肝静脉回流区切除术治疗肝癌的临床疗效

Clinical efficacy of hepatic vein drainage guided hepatectomy for hepatocellular carcinoma

目的探讨肝静脉回流区切除术治疗肝癌的临床疗效。方法采用回顾性描述性研究方法。收集2015年10月至2018年1月南京大学医学院附属鼓楼医院收治的10例肝癌患者的临床病理资料;男9例,女1例;平均年龄为57岁,年龄范围为35~68岁。10例患者术前行CT检查后进行肝脏、肝脏脉管系统、肿瘤的三维重建,评估肝脏脉管系统解剖与变异、肿瘤与肝脏脉管系统的空间毗邻关系。根据患者情况施行3种手术方式:(1)肝右静脉回流区切除术。(2)肝中静脉回流区切除术。(3)肝左静脉+肝中静脉回流区切除术。观察指标:(1)术前三维重建及规划情况。(2)手术及术后情况。(3)随访情况。采用门诊和电话方式进行随访,了解患者术后生存及肿瘤复发、转移情况。随访时间截至2018年5月。正态分布的计量资料以平均数(范围)表示,计数资料以绝对数表示。结果(1)术前三维重建及规划情况:10例患者中肿瘤位于肝脏S4段3例,S4、S8段1例,S5、S6、S7段1例,S6、S7段4例,S6、S7、S8段1例;10例患者的肿瘤均邻近(距离<5 mm)肝静脉主干,其中肿瘤邻近肝右静脉6例,肿瘤邻近肝中静脉1例,肿瘤邻近肝左静脉+肝中静脉3例;肿瘤直径为7.3 cm(4.0~13.5 cm)。10例患者拟行保留肝静脉肝切除术,其剩余肝脏体积与标准肝脏体积比值(RLV/SLV)为36.2%(22.0%~46.0%),其中7例患者RLV/SLV<40.0%;拟行静脉回流区切除术,其RLV/SLV为51.9%(40.0%~61.0%)。(2)手术及术后情况:10例患者均顺利完成肝静脉回流区切除术。其中6例患者肿瘤邻近肝右静脉行肝右静脉回流区切除术,1例患者肿瘤邻近肝中静脉行肝中静脉回流区切除术,3例患者肿瘤邻近肝左静脉+肝中静脉行肝左静脉+肝中静脉回流区切除术。10例患者手术时间为350 min(240~470 min),术中出血量为525 mL(200~1000 mL),手术切缘距肿瘤距离为8.3 mm(5.0~20.0 mm)。10例患者术后无出血、肝衰竭、胆瘘等并发症。10例患者术后住院时间为13 d(11~21 d)。(3)随访情况:10例患者均获得随访,随访时间为4~31个月,中位随访时间18个月。随访期间患者一般情况良好,均未出现肿瘤复发及转移。结论肝静脉回流区切除术治疗肝癌安全、有效。该手术方式通过三维重建软件进行术前虚拟手术规划,对邻近或侵犯肝静脉主干的肝脏肿瘤,既能保留更多肝实质,又能获得理想切缘。

Objective To investigate the clinical efficacy of hepatic venous drainage guided hepatectomy(HVDGH)for hepatocellular carcinoma.Methods The retrospective and descriptive study was conducted.The clinicopathological data of 10 patients with hepatocellular carcinoma who were admitted to Nanjing Drum Tower Hospital Affiliated to Nanjing University Medicine School from October 2015 to January 2018 were collected.There were 9 males and 1 female,aged from 35 to 68 years,with an average age of 57 years.Three dimensional reconstruction of liver,hepatic vasculature,and carcinoma was performed in the 10 patients to evaluate the anatomy and variation of hepatic vasculature,and the spatial relationship between carcinoma and hepatic vasculature.Patients were performed right HVDGH,middle HVDGH,left and middle HVDGH,according to their conditions.Observation indicators:(1)preoperative three dimensional reconstruction and planning;(2)surgical and postoperative conditions;(3)follow up.Follow up using outpatient examination and telephone interview was performed to detect tumor recurrence and metastasis of patients up to May 2018.Measurement data with normal distribution were described as average(range),and count data were described as absolute numbers.Results(1)Preoperative three dimensional reconstruction and planning:of the 10 patients,3 had the tumor located at S4 of the liver,1 had the tumor located at S4 and S8 of the liver,1 had the tumor located at S5,S6,and S7 of the liver,4 had the tumor located at S6 and S7 of the liver,1 had the tumor located at S6,S7,and S8 of the liver.All the 10 patients had tumor close to the main hepatic vein with a distance<5 mm,including 6 with the tumor adjacent to the right hepatic vein,1 adjacent to the middle hepatic vein,and 3 adjacent to the left hepatic vein and the middle hepatic vein.The tumor diameter was 7.3 cm(range,4.0-13.5 cm).The residual liver volume/standard liver volume(RLV/SLV)of 10 patients undergoing hepatic vein preserving hepatectomy was 36.2%(range,22.0%-46.0%),of which 7 had RLV/SLV less than 40.0%.The RLV/SLV of 10 patients undergoing HVDGH was 51.9%(range,40.0%-61.0%).(2)Surgical and postoperative conditions:all the 10 patients underwent HVDGH successfully,including 6 with tumor adjacent to right hepatic vein undergoing right HVDGH,1 with tumor adjacent to middle hepatic vein undergoing middle HVDGH,3 with tumor adjacent to left and middle hepatic vein undergoing left and middle HVDGH.The operation time,volume of intraoperative blood loss,and the distance between surgical margin and carcinoma were 350 minutes(range,240-470 minutes),525 mL(range,200-1000 mL),and 8.3 mm(range,5.0-20.0 mm).There was no postoperative complication such as hemorrhage,liver failure,or biliary fistula in 10 patients.The duration of postoperative hospital stay was 13 days(range,11-21 days).(3)Follow up:10 patients were followed up for 4-31 months,with a median follow up time of 18 months.During the follow up period,10 patients were generally in good condition,and no tumor recurrence or metastasis occurred.Conclusions HVDGH is safe and effective for the treatment of hepatocellular carcinoma,which can be programmed by preoperative three dimensional reconstruction software.For tumors adjacent to or invading hepatic veins,HVDGH can not only retain more liver parenchyma,but also obtain ideal resection margin.