End-stage liver disease score and future liver remnant volume predict post-hepatectomy liver failure in hepatocellular carcinoma

BACKGROUND Hepatocellular carcinoma(HCC)is the world’s sixth most common malignant tumor and the third cause of cancer death.Although great progress has been made in hepatectomy,it is still associated with a certain degree of risk of posthepatectomy liver failure(PHLF),which extends the length of hospital stay and remains the leading cause of postoperative death.Studies have shown that assessment of hepatic functional reserve before hepatectomy is beneficial for reducing the incidence of PHLF.AIM To assess the value of model for end-stage liver disease(MELD)score combined with standardized future liver remnant(sFLR)volume in predicting PHLF in patients undergoing hepatectomy for HCC.METHODS This study was attended by 238 patients with HCC who underwent hepatectomy between January 2015 and January 2018.Discrimination of sFLR volume,MELD score,and sFLR/MELD ratio to predict PHLF was evaluated according to the area under the receiver operating characteristic curve.RESULTS The patients were divided into two groups according to whether PHLF occurred after hepatectomy.The incidence of PHLF was 8.4%in our research.The incidence of PHLF increased with the decrease in sFLR volume and the increase in MELD score.Both sFLR volume and MELD score were considered independent predictive factors for PHLF.Moreover,the cut-off value of the sFLR/MELD score to predict PHLF was 0.078(P<0.001).This suggests that an sFLR/MELD≥0.078 indicates a higher incidence of PHLF than an sFLR/MELD<0.078.CONCLUSION MELD combined with sFLR is a reliable and effective PHLF predictor,which is superior to MELD score or sFLR volume alone.

Simultaneous portal and hepatic vein embolization is better than portal embolization or ALPPS for hypertrophy of future liver remnant before major hepatectomy: A systematic review and network meta-analysis

Background:Post-hepatectomy liver failure(PHLF)is the Achilles’heel of hepatic resection for colorectal liver metastases.The most commonly used procedure to generate hypertrophy of the functional liver remnant(FLR)is portal vein embolization(PVE),which does not always lead to successful hypertrophy.Associating liver partition and portal vein ligation for staged hepatectomy(ALPPS)has been proposed to overcome the limitations of PVE.Liver venous deprivation(LVD),a technique that includes simultaneous portal and hepatic vein embolization,has also been proposed as an alternative to ALPPS.The present study aimed to conduct a systematic review as the first network meta-analysis to compare the efficacy,effectiveness,and safety of the three regenerative techniques.Data sources:A systematic search for literature was conducted using the electronic databases Embase,PubMed(MEDLINE),Google Scholar and Cochrane.Results:The time to operation was significantly shorter in the ALPPS cohort than in the PVE and LVD cohorts by 27 and 22 days,respectively.Intraoperative parameters of blood loss and the Pringle maneuver demonstrated non-significant differences between the PVE and LVD cohorts.There was evidence of a significantly higher FLR hypertrophy rate in the ALPPS cohort when compared to the PVE cohort,but non-significant differences were observed when compared to the LVD cohort.Notably,the LVD cohort demonstrated a significantly better FLR/body weight(BW)ratio compared to both the ALPPS and PVE cohorts.Both the PVE and LVD cohorts demonstrated significantly lower major morbidity rates compared to the ALPPS cohort.The LVD cohort also demonstrated a significantly lower 90-day mortality rate compared to both the PVE and ALPPS cohorts.Conclusions:LVD in adequately selected patients may induce adequate and profound FLR hypertrophy before major hepatectomy.Present evidence demonstrated significantly lower major morbidity and mortality rates in the LVD cohort than in the ALPPS and PVE cohorts.

CD4^(+)CD25^(+) regulatory T cells decreased future liver remnant after associating liver partition and portal vein ligation for staged hepatectomy

BACKGROUND Associating liver partition and portal vein ligation for staged hepatectomy(ALPPS)is an innovative surgical approach for the treatment of massive hepatocellular carcinoma(HCC),the key to successful planned stage 2 ALPPS is future liver remnant(FLR)volume growth,but the exact mechanism has not been elucidated.The correlation between regulatory T cells(Tregs)and postoperative FLR regeneration has not been reported.AIM To investigate the effect of CD4^(+)CD25^(+)Tregs on FLR regeneration after ALPPS.METHODS Clinical data and specimens were collected from 37 patients who developed massive HCC treated with ALPPS.Flow cytometry was performed to detect changes in the proportion of CD4^(+)CD25^(+)Tregs to CD4^(+)T cells in peripheral blood before and after ALPPS.To analyze the relationship between peripheral blood CD4^(+)CD25^(+)Treg proportion and clinicopathological information and liver volume.RESULTS The postoperative CD4^(+)CD25^(+)Treg proportion in stage 1 ALPPS was negatively correlated with the amount of proliferation volume,proliferation rate,and kinetic growth rate(KGR)of the FLR after stage 1 ALPPS.Patients with low Treg proportion had significantly higher KGR than those with high Treg proportion(P=0.006);patients with high Treg proportion had more severe postoperative pathological liver fibrosis than those with low Treg proportion(P=0.043).The area under the receiver operating characteristic curve between the percentage of Tregs and proliferation volume,proliferation rate,and KGR were all greater than 0.70.CONCLUSION CD4^(+)CD25^(+)Tregs in the peripheral blood of patients with massive HCC at stage 1 ALPPS were negatively correlated with indicators of FLR regeneration after stage 1 ALPPS and may influence the degree of fibrosis in patients’livers.Treg percentage was highly accurate in predicting the FLR regeneration after stage 1 ALPPS.

Functional transition:Inconsistently parallel to the increase in future liver remnant volume after preoperative portal vein embolization

BACKGROUND Preoperative portal vein embolization(PVE)is a widely used strategy to enable major hepatectomy in patients with insufficient liver remnant.PVE induces hypertrophy of the future liver remnant(FLR)and a shift of the functional reserve to the FLR.However,whether the increase of the FLR volume(FLRV)corresponds to the functional transition after PVE remains unclear.AIM To investigate the sequential relationship between the increase in FLRV and functional transition after preoperative PVE using 3-dimensional(3D)computed tomography(CT)and 99mTc-galactosyl-human serum albumin(99mTc-GSA)singlephoton emission computed tomography(SPECT)fusion images.METHODS Thirty-three patients who underwent major hepatectomy following PVE at the Department of Gastroenterological Surgery I,Hokkaido University Hospital between October 2013 and March 2018 were enrolled.Three-phase dynamic multidetector CT and 99mTc-GSA SPECT scintigraphy were performed at pre-PVE,and at 1 and 2 wk after PVE;3D 99mTc-GSA SPECT CT-fused images were constructed from the Digital Imaging and Communications in Medicine data using 3D image analysis system.Functional FLRV(FFLRV)was defined as the total liver volume×(FLR volume counts/total liver volume counts)on the 3D 99m Tc-GSA SPECT CT-fused images.The calculated FFLRV was compared with FLRV.RESULTS FFLRV increased by a significantly larger extent than FLRV at 1 and 2 wk after PVE(P<0.01).The increase in FFLRV and FLRV was 55.1%±41.6%and 26.7%±17.8%(P<0.001),respectively,at 1 wk after PVE,and 64.2%±33.3%and 36.8%±18.9%(P<0.001),respectively,at 2 wk after PVE.In 3 of the 33 patients,FFLRV levels decreased below FLRV at 2 wk.One of the three patients showed rapidly progressive fatty changes in FLR.The biopsy at 4 wk after PVE showed macroand micro-vesicular steatosis of more than 40%,which improved to 10%.Radical resection was performed at 13 wk after PVE.The patient recovered uneventfully without any symptoms of pos-toperative liver failure.CONCLUSION The functional transition lagged behind the increase in FLRV after PVE in some cases.Evaluating both volume and function is needed to determine the optimal timing of hepatectomy after PVE.

Portal vein embolization for induction of selective hepatic hypertrophy prior to major hepatectomy: rationale,techniques, outcomes and future directions

The ability to modulate the future liver remnant(FLR) is a key component of modern oncologic hepatobiliary surgery practice and has extended surgical candidacy for patients who may have been previously thought unable to survive liver resection. Multiple techniques have been developed to augment the FLR including portal vein embolization(PVE), associating liver partition and portal vein ligation(ALPPS), and the recently reported transhepatic liver venous deprivation(LVD). PVE is a well-established means to improve the safety of liver resection by redirecting blood flow to the FLR in an effort to selectively hypertrophy and ultimately improve functional reserve of the FLR. This article discusses the current practice of PVE with focus on summarizing the large number of published reports from which outcomes based practices have been developed. Both technical aspects of PVE including volumetry, approaches, and embolization agents; and clinical aspects of PVE including data supporting indications, and its role in conjunction with chemotherapy and transarterial embolization will be highlighted. PVE remains an important aspect of oncologic care; in large part due to the substantial foundation of information available demonstrating its clear clinical benefit for hepatic resection candidates with small anticipated FLRs.

Current strategies to induce liver remnant hypertrophy before major liver resection

Hepatic resection is the gold standard for patients affected by primary or metastatic liver tumors but is hampered by the risk of post-hepatectomy liver failure.Despite recent impro-vements,liver surgery still requires excellent clinical judgement in selecting patients for surgery and,above all,efficient pre-operative strategies to provide adequate future liver remnant.The aim of this article is to review the literature on the rational,the preliminary assessment,the advantages as well as the limits of each existing technique for preparing the liver for major hepatectomy.

Associating liver partition and portal vein ligation for staged hepatectomy: From technical evolution to oncological benefit

Associating liver partition and portal vein ligation for staged hepatectomy(ALPPS) is a novel approach in liver surgery that allows for extensive resection of liver parenchyma by inducing a rapid hypertrophy of the future remnant liver. However,recent reports indicate that not all patients eligible for ALPPS will benefit from this procedure. Therefore,careful patient selection will be necessary to fully exploit possible benefits of ALPPS. Here,we provide a comprehensive overview of the technical evolution of ALPPS with a special emphasis on safety and oncologic efficacy. Furthermore,we review the contemporary literature regarding indication and benefits,but also limitations of ALPPS.

Portal vein embolization effect on colorectal cancer liver metastasis progression:Lessons learned

Colorectal liver metastasis(CRLM) is the major cause of death in patients diagnosed with colorectal cancer. The gold standard treatment of CRLM is surgical rese-ction. Yet, in the past, more than half of these patients were deemed unresectable due to the inadequate future liver remnant(FLR). The introduction of efficient portal vein embolization(PVE) preoperatively allowed more resections of metastasis in CRLM patients by stimulating adequate liver hypertrophy. However, several exp-erimental and clinical studies reported tumor progression after PVE which critically influences the subsequent management of these patients. The underlying path-ophysiological mechanism of tumor progression post-PVE is still not fully understood. In spite of the adverse effects of PVE, it remains a potentially curative procedure in patients who would remain otherwise unresectable because of the insufficient FLR. Currently, the challenge is to halt tumor proliferation following PVE in patients who require this technique. This could potentially be achieved by either attempting to suppress the underlying oncologic stimulus or by inhibiting tumor growth once observed after PVE, without jeopardizing liver regeneration. More research is still required to better identify patients at risk of experiencing tumor growth post-PVE.

Rescue associating liver partition and portal vein ligation for staged hepatectomy after portal embolization: Our experience and literature review

AIM To report a single-center experience in rescue associating liver partition and portal vein ligation for staged hepatectomy(ALPPS), after failure of previous portal embolization. We also performed a literature review.METHODS Between January 2014 and December 2015, every patient who underwent a rescue ALPPS procedure in Toulouse Rangueil University Hospital, France, was included. Every patient included had a project of major hepatectomy and a previous portal vein embolization(PVE) with insufficient future liver remnant to body weight ratio after the procedure. The ALPPS procedure was performed in two steps(ALPPS-1 and ALPPS-2), separated by an interval phase. ALPPS-2 was done within 7 to 9 d after ALPPS-1. To estimate the FLR, a computed tomography scan examination was performed 3 to 6 wk after the PVE procedure and 6 to 8 d after ALPPS-1. A transcystic stent was placed during ALPPS-1 and remained opened duringthe interval phase, in order to avoid biliary complications. Postoperative liver failure was defined using the 50-50 criteria. Postoperative complications were assessed according to the Dindo-Clavien Classification.RESULTS From January 2014 to December 2015, 7 patients underwent a rescue ALPPS procedure. Median FLR before PVE, ALPPS-1 and ALPPS-2 were respectively 263 cc(221-380), 450 cc(372-506), and 660 cc(575-776). Median FLR/BWR before PVE, ALPPS-1 and ALPPS-2 were respectively 0.4%(0.3-0.5), 0.6%(0.5-0.8), and 1%(0.8-1.2). Median volume growth of FLR was 69%(18-92) after PVE, and 45%(36-82) after ALPPS-1. The combination of PVE and ALPPS induced a growth of median initial FLR of +408 cc(254-513), leading to an increase of +149%(68-199). After ALPPS-2, 4 patients had stage Ⅰ-Ⅱ complications. Three patients had more severe complications(one stage Ⅲ, one stage Ⅳ and one death due to bowel perforation). Two patients suffered from postoperative liver failure according to the 50/50 criteria. None of our patients developed any biliary complication during the ALPPS procedure.CONCLUSION Rescue ALPPS may be an alternative after unsuccessful PVE and could allow previously unresectable patients to reach surgery. Biliary drainage seems to reduce biliary complications.

Optimization of the future remnant liver:review of the current strategies in Europe

Liver resection still represent the treatment of choice for liver malignancies,but in some cases inadequate future remnant liver(FRL)can lead to post hepatectomy liver failure(PHLF)that still represents the most common cause of death after hepatectomy.Several strategies in recent era have been developed in order to generate a compensatory hypertrophy of the FRL,reducing the risk of post hepatectomy liver failure.Portal vein embolization,portal vein ligation,and ALLPS are the most popular techniques historically adopted up to now.The liver venous deprivation and the radio-embolization are the most recent promising techniques.Despite even more precise tools to calculate the relationship among volume and function,such as scintigraphy with^(99m)Tc-mebrofenin(HBS),no consensus is still available to define which of the above mentioned augmentation strategy is more adequate in terms of kind of surgery,complexity of the pathology and quality of liver parenchyma.The aim of this article is to analyse these different strategies to achieve sufficient FRL.

Neoadjuvant chemotherapy for colorectal liver metastases:A contemporary review of the literature

Colorectal carcinoma(CRC)is one of the leading causes of cancer-related deaths worldwide,and up to 50%of patients with CRC develop colorectal liver metastases(CRLM).For these patients,surgical resection remains the only opportunity for cure and long-term survival.Over the past few decades,outcomes of patients with metastatic CRC have improved significantly due to advances in systemic therapy,as well as improvements in operative technique and perioperative care.Chemotherapy in the modern era of oxaliplatin-and irinotecancontaining regimens has been augmented by the introduction of targeted biologics and immunotherapeutic agents.The increasing efficacy of contemporary systemic therapies has led to an expansion in the proportion of patients eligible for curative-intent surgery.Consequently,the use of neoadjuvant strategies is becoming progressively more established.For patients with CRLM,the primary advantage of neoadjuvant chemotherapy(NCT)is the potential to down-stage metastatic disease in order to facilitate hepatic resection.On the other hand,the routine use of NCT for patients with resectable metastases remains controversial,especially given the potential risk of inducing chemotherapy-associated liver injury prior to hepatectomy.Current guidelines recommend upfront surgery in patients with initially resectable disease and low operative risk,reserving NCT for patients with borderline resectable or unresectable disease and high operative risk.Patients undergoing NCT require close monitoring for tumor response and conversion of CRLM to resectability.In light of the growing number of treatment options available to patients with metastatic CRC,it is generally agreed that these patients are best served at tertiary centers with an expert multidisciplinary team.

Minimizing the risk of small-for-size syndrome after liver surgery

Background: Primary and secondary liver tumors are not always amenable to resection due to location and size. Inadequate future liver remnant(FLR) may prevent patients from having a curative resection or may result in increased postoperative morbidity and mortality from complications related to small-forsize syndrome(SFSS). Data sources: This comprehensive review analyzed the principles, mechanism and risk factors associated with SFSS and presented current available options in the evaluation of FLR when planning liver surgery. In addition, it provided a detailed description of specifc modalities that can be used before, during or after surgery, in order to optimize the conditions for a safe resection and minimize the risk of SFSS. Results: Several methods which aim to reduce tumor burden, preserve healthy liver parenchyma, induce hypertrophy of FLR or prevent postoperative complications help minimize the risk of SFSS. Conclusions: With those techniques the indications of radical treatment for patients with liver tumors have signifcantly expanded. The successful outcome depends on appropriate patient selection, the individualization and modifcation of interventions and the right timing of surgery.

Novel liver vein deprivation technique that promotes increased residual liver volume(with video):A case report

BACKGROUND Inadequate volume of future liver remnant(FLR)is a major challenge for hepatobiliary surgeons treating large or multiple liver tumors.As an alternative to associating liver partition and portal vein ligation(ALPPS)for staged hepatectomy and liver venous deprivation(LVD)using stage 1 interventional radiology for vascular embolization combined with stage 2 open liver resection have been used.CASE SUMMARY A novel modified LVD technique was performed in a patient with pancreatic neuroendocrine tumor with liver metastases by using stage 1 laparoscopic ligation of the right hepatic vein,right posterior portal vein,and short hepatic veins combined with local excision of three liver metastases in the left hemiliver.The operation was followed three days later by interventional radiology to embolize an anomalous right anterior portal vein to complete LVD.A stage 2 laparoscopic right hemihepatectomy and pancreaticosplenectomy were then carried out.CONCLUSION The minimally invasive technique promoted a rapid increase,comparable to ALPPS,in volume of the FLR after the stage 1 operation to allow the laparoscopic stage 2 resection to be performed.

残肝体积不足的肝恶性肿瘤患者转化治疗的研究进展

对于肝脏原发或局限性转移的恶性肿瘤患者,获得长期生存的唯一机会是完全切除肝脏肿瘤。但肝切除术后肝衰竭(PHLF)仍然是肝切除术后主要死亡原因,而残余肝体积不足已经被证明是PHLF的主要危险因素。目前已有多种方法来进行术前转化治疗,门静脉栓塞和联合肝脏离断和门静脉结扎的二步肝切除术是目前应用最多的两种方法,但各自都有明显的优缺点。随着恶性肿瘤综合治疗的发展,多种治疗方法正在探索中,本研究对比了不同的转化治疗方法,旨在为临床提供参考。

肝脏分隔及门静脉右支结扎术后肝内门静脉侧支血管开放与肝组织增生关联分析

【目的】探讨肝实质分隔和门静脉右支结扎术后肝内门静脉侧支血管开放对残余肝组织增生水平的影响。【方法】回顾性分析2013年4月至2022年6月在中山大学附属第一医院行肝实质分隔和门静脉右支结扎术的肝细胞癌患者的临床资料。根据患者一期术后肝内门静脉开放侧支血管的数量分为3组:未开放组,开放血管1条组和开放血管≥2条组。首先分析3组在术前、术中及术后肝功能、肝组织增生情况、二期手术情况等方面的分布差异,进一步采用多重线性回归分析探讨影响一期术后肝内门静脉开放侧支血管数量不同的因素。【结果】合计37例实施了肝实质分隔和门静脉右支结扎术肝癌患者最终纳入本研究。3组术前情况差异均无统计学意义(P>0.05)。3组患者肝实质分隔方式存在差异,采用微波消融分隔肝实质法的患者开放血管≥2条的比例大于肝实质离断法的患者(57.14%vs.42.56%,P=0.031),而3组在手术时间、失血量、输血量水平等指标的差异均无统计学意义(P>0.05)。3组患者每日残余肝组织增长体积[侧支血管≥2 vs.侧支血管=1 vs.侧支血管=0,(14.25±8.81 vs.20.65±9.85 vs.30.10±19.31)mL;P=0.018],差异有统计学意义。3组行二期切除者的比例无差异(P=0.363),但侧支血管开放≥2条者手术间隔天数显著长于未开放或只开放1条者[(16.31±5.44 vs.10.30±3.40 vs.12.78±3.35)d;P=0.023]。采用多重线性回归分析,逐步法纳入性别、年龄、术前肝功能分级、门静脉高压、肿瘤数目等相关因素,结果发现肝实质分隔方式是唯一影响肝内门静脉侧支血管开放数目的因素(P=0.031),微波消融和肝脏离断分隔肝实质后形成的肝内门静脉侧支血管数目分别为[2.0(1.5)vs.1.0(1.0)条,P=0.031]。【结论】肝实质分隔及门静脉右支结扎术后肝内门静脉侧支血管开放数目与肝组织增生水平负相关,采用肝实质离断分隔肝实质形成的侧支血管数目较少。

联合肝脏分割和门静脉结扎的二步肝切除术术后早期复发原因的分析

目的回顾性分析联合肝脏分割和门静脉结扎的二步肝切除术(associating liver partition and portal vein ligation for staged hepatectomy,ALPPS)后早期复发情况的原因。方法选取2014年6月~2016年6月接受ALPPS或射频消融辅助ALPPS(radiofrequencyablationassistedALPPS,RALPPS)治疗的12例患者为研究对象。对患者的肝功能、Child-Pugh评分、病灶、肝脏分割程度、术后无病生存时间、总生存时间等指标进行回顾性分析。结果阶段-1ALPPS后,FLR体积从(333.7±54.1)mL增加至(577.1±83.7)mL,差异有统计学意义(P<0.001)。阶段-1和阶段-2之间的间隔为:完全性ALPPS为(10.0±1.6)d,部分性ALPPS为(31.3±5.2)d,差异有统计学意义(P<0.001)。术后90d内死亡率为0%(0/12),Clavien-Dindo并发症分级为Ⅰ~Ⅲa。术后3、6个月和12个月复发率分别为16.7%(2/12)、83.3%(10/12)和100.0%(12/12);平均DFS时间为(4.5±0.6)个月,平均生存时间为(9.0±0.7)个月,中位随访时间为11.0个月。结论ALPPS以及RALPPS术后患者易出现早期复发。手术创伤、部分性ALPPS过长的FLR再生时间、肝实质的不完全分割、肿瘤细胞的不完全消融等均可能是术后早期复发的原因。

联合肝脏离断和门静脉结扎两阶段肝切除术的现状及进展

联合肝脏离断和门静脉结扎两阶段肝切除术(associating liver partition and portal vein ligation for staged hepatectomy,ALPPS),是近几年提出的一种新的手术方式。因其能够诱导肝脏体积急剧增长,所以主要用于治疗剩余肝脏体积不足、不能接受大范围切除的肝脏肿瘤。但它同时也存在着一些问题,诸如:术后感染、胆漏等并发症的发生率和死亡率较高。本文即对ALPPS的形成、术后肝脏增生机制、优缺点及相关进展进行综述。

终末期肝病模型评分和标准化残肝体积比预测肝细胞癌肝切除术后肝功能衰竭

目的 评价标准化残肝体积比(sFLR)和终末期肝病模型(MELD)评分预测肝细胞癌(HCC)患者肝切除术后肝功能衰竭(PHLF)的价值。方法 2015年10月至2021年2月术前腹部三维CT重建、施行肝切除术HCC患者74例(男58例、女16例)。采用单因素和多因素Logistic回归分析探讨与PHLF相关的影响因素,ROC曲线分析确定PHLF独立影响因素。结果 74例HCC患者PHLF28例(PHLF组)、非PHLF46例(非PHLF组)。PHLF组、非PHLF组患者PLT分别为123(29,238)×10^(9)/L、168(38,538)×10^(9)/L,差异具有统计学意义(P<0.05);Alb分别为36.3(26.0,41.2)g/L、42.8(25.6,48.8)g/L,差异具有统计学意义(P<0.05);sFLR分别为0.50(0.38,0.78)、0.67(0.36,0.99),差异具有统计学意义(P<0.05);MELD评分分别为9(6,12)分、7(6,10)分,差异具有统计学意义(P<0.05)。而两组年龄、性别、PT、INR、ALT、HBsAg及肿瘤直径等均不存在显著差异(P>0.05)。将PLT、Alb、sFLR及MELD评分纳入多因素Logistic回归分析,提示PLT、Alb、sFLR及MELD评分均是HCC患者PHLF发生的独立预测因素(P<0.05)。sFLR诊断HCC患者PHLF发生时的截断值、敏感度、特异度分别为0.54、76.9%及73.9%,MELD评分诊断HCC患者PHLF发生时的截断值、敏感度、特异度分别为8.5、53.8%及82.6%,两者联合诊断时敏感度、特异度为80.8%、91.3%。sFLR联合MELD评分诊断HCC患者PHLF发生时的AUC值均分别显著高于sFLR、MELD评分(P<0.05)。结论 sFLR联合MELD评分是预测HCC患者PHLF发生的有效指标,该预测模型能有效指导肝切除术后的早期处理,改善预后,降低死亡率,为肝切除术的术前评估提供了新思路。

术前经皮选择性门静脉栓塞术在肝胆肿瘤的应用体会

目的探讨术前经皮选择性门静脉栓塞术在肝胆肿瘤治疗中的应用价值。方法回顾近2年来我院收治的因预计术后残余肝脏体积(FLR)不足而不宜一期手术切除的5例肝胆肿瘤患者,选择术前行经皮门静脉栓塞术(PVE),观察PVE治疗后的全身反应、各肝叶体积的动态变化,二期手术切除率及对患者预后情况的影响。结果 5例患者PVE后均有一过性肝功能损害,表现为轻度黄疸、肝功转氨酶增高等,但经过对症处理后很快好转,无严重并发症发生。PVE前平均FLR为397.7±41.6mL,FLR/SLV为33.8±1.9%;PVE后平均FLR为486.8±46.4mL,平均增加了22.4%,FLR/SLV为42.5±5.6%,平均增加了25.7%。其中4例患者行了根治性切除手术,均能达到了R0切除。PVE至手术切除间隔时间平均为20.2天,术后无1例发生肝功能衰竭。术后随访3个月~1.5年,手术切除患者目前均无肿瘤复发。结论术前经皮选择性门静脉栓塞术可以显著增加患者残余肝体积,使原本无法耐受手术的肝胆肿瘤患者获得手术切除机会,减少术后肝功能衰竭的发生,有效改善肝胆肿瘤患者的预后。

Sequential transcatheter arterial chemoembolization and portal vein embolization before right hemihepatectomy in patients with hepatocellular carcinoma

Background:Recent studies showed that sequential selective transcatheter arterial chemoembolization(TACE)and portal vein embolization(PVE)provided better future liver remnant(FLR)regeneration rate and disease-free survival following surgery compared with PVE alone.The present study aimed to clarify whether preoperative sequential TACE and PVE before right hemihepatectomy can reduce postoperative hepatocellular carcinoma(HCC)recurrence and improve long-term disease-free and overall survival.Methods:Recurrence and survival outcomes were retrospectively evaluated in 205 patients with HCC who underwent right hemihepatectomy by a single surgeon from November 1993 to November 2017.Patients were divided into four groups according to the procedure performed before the surgery:sequential TACE and PVE(TACE-PVE),PVE-only,TACE-only,or na?ve control groups.The baseline patient and tumor characteristics,postoperative outcomes,recurrence-free survival and overall survival were analyzed.Results:Baseline patient and tumor characteristics upon diagnosis were similar in all four groups,while sequential TACE and PVE were well tolerated.The TACE-PVE group had a higher mean increase in percentage FLR volume compared with that of the PVE-only group(17.46%±6.63%vs.12.14%±5.93%;P=0.001).The TACE-PVE group had significantly better overall and disease-free survival rates compared with the other groups(both P<0.001).Conclusions:Sequential TACE and PVE prior to surgery can be an effective therapeutic strategy for patients with HCC scheduled for major hepatic resection.The active application of preoperative sequential TACE and PVE for HCC would allow more patients with marginal FLR volume to become candidates for major hepatic resection by promoting compensatory FLR hypertrophy without the deterioration of basal hepatic functional reserve or tumor progression.