对门静脉癌栓的新认识与新实践

New insights into and new practices for portal vein tumor thrombus

肝细胞癌合并门静脉癌栓为临床常见情况,但人们对其认识仍然存在不足。本文从门静脉癌栓的形成机制、门静脉癌栓的可见度分型以及肝内播散转移的原因和机制等方面提出了一些新的认识;在这些认识的基础上,又提出“门静脉优先”理念,即术中先要分离、结扎或阻断肿瘤所在区域的门静脉,然后游离肝脏、切除肿瘤;同时提出“门静脉探查”理念,即离断肝脏时要探查断面管道有无癌栓,然后才能结扎;最后提出“门静脉原位切开直视下取栓术”,即对于程氏Ⅱ型及部分Ⅲ型癌栓,先要游离、阻断门静脉主干及对侧分支,然后切开癌栓所在部位的门静脉,直视下取出癌栓。

Hepatocellular carcinoma complicated with portal vein tumor thrombus(PVTT)is a common clinical predicament,and its understanding remains insufficient.Here,some new ideas on the formation mechanism of PVTT,visibility classification of PVTT,and causes and mechanism of intrahepatic dissemination and metastasis are presented.Based on these ideas,the authors put forward the concept of"portal vein priority",that is,the portal vein in the area where the tumor is located should be dissected,ligated or blocked before mobilizing the liver and removing the tumor,the concept of"portal vein exploration",that is,during parenchymal dissection,the ducts on liver section should be explored for tumor thrombus before ligation,and"thrombectomy under direct vision with portal vein in situ incision",that is,for Chen's typeⅡand some typeⅢtumor thrombi,the main portal vein and the contralateral branch should be dissected and blocked first,then the portal vein is incised at the location of tumor thrombus and the tumor thrombus is extracted under direct vision.