联合肝脏离断和门静脉结扎的分阶段肝切除术治疗肝细胞癌

Associating liver partition and portal vein ligation for staged hepatectomy for the treatment of hepatocellular carcinoma

目的探讨联合肝脏离断和门静脉结扎的分阶段肝切除术(ALPPS)治疗肝细胞癌(肝癌)的经验。方法回顾性分析2015年3月在第四军医大学唐都医院行ALPPS的1例肝癌患者临床资料。患者男,31岁,因"肝癌介入术后2周"入院。既往有乙型病毒性肝炎(乙肝)病史20余年。皮肤及巩膜无黄染,肝区叩击痛阳性。HBs Ag阳性,AFP 10 196μg/L。CT检查提示肝右叶巨块型肝癌,直径约15 cm。入院诊断:肝右叶肝癌。术前评估:肝功能Child-Pugh分级A级。CT评估肝脏体积3 464 ml,右半肝体积2 693 ml,左半肝体积771 ml,切除右半肝及部分肝左内叶后残肝体积占标准肝体积(SLV)的35%,标准残肝体积(SRLV)为328 ml/m2,无法耐受一期手术,决定行ALPPS。患者签署知情同意书,符合医学伦理学规定。结果 ALPPS一期行肝脏离断、门静脉癌栓取出、门静脉右支结扎、部分肝左内叶切除。二期行右半肝切除,门静脉化疗泵置入术。ALPPS一期术后2周复查CT示SRLV 610 ml/m2,左半肝体积增至1 245 ml,占SLV的86%。二期术后患者腹腔大出血,行肝动脉数字减影血管造影(DSA)+栓塞止血术后出血停止。2015年4月17日病情稳定出院。结论 ALPPS适用于无法耐受一期肝切除的中晚期肝癌的治疗,可为强调综合治疗的肝癌患者争取更长的存活时间,为接受后期的综合治疗提供机会。

Objective To discuss the experience of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) for the treatment of hepatocellular carcinoma (HCC). Methods Clinical data of one patient with HCC undergoing ALPPS in Tangdu Hospital of the Forth Military Medical University in March 2015 were retrospectively analyzed. The patient was male, aged 31 years, was hospitalized at 2 weeks after interventional therapy of HCC. Hehadahistory of hepatitis B forover 20 years. No yellow skin or sclera was observed. Percussion pain of hepatic region was positive. HBsAg was positive and the level of AFP was 10 196μg/L. A massive HCC in the right lobe was observed by computer tomography (CT) scan, approximately 15 cm in diameter. The admitting diagnosis was HCC of the right lobe. Preoperative evaluation: Child-Pugh classification A. The liver volume was 3 464 ml, the right lobe was 2 693 ml and the left lobe was 771 ml assessed by CT scan. After resection of the right lobe and partial inferior left lobe, the remnant liver volume accounted for 35%of the standard liver volume (SLV). The standard remnant liver volume (SRLV) was 328 ml/m2. The patient was unable to tolerate one-stage operation and ALPPS was performed subsequently. The informed consents of the patient was obtained and the local ethical committee approval was received. Results During the ifrst-stage ALPPS, liver separation, removal of portal vein tumor thrombosis, ligation of the right branch of portal vein, partial resection of the inferior left lobe were performed. During the second-stage surgery, right hemihepatectomy was performed and chemotherapy pump was implanted in portal vein. CT scan revealed that the SRLV was 610 ml/m2, and the volume of left liver lobe grew to 1 245 ml, accounting for 86%of SLV 2 weeks after the ifrst-stage of ALPPS. The patient developed massive abdominal hemorrhage following the second-stage surgery and bleeding was stopped after receiving digital subtraction angiography (DSA) of the hepatic artery+embolization. The patient was discharged in stable condition on April 17th, 2015. Conclusions ALPPS is suitable for patients with middle- and advanced-stage HCC who are intolerable of one-stage hepatectomy. For those requiring comprehensive therapy, ALPPS can prolong the survival time of patients to provide the opportunity of receiving subsequent comprehensive treatments.