前入路肝切除联合选择性肝静脉阻断技术在ALPPS治疗肝右叶巨块型肝癌中的应用(附9例报道)

Application of anterior approach combined with selective hepatic vein(s) occlusion in ALPPS for giant hepatocellular carcinoma in right lobe(report of 9 cases)

目的探讨前入路肝切除联合选择性肝静脉阻断技术在联合肝脏分隔和门静脉结扎的二步肝切除(ALPPS)治疗肝右叶巨块型肝癌中的应用价值。方法收集广西医科大学第一附属医院肝胆外科2017年1月至2017年9月期间采用前入路肝切除联合选择性肝静脉阻断技术行ALPPS治疗的9例肝右叶巨块型肝癌患者的临床资料。结果6例患者完整接受ALPPS手术,3例患者因第一期手术后剩余肝脏体积增长不达标而未行第二期手术。ALPPS第一期术后剩余肝脏平均增长体积为139.1 cm^3(46.4~291.6 cm^3),剩余肝脏体积平均增长率为37.8%(15.1%~76.2%),术中平均出血量为356 m L(200~600 m L)。ALPPS第二期手术行右半肝切除4例,扩大右半肝切除2例;术中平均出血量为617 m L(300~1 400 m L)。无胆汁漏及肝功能衰竭并发症发生,无围手术期死亡病例。结论本组有限病例的初步研究结果提示,前入路手术方法联合选择性肝静脉阻断在ALPPS治疗右肝巨块型肝癌中应用是安全、有效的,更符合肿瘤外科的"无瘤"原则,能减少术中出血、胆汁漏等并发症,但其针对合并乙肝后肝硬变肝细胞癌患者的长期治疗效果还需要进一步的病例积累。

Objective To evaluate application of anterior approach combined with selective hepatic vein（s） occlusion in associating liver partition and portal vein ligation for staged hepatectomy （ALPPS） for giant hepatocellular carcinoma （HCC） in right lobe. Method The clinical data of 9 patients underwent the ALPPS in the First Affiliated Hospital of Guangxi Medical University from January 2017 to September 2017 were retrospectively analyzed. Results Six cases underwent the complete ALPPS, 3 cases lost because it couldn＇t match the standard for the second step. After the first step, The average increased volume of the future liver remnant （FLR） was 139.1 cm3 （46.4-291.6 cm3）, and the average increased volume rate of FLR was 37.8% （15.1%-76.2%）. The average blood loss was 356 mL （200-600 mL）. In the second step, 4 cases underwent the right hemihepatectomy and 2 cases underwent the extend right hemihepatectomy, the average blood loss was 617 mL （300-1 400 mL）. There was no bile fistula, liver failure, and death.Conclusions Preliminary results of limited cases in this study show that application of anterior approach combined with selective hepatic vein（s） occlusion is a safe and feasible strategy in ALPPS for giant HCC in right lobe. This strategy is conformity with the ＂no touch＂ principle of oncology surgery, and reduces blood loss and decreases complications. Long-term oncological result of ALPPS in HCC patients with cirrhosis is unknown.