经皮微波或射频消融肝实质分隔联合门静脉栓塞计划性肝切除术治疗余肝体积不足肝癌及胆管癌3例报告

Percutaneous microwave/ radiofrequency ablation liver partition and portal vein embolization for planned hepatectomy(PAPEP) for HCC and perihilar cholangiocarcinoma with insufficient future liver remnant:A report of 3 casess

目的探讨经皮微波或射频消融肝实质分隔联合门静脉栓塞计划性肝切除术（percutaneous microwave／radiofrequency ablation liver partition and portal vein embolization for planned hepatectomy，PAPEP）替代联合肝脏分隔和门静脉结扎的二步肝切除术（associating liver partition and poem vein ligation for staged hepatectomy，ALPPS）治疗剩余肝体积（future liver remnant，FLR）不足肝癌和胆管癌的可行性和安全性。方法回顾性分析2015年7-9月浙江省人民医院肝胆胰外科应用PAPEP治疗FLR不足的2例原发性肝癌和1例肝门部胆管癌的临床资料。先超声引导下经皮微波消融分隔预留侧和切除侧肝实质（pereutaneous microwave ablation liver partition，PMA），PMA后1～3d行门静脉栓塞术（portal vein embolization，PVE），PVE后10～13d测量FLR，术前系统评估后限期肝切除术：2例肝癌分别行肝右三叶和右尾叶切除术、扩大右半肝切除术，l例肝门部胆管癌行肝右三叶和尾叶切除、肝肠内引流术。结果PMA前3例标准全肝体积（standard liver volume，SLV）分别为1231．2mL、1202．9mL、1217．1mL，FLR分别为355．6mL、383．4mL、385．0mL，FLR／SLV分别为28．9％、31．9％、31．6％。PMA时间118～132min，PVE时间158—180min，PMA或PVE术后病人低热经对症处理好转，肝功能无明显变化。PMA＋PVE后10～13dFLR分别为502．1mL、527．4mL、476．3mL，较术前分别增大41．2％、37．6％、23．7％。肝切除术时间230～440min，术中出血120～1800mL。肝门部胆管癌术后并发膈下脓肿，经穿刺后治愈；1例肝癌术后并发腹水、黄疸，经内科治疗后治愈，术后住院时间15～40d。结论PAPEP有望代替ALPPS治疗剩余肝体积不足的肝癌或肝门部胆管癌。

Objective To evaluate the safety and effectiveness of percutaneous microwave/radiofrequency ablation liver partition and portal vein embolization for planned hepateetomy （PAPEP） for hepatoeellnar carcinoma（HCC） and perihilar cbolangiocareinoma with insufficient future liver remnant. Methods B ultrasound guided percutaneous microwave ablation liver partition （PMA） was applied on the future transection plane, the tumor in the left lobe was synehronal treated by dehydrated alcohol injection, one to three days after PMA, portal vein embolization （PVE） was performed. Ten to thirteen days after PVE, right trisectionectomy extended right hepatectomv surzerv procedure was performe. Results The standard liver volume （SLV）was 1231.2mL, 1202.9mL and 1217.1mL respectively, and the remnant liver volume was 355.6mL, 383.4mL and 385.0mL, which was 28.9%, 31.9% and 31.6% of the SLV before PMA. The time for PMA and PVE was llS-132min and 158-180min respectively. The FLR was increased by 41.2%, 37.6%, 23.7% to 502.1mL, 527.4mL, 476.3mL after PMA ＋ PVE. The operation time was 230-440min, the intraoperative blood loss was 120-1800mL. One of HCC patients complicated aseites and jaundice was cured by expectant treatment; the PHCC patient suffered subphrenic abscess which was cured by pereutaneous drainage. The patients were discharged 15-40d postoperatively. Conclusion PAPEP maybe a revolutionary strategy in place of ALPPS to treat HCC and PHCC with insufficient FLR.