经前入路肝尾状叶全切除术治疗累及腔静脉旁部肝肿瘤的临床疗效

Clinical efficacy of total caudate lobectomy via anterior hepatic transaction in treatment of hepatic tumor involving paracaval portion of caudate lobe

目的：探讨经前入路肝尾状叶全切除术治疗累及腔静脉旁部肝肿瘤的临床疗效。方法：采用回顾性横断面研究方法。收集2004年8月至2014年5月第二军医大学东方肝胆外科医院收治的72例累及肝尾状叶腔静脉旁部肿瘤患者的临床资料。72例患者中，肝恶性肿瘤49例，肝良性肿瘤23例；43例肿瘤超出肝尾状叶范围，29例肿瘤局限于肝尾状叶。根据肿瘤累及范围选择行经前入路单纯肝尾状叶全切除术或肝中叶联合肝尾状叶全切除术。观察指标：（1）手术情况：手术方式、肝血流阻断方式、第一肝门阻断时间、手术时间、术中出血量、术中输血例数。（2）术后恢复情况：术后住院时间、术后并发症发生情况。（3）术后病理学检查情况：肝恶性肿瘤患者手术切缘。（4）随访情况。采用门诊和电话方式进行随访，了解患者术后生存情况。随访时间截至2016年8月。偏态分布的计量资料以M（范围）表示。采用 KaplanMeier法计算生存率。结果：（1）手术情况：72例患者均成功完成经前入路肝尾状叶全切除术，无围术期死亡患者。72例患者中，17例行单纯肝尾状叶全切除术，其中2例行第一肝门阻断、13例行第一肝门联合选择性肝静脉阻断、2例行全肝血流阻断；42例行肝Ⅳ段联合肝尾状叶全切除术，其中12例行第一肝门阻断、27例行第一肝门联合选择性肝静脉阻断、3例行全肝血流阻断；13例行肝Ⅳ、Ⅴ、Ⅷ段联合肝尾状叶全切除术，其中2例行第一肝门阻断、11例行第一肝门联合选择性肝静脉阻断。72例患者手术时间、第一肝门阻断时间、术中出血量、术中输血例数分别为205 min（120～445 min）、49 min（24～139 min）、 800 mL（200～5 000 mL）、41例；其中17例行单纯肝尾状叶全切除术患者上述指标分别为245 min（140～345 min）、52 min（29～75 min）、700 mL（200～3 000 mL）、10例，42例行肝Ⅳ段联合肝尾状叶全切除术患者上述指标分别为200 min（120～370 min）、48 min（24～120 min）、675 mL（200～36 00 mL）、21例，13例行肝Ⅳ、Ⅴ、Ⅷ段联合肝尾状叶全切除术患者上述指标分别为210 min（145～300 min）、50 min（26～139 min）、 1 000 mL（300～5 000 mL）、10例。（2）术后恢复情况：72例患者术后住院时间为9 d（7～18 d）。72例患者中，25例术后发生并发症，其中术区积液7例、腹腔积液5例、出血4例、胆汁漏4例、胸腔积液4例、肺部感染1例。4例出血患者行再次手术止血。其余并发症患者均经对症处理后好转。（3）术后病理学检查情况：49例肝恶性肿瘤患者中， 9例患者手术切缘〉5 mm，11例为1～5 mm，27例无手术切缘但肿瘤完整切除，2例切除过程中肿瘤破裂。（4）随访情况：72例患者均获得术后随访，随访时间为6～141个月，中位随访时间为46个月。49例肝恶性肿瘤患者1、3、5年总体生存率分别为83.5%、61.1%、36.4%，1、3、5年无瘤生存率分别为66.3%、40.7%、27.1%。23例肝良性肿瘤患者均健康生存。结论：经前入路肝尾状叶全切除术技术可行，安全有效，适合切除位于肝尾状叶腔静脉旁部的肿瘤和累及肝中叶的尾状叶肿瘤。

Objective：To explore the clinical efficacy of total caudate lobectomy via anterior hepatic transaction in treatment of hepatic tumor involving paracaval portion of caudate lobe. Methods：The retrospective crosssectional study was conducted. The clinical data of 72 patients with hepatic tumor involving paracaval portion of caudate lobe who were admitted to the Eastern Hepatobiliary Hospital of Second Military Medical University from August 2004 to May 2014 were collected. Of 72 patients, 49 had malignant hepatic tumors and 23 had benign hepatic tumors. Tumors of 43 patients exceeded caudate lobe of the liver and tumors of 29 patients didn′t exceed caudate lobe of the liver. According to hepatic tumor involving range, total caudate lobectomy via anterior hepatic transaction or mesohepatectomy with total caudate lobectomy were selected. Observation indicators： （1） operation situations： surgical procedures, hepatic vascular occlusion, time of the first hepatic hilum occlusion, operation time, volume of intraoperative blood loss, number of patient with blood transfusion; （2） postoperative recovery situations： duration of hospital stay, postoperative complications; （3） postoperative pathological examinations： surgical margin of malignant hepatic tumor; （4） followup. Followup using outpatient examination and telephone interview was performed to detect postoperative survival of patients up to August 2016. Measurement data with skewed distribution were described as M （range）. Survival rate was calculated by the KaplanMeier method. Results： （1） Operation situations： all 72 patients received successful total caudate lobectomy via anterior hepatic transaction, without perioperative death. Of 17 patients undergoing single total caudate lobectomy, 2 underwent the first hepatic hilum occlusion, 13 underwent the first hepatic hilum occlusion combined with hepatic veins occlusion and 2 underwent total hepatic vascular occlusion. Of 42 patients undergoing hepatic segment Ⅳresection combined with total caudate lobectomy, 12 received the first hepatic hilum occlusion, 27 received the first hepatic hilum occlusion combined with selective hepatic veins occlusion and 3 received total hepatic vascular occlusion. Of 13 patients undergoing hepatic segment Ⅳ, Ⅴ and Ⅷ resection combined with total caudate lobectomy, 2 received the first hepatic hilum occlusion and 11 received the first hepatic hilum occlusion combined with selective hepatic veins occlusion. Operation time, time of the first hepatic hilum occlusion, volume of intraoperative blood loss and number of patients with blood transfusion were 205 minutes （range, 120-445 minutes）, 49 minutes （range, 24-139 minutes）, 800 mL （range, 200-5 000 mL）, 41 in all the 72 patients and 245 minutes （range,140- 345 minutes）, 52 minutes （range, 29-75 minutes）, 700 mL （range, 200-3 000 mL）, 10 in 17 patients undergoing single total caudate lobectomy and 200 minutes （range, 120-370 minutes）, 48 minutes （range, 24-120 minutes）, 675 mL （range, 200-36 00 mL）, 21 in 42 patients undergoing hepatic segment Ⅳ resection combined with total caudate lobectomy and 210 minutes （range, 145-300 minutes）, 50 minutes （range, 26- 139 minutes）, 1 000 mL （range, 300-5 000 mL）, 10 in 13 patients undergoing hepatic segment Ⅳ, Ⅴ and Ⅷ resection combined with total caudate lobectomy, respectively. （2） Postoperative recovery situations： duration of hospital stay was 9 days （range, 7-18 days） in 72 patients. Twentyfive patients had postoperative complications, including 7 with effusion at surgical area, 5 with intraabdominal effusion, 4 with bleeding, 4 with bile leakage, 4 with pleural effusion and 1 with pulmonary infection. Four patients with bleeding received reoperation haemostasis. Other patients with complications were improved by symptomatic treatment. （3） Postoperative pathological examinations： of 49 patients with malignant hepatic tumors, surgical margin 〉5 mm was detected in 9 patients and 1 mm〈 surgical margin 〈5 mm was detected in 11 patients. Twentyseven patients without surgical margin had complete excision of tumors, and 2 patients had tumor rupture during the operation. （4） Followup： all the 72 patients were followed up for 6-141 months, with a median time of 46 months. The 1, 3, 5year overall survival rates and 1, 3, 5year tumorfree survival rates were 83.5%, 61.1%, 36.4%, 66.3%, 40.7%, 27.1% in 49 patients with malignant tumor, respectively. Twentythree patients with benign hepatic tumor had healthy living.Conclusion：Total caudate lobectomy via anterior hepatic transaction is safe and feasible in treatment of hepatic tumor involving paracaval portion of caudate lobe and middle lobe.