前入路右半肝切除+肝Ⅳ段结节切除术。例3入院后保守治疗1周,自然分娩出1健康男婴,1周后行前入路肝Ⅵ、Ⅶ、Ⅷ段切除术。结果例1术后恢复顺利,于2013年1月发现肝内多发性转移,予以经导管动脉化疗栓塞(TACE)。例2术后10 d好转出院,术后4个月复查示肝、肺多发性转移,予以索拉非尼靶向治疗联合局部射频消融治疗。例3术后发生胆漏、胆道及右膈下感染、胰尾感染坏死,经过反复抗感染、多次腹腔穿刺引流、肠内营养支持等治疗93 d后好转出院,2013年2月发现肺多发性转移。3例患者至投稿日期仍存活。结论晚期妊娠合并肝癌一旦确诊,建议保胎至32周,在挽救胎儿的同时,尽早行肝切除术。患者多为晚期肝癌,疗效差。

Objective To discuss the surgical treatment and its effects for hepatocellular carcinoma （HCC） in late pregnancy. Methods Clinical data of 3 patients with HCC in late pregnancy who were admitted in Department Hepatobiliary Surgery, the First People＆#39;s Hospital of Foshan from November 2011 to December 2011 were analyzed retrospectively. The age of the patients was 23, 33 and 26 years old respectively. Case 1 with 35 weeks pregnancy was admitted to hospital for 3＋weeks of progressive jaundice in skin and sclera after caesarean, and the alpha-fetoproteins （AFP） was 49 096μg/L. Case 2 with 29＋4 weeks pregnancy was admitted to hospital after 1 week of ifnding a giant occupying lesion in the right lobe of liver, and the AFP was 973μg/L. Case 3 with 30＋6 weeks pregnancy was admitted to hospital for 1 month of right upper quadrant abdominal dull pain after 2 d of ifnding a giant occupying lesion in the right lobe of liver,＆amp;nbsp;and the AFP was＆gt;1 210μg/L. The patients who had a history of viral hepatitis B began to take obstetrical examinations from 3＋month of pregnancy, but not including the upper abdomen ultrasonic scan. All of them were diagnosed with HCC by ultrasound, computed tomography （CT）, or magnetic resonance imaging （MRI）. The informed consents of 3 patients were obtained and the ethical committee approval was received. Case 1 underwent percutaneous transhepatic cholangial drainage （PTCD） to reduce jaundice, then underwent right hemihepatectomy by anterior approach＋thrombectomy through choledochotomy＋left hepatic duct-jejunum end-to-side anastomosis. Case 2 delivered a healthy baby girl by caesarean after 2 weeks of conservative treatment, then underwent right hemihepatectomy by anterior approach＋hepatic segmentⅣnodulectomy. Case 3 delivered a healthy baby boy naturally after 1 week of conservative treatment, then underwent segmentⅥ,Ⅶ,Ⅷhepatectomy by anterior approach. Results Case 1 recovered well after operation and was found with multiple intrahepatic metastasis in January 2013. Then transcatheter arterial chemoembolization （TACE） was performed. Case 2 was discharged from hospital with improvement 10 d after operation. Multiple hepatic and pulmonary metastasis was found 4 months after operation, and then treatments of targeted therapy of sorafenib combined with local radiofrequency ablation were given to the patient. Case 3 suffered bile leakage, bile duct and right subphrenic infection, and pancreatic tail infection and necrosis after operation and was discharged from hospital with improvement 93 d after treatments of repeated anti-infection, percutaneous peritoneal drainage, enternal nutrition support and so on. And then multiple pulmonary metastasis was found in February 2013. All the patients survived till this article was submitted. Conclusions Once the diagnosis of HCC in late pregnancy is conifrmed, the patient is suggested to keep pregnant till 32 weeks in order to save baby’s life and undergo hepatectomy as early as possible. Most of the patients are late HCC and the curative effect is poor.