精准肝切除治疗大肝癌的临床疗效

Clinical effect of precise liver resection for large hepatoceUular carcinoma

目的探讨精准肝切除术治疗大肝癌的临床疗效。方法采用回顾性描述性研究方法。收集2014年6月至2015年6月中山大学附属第一医院收治的49例原发性肝癌患者的临床资料。术前对患者一般情况、肝功能分级进行评估，计算剩余肝脏体积／标准肝脏体积（FLV／SLV）比值。符合行大肝癌切除术标准者行右半肝切除术、扩大右半肝切除术或联合肝脏分隔和门静脉结扎的二步肝切除术（ALPPS）。观察指标：（1）术前评估结果。（2）手术情况：手术方式，肝切除术手术时间，术中出血量及围术期输血情况：ALPPS第1步手术时间、第1步术中出血量、第1步与第2步手术间隔时间、至第2步手术时肝体积增长率、第2步手术时间和术中出血量。（3）术后情况：术后住院时间、术后并发症（肝功能不全、胆汁漏、腹腔感染、切口感染、胸腔积液、腹腔积液、膈下积液等）。（4）随访情况。采用门诊方式进行随访，了解患者术后肿瘤复发率。随访时间截至2016年6月。正态分布的计量资料以x^-±s表示，偏态分布的计量资料用肘（范围）表示。结果（1）术前评估结果：49例患者中，46例术前肝功能Child—Pugh分级A级，3例B级；46例ICGR15〈10％及FLV／SLV〉35％，3例ICGR15〉15％或FLV／SLV〈35％。（2）手术情况：49例患者中，44例行右半肝切除术，2例行扩大右半肝切除术，3例行ALPPS。44例行右半肝切除术及2例行扩大右半肝切除术患者手术时间为230min（170～405min），术中出血量为400mL（100～5000mL），围术期输血19例，输血量为550mL（200～2750mL）。3例行ALPPS患者均成功完成2步手术，第1步手术时间分别为80、190、180min，术中出血量分别为100、300、150mL。第1步与第2步手术间隔时间分别为9、11、13d，至第2步手术时肝体积增长率分别为88．4％、78．0％、94．6％，第2步手术时间分别为180、215、150min，术中出血量分别为100、100、400mL。（3）术后情况：44例行右半肝切除术及2例行扩大右半肝切除术患者术后住院时间为17d（9～45d），11例发生术后并发症，其中肝功能不全1例，予积极保肝治疗后治愈；胆汁漏合并腹腔感染1例，予以对症处理及抗感染治疗后治愈；切口感染2例，敞开伤口换药处理后伤口愈合；胸腔积液、腹腔积液或膈下积液7例，穿刺置管引流后复查未见积液残留。3例行ALPPS患者术后未发生明显并发症。（4）随访情况：49例患者均获得随访，术后1年内12例肿瘤复发，复发率为24．5％（12／49）。结论精准肝切除术治疗大肝癌安全有效。术前精准评估和术中精准操作可有效降低术后肝衰竭发生率。

Objective：To evaluate the clinical effect of precise liver resection for large hepatocellular carcinoma （HCC） under the guidance of precision surgery theory. Methods：The retrospective and descriptive study was conducted. The clinical data of 49 patients with HCC who were admitted to the First Affiliated Hospital of Sun YatSen University between June 2014 and June 2015 were collected. The preoperative assessments of general condition and liver function were conducted, and the ratio of future liver volume/standard liver volume （FLV/SLV） was calculated. Patients underwent right hemihepatectomy, extended right hemihepatectomy or associating liver partition and portal vein ligation for staged hepatectomy （ALPPS） based on preoperative comprehensive assessment.Observation indicators： （1） results of preoperative assessment; （2） operation situations： surgical procedures, time of hepatectomy, volumes of intraoperative blood loss and perioperative blood transfusion; time and volume of intraoperative blood loss in the first surgery, interval time between the first and second surgery, growth rate of liver volume up to the second surgery, time and volume of intraoperative blood loss in the second surgery; （3） postoperative situations： duration of postoperative hospital stay, postoperative complications （hepatic dysfunction, bile leakage, intraabdominal infection, wound infection, pleural effusion, peritoneal effusion and subphrenic effusion）; （4） followup situation. Followup using outpatient examination was performed to detect 1year recurrence rate of patients up to June 2016. Measurement data with normal distribution were represented as x^-±s and measurement data with skewed distribution were represented as M （range）. Results： （1） Results of preoperative assessment： of 49 patients, grade A of Childpugh classification was found in 46 patients and grade B in 3 patients. ICG R15〈10% and FLV/SLV〉35% was detected in 46 patients,and ICG R15〉15% or FLV/SLV〈35% in 3 patients. （2） Operation situations： of 49 patients, 44, 2 and 3 patients underwent right hemihepatectomy, extended right hemihepatectomy and ALPPS, respectively. Operation time, volume of intraoperative blood loss, number of patients with perioperative blood transfusion and volume of perioperative blood transfusion were 230 minutes （range,170-405 minutes）, 400 mL （range, 100-5 000 mL）, 19, 550 mL （range, 200-2 750 mL） in 44 patients undergoing right hemihepatectomy and 2 undergoing extended right hemihepatectomy, respectively. Three patients with ALPPS underwent successfully the first and second surgeries. Operation time, volume of intraoperative blood loss and interval time between the first and second surgeries were 80 minutes, 190 minutes, 180 minutes, 100 mL, 300 mL, 150 mL, 9 days, 11 days and 13 days in 3 patients with ALPPS, respectively. Growth rate of liver volume up to the second surgery, operation time and volume of intraoperative blood loss in the second surgery were 88.4%, 78.0%, 94.6%, 180 minutes, 215 minutes, 150 minutes, 100 mL, 100 mL, 400 mL in 3 patients with ALPPS, respectively. （3） Postoperative situations： duration of postoperative hospital stay of 44 patients with right hemihepatectomy and 2 with extended right hemihepatectomy was 17 days （range, 9- 45 days）. Eleven patients had postoperative complications. One patient with hepatic dysfunction was cured by liver protection therapy. One patient with bile leakage and abdominal infection was cured by symptomatic and antibiotic treatments. Two patients with wound infection received wound dressing and then wound was healed. Seven patients with pleural effusion, peritoneal effusion and subphrenic effusion received percutaneous catheter drainage, and no residual effusion was detected. Three patients with ALPPS didn＇t have postoperative complications. （4） Followup situation： all the 49 patients were followed up. The postoperative recurrence was detected in 12 patients within 1 year, with a recurrence rate of 24.5% （12/49）. Conclusion：Precise liver resection for large HCC under the guidance of precision surgery theory can effectively evaluate surgery risks and reduce the incidence of postoperative hepatic dysfunction.