补救性射频消融或门静脉栓塞术联合射频辅助肝脏分隔和门静脉结扎的二步肝切除术治疗肝硬化肝癌

Remedial radiofrequency ablation or portal vein embolization combined with radiofrequency ablation- assistant associating liver partition and portal vein ligation for staged hepatectomy in the treatment of patients with hepatocellular carcinoma with cirrhosis

目的探讨行RFA或门静脉栓塞术（PVE）补救治疗射频辅助联合肝脏分隔和门静脉结扎的二步肝切除术（RALPPS）一期术后剩余肝体积（FLR）增长不良的合并肝硬化肝癌患者的临床疗效。方法采用回顾性描述性研究方法。收集2014年9月至2016年2月第三军医大学西南医院收治的5例行RFA或PVE补救治疗RALPPS一期术后FLR增长不良合并肝硬化肝癌患者的临床资料。标准肝脏体积（SLV）：613．0X体表面积＋162．8；体表面积=0．0071×身高＋0．0133×体质量。对FLR〈40％的肝癌患者行RALPPS。一期术中采用RFA在患侧和健侧肝叶间烧灼出1条凝固无血带，结扎门静脉右支。术后对于FLR增长不足的患者行经皮RFA或PVE补救治疗，刺激FLR增长，达到目标值后行二期肿瘤切除术。观察指标：（1）围术期并发症发生和死亡情况。Clavien—DindoⅢa级及以上并发症定义为主要并发症。（2）FLR变化及肿瘤进展情况。（3）术中情况。（4）随访情况。采用门诊随访，随访时间截至2016年2月。随访项目包括常规实验室检查、肿瘤标志物、影像学检查（腹上区增强CT或超声造影）等。正态分布的计量资料采用面±s表示。结果（1）围术期并发症发生和死亡情况：2例患者未行二期手术，其余3例患者完成二期手术。5例患者术后均无主要并发症发生。1例患者于二期术后并发肾衰竭及严重肺部感染死亡。（2）FLR变化及肿瘤进展情况：5例患者一期术前FLR为（329±80）cm^3，占SLV百分比为25％±5％。3例患者二期术前FLR为（533±45）cm^3，占SLV百分比为43％±3％，增长率为44％～113％，间隔期时间为（29．0±2．2）d。3例完成二期手术患者一期术后第1周FLR增长率为33．5％～68．9％；行RFA或PVE补救治疗前FLR1周增长率为1．2％～14．3％；治疗后FLR1周增长率为9．7％～29．8％。2例未行二期手术患者：1例一期术后行4次PVE补救治疗，仍未达到安全切除标准，未行二期手术；另1例一期术后行RFA补救治疗，2周后FLR增长至762．0cm^3，平均1周内比前1周增加10．6％，但患者在间歇期发现预留肝组织肿瘤转移，放弃行二期手术。（3）术中情况：1例患者一期手术在腹腔镜辅助下完成，1例患者术中行肝左叶肿瘤RFA。5例患者一期手术时间为（240±43）min，其中RFA时间为（15±8）min；术中出血量为（190±136）mL，术中均未输血。一期手术后，5例患者共计行RFA补救治疗5次，PVE补救治疗7次。二期术中2例患者行右半肝切除术，1例行肝三叶切除术；3例行二期手术患者手术时间为（2574-33）min，术中出血量为（303±73）mL，术中均未输血，均为R0切除。（4）随访情况：除1例患者住院期间死亡外，其余4例患者获得术后随访。随访时间为1～12个月，中位随访时间为6个月。2例未行二期手术患者：1例后续行介入治疗，半年后死亡；另1例行TACE治疗，至随访截止时间仍生存。其余2例患者中，1例于术后2个月肿瘤复发，行介入、中医等综合治疗，6个月后死亡；另1例随访期间无肿瘤复发、转移。结论对于合并肝硬化肝癌行RALPPS一期术后FLR增长不良患者，行RFA或PVE补救治疗为促进FLR进一步增长，从而提高二期手术完成率提供了选择。

Objective To explore the clinical effect of remedial radiofrequency ablation （RFA） or portal vein cmbofization （PVE） combined with radiofrequency ablation-assistant associating liver partition and portal vein ligation for staged hepatectomy （RALPPS） in the treatment of patients with insufficient future liver remnant （FLR） after the first staged operation and hepatoeellular carcinoma （HCC） with cirrhosis. Methods The retrospective and descriptive cross-sectional study was adopted. The clinical data of 5 patients with insufficient FLR after the first staged of RALPPS and HCC with cirrhosis who underwent remedial RFA or PVE at the Southwest Hospital of the Third Military Medical University between September 2014 and February 2016 were collected. Standard liver volume （SLV） = 613.0 x body surface area （BSA） ＋ 162.8, BSA = 0.007 1 × height ＋ 0. 013 3 × body mass. Patients with FLR 〈40% received RALPPS. In the first staged operation, RFA was used to cauterize a coagulated avaseular area between the FLR and contralateral lobe, and then fight branch of portal vein was ligated. After the operation, remedial RFA or PVE was performed in patients with insufficient FLR. Once the FLR achieved the target value, the second staged RALPPS was performed. Observation indicators included （ 1 ） perioperative complications and death, complications in stage IIIa and above of Clavien-Dindo as main complications, （2） changes of FLR and tumor progression, （3） intraoperative situation, （4） follow-up. The follow-up using outpatient examination was performed up to February 2016, including laboratory examination, tumor markers and imaging examinations （enhanced scan of computed tomogxaphy in the epigastric region or ultrasound）. Measure-ment data with normal distribution were represented as x ± s. Results （ 1 ） Perioperative complications and death： of 5 patients, 2 didn＇t receive second staged RALPPS and 3 completed both stages. Five patients had no postoperative main complications and 1 died of renal failure and pulmonary infection after second staged RALPPS. （2） Changes of FLR and tumor progression： the average FLR and percentage of FLR to SLV were （ 329 ± 80） cm^3 , 25 % ±5 % in 5 patients before first staged operation and （ 533 ± 45 ） cm^3 , 43 % ± 3 % in 3 patients before second staged operation, with an average growth rate of 44%-113%. The average interval time of 5 patients was （29. 0 ± 2. 2） days. For the 3 patients which completed both stages, the 1-week increased percentage of FLR was 33.5%-68.9% after first staged operation, 1.2%-14.3% and 9.7%-29.8% before and after remedial RFA or PVE. Two patients didn＇t undergo the second staged operation, 1 patient was due to not reach standard of safe resection after 4 times remedial PVE, and 1 patient was due to tumor metastasis during intermittent stage after remedial RFA with average FLR after 2 weeks and average l-week increased percentage of 762.0 cm^3 and 10.6%. （3） Intraoperative situations： 1 patient underwent laparoseopic-assisted first staged RALPPS and 1 underwent RFA in the left lobe of liver. The first staged operation time, RFA time and volume of intraoperative blood loss were （240 ± 43 ） minutes, （ 15 ±8 ） minutes and （ 190 ± 136 ） mL, and no patient had blood transfusion. After first staged operation, 5 patients received 5 times remedial PVE and 7 times RFA. Two patients underwent fight hemihepatectomy and 1 patient underwent hepatic trisegmenteetomy in the second staged operation. The second staged operation time and volume of intraoperative blood loss of 3 patients were （257 ± 33 ） minutes and （303 ± 73） mL, and 3 patients received R0 resection and no intraoperative blood transfusion. （4） Follow-up： 1 patient was dead during hospitalization and 4 patients were followed up for 1-12 months with a median time of 6 months. Of 2 patients without second staged operation, 1 continued to undergo interventional treatment and then was dead after half year, and 1 continued to undergo transeatheter arterial ehemoembolization （TACE） and had good survival up to the end of follow-up. Of the other 2 patients, 1 with tumor recurrence at postoperative month 2 received interventional treatment and traditional Chinese medicine and then was dead after 6 months, and 1 had no tumor recurrence and metastasis during the follow-up. Conclusion For the patients with HCC with cirrhosis who had insufficient FLR after the first staged RALPPS, remedial RFA or PVE could promote further regeneration of FLR and thus improve the completion rate of both stages.