联合肝脏离断和门静脉结扎二步肝切除术治疗肝硬化肝癌疗效分析(附1例报告)

Associating liver partition and portal vein ligation for staged hepatectomy for HCC with liver cirrhosis:A report of 1 case

目的探讨联合肝脏离断和门静脉结扎二步肝切除术(ALPPS)在合并肝硬化的肝细胞性肝癌中的应用价值。方法对2014-03-07浙江省人民医院肝胆胰外科收治的1例合并肝硬化的右肝巨块性肝癌病人行ALPPS治疗,并对围手术期指标进行分析。手术方案:原位前入路离断左肝外侧叶和内侧叶后,肝劈离面用人工血管材料缝合覆盖,结扎门静脉右支;术后15 d,顺、逆法行肝右三叶切除术。结果第1步术前剩余肝脏体积(左肝外叶)460.8 mL,第2步术前增大至760.2 mL,增加65.0%。标准全肝体积1019.3 mL,第1步术前标准剩余肝体积320 mL/m2,第2步术前527.9 mL/m2;标准剩余肝体积占标准全肝体积分别为31.4%和52.0%。第1步和第2步手术时间分别为188 min和124 min;术中出血分别为2000 mL和400 mL;术后恢复肝功能时间分别为6 d和4 d。第1步术后并发胆瘘和少量腹水、右上肺小动脉部分栓塞;第2步术后无并发症,术后10 d出院。结论ALPPS为剩余肝体积不足的合并肝硬化的肝细胞性肝癌提供了新的治疗选择。

Objective To discuss the safety and effectiveness of associating liver partition and portal vein ligation for staged hepatectomy（ALPPS） in hepatocellular carcinoma complicated with liver cirrhosis. Methods ALPPS was performed for 1 cases of huge HCC on right liver complicated with liver cirrhosis on March 7, 2014 in Department of Hepatobiliarypancreatic Surgery, Zhejiang Provincial People＇s Hospital. Data of perioperative period were recorded and analyzed. The surgical plan includes：first,SⅡ,SⅢ and SⅣ segment were dissected with an anterior in situ approach and right portal vein was ligated. After 15 days, a combination of antegrade and retrograde approach were applied in right liver lobectomy. Results The remnant liver volume was 460.8 mL before the first step of operation,which was increased by65.0% to 760.2 mL before the second step of operation. The standard whole liver volume was 1019.3 mL. The standard remnant liver volume was 320 mL/m^2 before the first step of operation,and was 527.9 mL/m2 before the second step of operation,which accounted for 31.4% and 52.0% of the standard whole liver volume respectively. The operative time for the first step and second step of operation was 188 min and 124 min. The intraoperative bleeding was 2000 mL and 400 mL respectivey. The time for restore to normal liver function postoperatively was 6 d and 4 d. Complication of minimal bile leakage,ascites and partial arterial thrombosis in lower lobe of right lung occurred after the first step of operation. No complication occurred after the second step of operation. The patients were discharged 10 d postoperatively. Conclusion The modified ALPPS provides a new strategy for the cases of HCC with cirrhosis who couldn＇t tolerate the radical resection due to the insufficient remnant liver volume.