巨大肝癌的外科治疗分析(附72例报告)

目的探讨外科治疗巨大肝癌的可行性及其方法。方法回顾性分析72例巨大肝癌的临床资料,并对外科治疗中遇到的主要困难和相应的对策进行分析总结。结果72例肝癌中合并门静脉、肝静脉、IVC及胆管癌栓分别为11例、1例、1例和4例。合并乙肝肝硬化68例,丙肝肝硬化和无肝硬化各2例。72例中行Ⅰ期和Ⅱ期肝切除术分别为48例和24例;其中规则性右半肝和左半肝切除术分别为10例和15例、联合肝段切除术47例。术前PVE 6例;全肝、患侧半肝血流阻断切肝术分别为5例和8例。术中行门静脉、肝静脉、IVC及胆管癌栓取出术分别为11例、1例、1例和4例。72例中治愈69例(占95.8%);围手术期死亡3例(占4.2%)。术后1年生存率达76.4%(55/72)。结论巨大肝癌的手术治疗是安全可行的。充分评估和正确应对外科治疗过程中的主要困难是取得成功的关键。

Gastric cancer surgery in cirrhotic patients: Result of gastrectomy with D2 lymph node dissection

AIM： To explore the feasibility of performing gastrectomy with D2 lymphadenectomy in gastric cancer patients with liver cirrhosis. METHODS： A total of 7 178 patients were admitted with a diagnosis of liver cirrhosis from January 1993 to December 2003. We reviewed the records of 142 patients who were diagnosed with liver cirrhosis and gastric adenocarcinoma during the same period. Gastrectomy with D2 lymph node dissection for carcinoma of the stomach was performed in 94 patients with histologically proven hepatic cirrhosis. RESULTS： All but 12 patients were dassified as Child＇s class A. Only 35 patients （37.2%） were diagnosed with cirrhosis before operation. Seventy-three patients underwent a subtotal gastrectomy （77.7%） and 21 patients （22.3%） underwent a total gastrectomy, each with D2 or more lymph node dissection. Two patients （3.8%） who had prophylactic intra-operative drain placement, died of postoperative complications from hepatorenal failure with intractable ascites. Thirty-seven patients （39.4%） experienced postoperative complications. The extent of gastric resection did not influence the morbidity whereas serum aspartate aminotransferase level （P = 0.011） and transfusion did （P = 0.008）. The most common postoperative complication was ascites （13.9%） followed by wound infection （10.6%）. CONCLUSION： We concluded that the presence of compensated cirrhosis, i.e. Child class A, is not a contraindication against gastrectomy with D2 or more lymph node dissection, when curative resection for gastric cancer is possible. Hepatic reserve and meticulous hemostasis are the likely determinants of operative prognosis.

Prognostic analysis of surgical treatment of peripheral cholangiocarcinoma: Two decades of experience at Chang Gung Memorial Hospital

AIM: To analyze the prognostic factors influencing the overall survival of peripheral cholangiocarcinoma (PCC) patients undergoing surgical treatment during 25 years at a single institution. METHODS: This study retrospectively reviewed prospectively collecting data about 373 patients with historically proven PCC who underwent surgical treatment between 1977 and 2001. RESULTS: Three hundred and seventy-three PCC patients (159 men and 214 women) underwent surgical treatment from 1977 to 2001. Among them, 187 PCC patients underwent hepatectomy and 135 had curative resection (curative resectability rate: 36.2%). The follow-up duration ranged from 1.05 to 167.6 mo (mean/median = 14.1/7.2 mo). Overall cumulative survival rates at 1, 3, and 5 years were 32.5%, 9.2%, and 4.1%, respectively. Univariate log-rank analysis identified the following as adverse influences on overall survival: presence of symptoms, absence of mucobilia, elevated CEA and CA 19-9 levels, non-papillary tumor type, receiving non-hepatectomy, advanced tumor staging, lack of post-operative chemotherapy, and radiotherapy. Meanwhile, multivariate Cox's proportional hazard analysis demonstrated that absence of mucobilia, non-papillary tumor type, advanced tumor staging, non-hepatectomy, and lack of post-operative chemotherapy were the five independent prognostic factors that adversely affected overall survival. CONCLUSION: Favorable overall survival of PCC patients undergoing surgical treatment depends on early tumor stage, presence of mucobilia, papillary tumor type, hepatic resection, and post-operative chemotherapy.

Restrictive model of compensated carbon tetrachloride-induced cirrhosis in rats

AIM： To develop a simplified and quick protocol to induce cirrhosis and standardize models of partial liver resection in rats. METHODS： In Fischer F344 rats two modified protocols of phenobarbital-carbon tetrachloride （CCl4） （dilution 50%） gavage to induce cirrhosis （frequency adjusted according to weight, but each subsequent dose was systematically administered） were tested, i.e. the rapid and slow protocols. Prothrombin time （PT） and total bilirubin （TB） were also evaluated. Animals from the rapid group underwent 15% hepatectomy and animals from the slow group underwent 70% hepatectomy. RESULTS： Rapid protocol： This corresponded to 1 gavage/4 d over 6 wk （mortality 30%）. Mean PT was 35.2 ±2.8 s （normal： ld.5 s）, and mean TB was 1.8 ± 0.2 mg/dL （normal： 0.1 mg/dL）. Slow protocol： This cop responded to 1 gavage/6 d over 9 wk （mortality 10%）. Mean PT was 11.8 ± 0.2 s （normal： 14.5 s）, and mean TB was 0.4 ± 0.04 mg/dL （normal： 0.1 mg/dL）. Pathological analyses were performed in both protocols which showed persistent cirrhosis at 3 mo. Rat mortality in the rapid garage group who underwent 15% hepatectomy and in the slow garage group who underwent 70% hepatectomy was 50% and 70%, respectively, CONCLUSION： Our modified model is a simplified method to induce cirrhosis which is rapid （6 to 9 wk）, efficient and stable up to 3 mo. Using this method, ＂Child Pugh A＂ or ＂Child Pugh BC＂ cirrhotic rats were obtained. Our models of cirrhosis and hepatectomy can be used in various situations focusing on postoperative survival.

Hepatectomy for huge hepatocellular carcinoma in 634 cases

AIM： To clarify the safety and feasibility of hepatectomy for huge hepatocellular carcinoma （HCC）. METHODS： A total of 4765 patients with HCC operated at Tongji Hospital were retrospectively studied, of them, 780 patients had huge HCC （10 cm or more in diameter）. Hepatectomy was carried out on 634 patients （81.2%）. The majority of the liver resection were major resections, and combined resection of the adjacent organs or structures was common （17.2%）. The liver resection was combined with portal vein thrombectomy in 139 patients （21.9%）. RESULTS： Postoperative complications were common （26.8%） and required another laparotomy to prevent the complications in 5 patients （0.8%）. The 30-d mortality was 2.2%. The main causes of postoperative deaths were liver failure （n = 9）, postoperative bleeding （n = 4） and septic complication （n = 1）. The 3-, 5- and 10-year survival rates after liver resection were 35.1%, 18.2% and 3.5%, respectively. CONCLUSION： Hepatectomy for huge HCC is safe and effective. It should be used to treat patients with low surgical risks and resectable tumours.

Long-term outcome of percutaneous ethanol injection therapy for minimum-sized hepatocellular carcinoma

AIM： To evaluate long-term follow-up of minimum-sized hepatocellular carcinoma （HCC） treated with percutaneous ethanol injection （PEI）. METHODS： PEI was applied to 42 lesions in 31 patients （23 male and eight female） with HCC 〈 15 mm in diameter, over the past 15 years. RESULTS： Overall survival rate was 74.1% at 3 years, 49.9% at 5 years, 27.2% at 7 years and 14.5% at 10 years. These results are superior to, or at least the same as those for hepatic resection and radiofrequency ablation. Survival was affected only by liver function, but not by sex, age, etiology of Hepatitis B virus or Hepatitis C virus, α-fetoprotein levels, arterial and portal blood flow, histological characteristics, and tumor multiplicity or size. Patients in Chiid-Pugh class A and B had 5-, 7- and 10-years survival rates of 76.0%, 42.2% and 15.8%, and 17.1%, 8.6% and 0%, respectively （P = 0.025）. CONCLUSION： Treatment with PEI is best indicated for patients with HCC 〈 15 mm in Child-Pugh class A.

Relationship between microvessel count and post-hepatectomy survival in patients with hepatocellular carcinoma

AIM: To elucidate the relationship between the microvessel count (MVC) by CD34 analyzed by immunohistochemical method and prognosis in hepatocellular carcinoma (HCC) patients who underwent hepatectomy based on our preliminary study. METHODS: We examined relationships between MVC and clinicopathological factors in 128 HCC patients. The modifi ed Japan Integrated Staging score (mJIS) was applied to examine subsets of HCC patients. RESULTS: Median MVC was 178/mm^2, which was used as a cut-off value. MVC was not signif icantly associated with any clinicopathologic factors or postoperative recurrent rate. Lower MVC was associated with poor disease-free and overall survivals by univariate analysis (P = 0.039 and P = 0.087, respectively) and lower MVC represented an independent poor prognostic factor in disease-free survival by Cox’s multivariateanalysis (risk ratio, 1.64; P = 0.024), in addition to tumor size, vascular invasion, macroscopic fi nding and hepatic dysfunction. Signifi cant differences in disease-free and overall survivals by MVC were observed in HCC patients with mJIS 2 (P = 0.046 and P = 0.0014, respectively), but not in those with other scores. CONCLUSION: Tumor MVC appears to offer a useful prognostic marker of HCC patient survival, particularly in HCC patients with mJIS 2.

Favorable outcomes of hilar duct oriented hepatic resection for high grade Tsunoda type hepatolithiasis

AIM： To evaluate the efficacy of hilar duct oriented hepatectomy for intractable hepatolithiasis, the ventral hilum exposure （VHE） method that has been applied by the authors. METHODS： From June 1994 to June 2004 for a period of 10 years, 153 patients who had Tsunoda type Ⅲ or Ⅳ hepatolithiasis, received hepatectomy at our institution. Among these patients, 128 who underwent hepatectomy by the VHE method were the subjects for the study. We analyzed the risk of this procedure, residual rate of intrahepatic stones, and stone recurrent rates. RESULTS： The average age was 54.2 years, and the male to female ratio was 1：1.7. The average follow-up period was 25.6 mo （6-114 too）. There was no postoperative severe complication or mortality after the operation. The rate of residual stones was 5.4% and the rate of recurrent stones was 4.2%. CONCLUSION： VHE is a safe surgical procedure and provides favorable treatment results of intractable hepatolithiasis. Especially, this procedure has advantage in that intra-hepatic bile duct stricture may be confirmed and corrected directly during surgery.

Long-term survival for spontaneous rupture of hepatocellular carcinoma treated with hepatectomy

Objective- To determine the prognostic factors of ruptured hepatocellular carcinoma （HCC） and report the management of patients with spontaneous rupture of HCC in a single center during a 5-year period and to evaluate one-stage hepatectomy Methods- A series of 4,209 patients with HCC were collected at Eastern Hepatobiliary Surgery Hospital from April 2002 to November 2006, of whom 200 patients （4.8%） with ruptured HCC were studied retrospectively regarding their clinical characteristics and prognostic factors. The one-stage therapeutic approach to manage ruptured HCC consisted of initial management by conservative method, transarterial embolization （TAE） or surgical hepatectomy. Results of various treatments were evaluated and compared in the randomly selected 202 patients with no history of rupture during the same study period. Results： A total of 200 patients with spontaneous rupture of HCC were studied who underwent surgical treatment （n=105）, TAE 33 and conservative treatment （ConT 62）. A multivariate analysis using the Cox hazard regression model （including all the patients n=200） identified surgical hepatectomy as the only independent factor determining a relatively long survival period （P〈0.0001） On the other hand, in a further analysis of the patients in whom surgical hepatectomy was successfully performed （n=105）, which identified a maximum tumor size exceeding 6 cm as significant determinants of a poor 12-month （P=0.036）, and a multivariate analysis did not identify as any inverse independent factor determining relatively long-term survival, only a maximum tumor size exceeding 6 cm exhibited a tendency toward being a determinant factor （P=0.083）. Conelusionz Considering the high propensity to spontaneous rupture, as long as preoperatively clinical evaluation meet surgery requirements, elective one-stage hepatectomy for patients with ruptured HCC is the first treatment option. Prolonged survival could be achieved in selected patients with hepatic resection, although the survival results were inferior to those of the patients who did not have the complication of rupture

Current management strategy of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) still remains a considerable challenge for surgeons.Surgery,including liver transplantation,is the most important therapeutic approach for patients with this disease.HCC is frequently diagnosed at advanced stages and has a poor prognosis with a high mortality rate even when surgical resection has been considered potentially curative.This brief report summarizes the current status of the management of this malignancy and includes a short description of new pharmacological approaches in HCC treatment.

Hepatocellular carcinoma:Defining the place of surgery in an era of organ shortage

Liver resection (LR) and transplantation offer the only potential chance of cure for patients with hepatocellular carcinoma (HCC). Historically, all patients were treated by hepatic resection. With the advent of liver transplantation (LT) patients with HCC were preferentially placed on the waiting list for LT. However, early experience with LT was associated with a high rate of tumour recurrence and poor long-term survival. The increasing scarcity of donor livers resulted in restrictions being placed on tumour size, and an improvement in patient survival. To date there have been no randomised clinical trials comparing LR to LT. We review the evidence supporting LR and/or LT for HCC and discuss the role of neoadjuvant therapy. The decision of whether to resect or transplant remains debatable and is often determined by centre experience, availability of LT and donor organs.

Current treatment for colorectal liver metastases

Surgical resection offers the best opportunity for survival in patients with colorectal cancer metastatic to the liver,with five-year survival rates up to 58% in selected cases.However,only a minority are resectable at the time of diagnosis.Continuous research in this field aims at increasing the percentage of patients eligible for resection,refining the indications and contraindications for surgery,and improving overall survival.The use of surgical innovations,such as staged resection,portal vein embolization,and repeat resection has allowed higher resection rates in patients with bilobar disease.The use of neoadjuvant chemotherapy allows up to 38% of patients previously considered unresectable to be significantly downstaged and eligible for hepatic resection.Ablative techniques have gained wide acceptance as an adjunct to surgical resection and in the management of patients who are not surgical candidates.Current management of colorectal liver metastases requires a multidisciplinary approach,which should be individualized in each case.

ERCP for the treatment of bile leak after partial hepatectomy and fenestration for symptomatic polycystic liver disease

AIM: To describe endoscopic treatment of bile leaks in these patients and to identify risk factors in these patients which can predict the development of bile leaks. METHODS: Retrospective case-control study examining consecutive patients who underwent partial hepatectomy for polycystic liver disease (PLD) and developed a postoperative bile leak managed endoscopically over a ten year period. Each case was matched with two controls with PLD who did not develop a postoperative bile leak. RESULTS: Ten cases underwent partial hepatectomy with fenestration for symptoms including abdominal distention, pain and nausea. Endoscopic retrograde cholangiopancreatography (ERCP) showed anatomic abnormalities in 1 case. A biliary sphincterotomy was performed in 4 cases. A plastic biliary stent was placed with the proximal end at the site of the leak in 9 cases; in 1 case two stents were placed. The overall success rate of ERCP to manage the leak was 90%. There were no significant differences in age, gender, comorbidities, duration of symptoms, history of previous surgery or type of surgery performed between cases and controls. CONCLUSION: ERCP with stent placement is safe and effective for management of post-hepatectomy bile leak in patients with PLD.

Resection of Huge Liver Cancer Involving the Second Porta Hepatis: A Report of 55 Cases

Objective To investigate the possibility and surgical procedures for huge liver cancer involving the second porta hepatis.Methods 55 cases of huge liver cancer, with the diameter of 8-28 cm(mean 12.7 cm) were studied. Right subcostal or “rooftop” incision was made, the liver ligments were divided, good exposure of the tumor and access to retrohepatic inferior vena cava were achieved.Hepatectomies were completed under intermittent interruption of first porta hepatis. Occluding tape around vena cava was applied before liver resection if necessary.Results All tumors were successfully resected without death during operation.The longest survival time was now 4 years in one case. The 1-4 year postoperative survival rates were 63%,50%,50% and 30% respectively.Conclusion Young patients with solitary large liver tumor, which grows slowly over a long period on basis of non-cirrhotic or mild cirrhotic liver, should undergo an exploration in an attempt of resection irrespective of the image contraindication, provided that there is no extra-hepatic metastasis.

Low preoperative platelet counts predict a high mortality after partial hepatectomy in patients with hepatocellular carcinoma

AIM： To assess the validity of our selection criteria for hepatectomy procedures based on indocyanine green disappearance rate （KICG）, and to unveil the factors affecting posthepatectomy mortality in patients with hepatocellular carcinoma （HCC）. METHODS： A retrospective analysis of 198 consecutive patients with HCC who underwent partial hepatectomies in the past 14 years was conducted. The selection criteria for hepatectomy procedures during the study period were KICG≥0.12 for hemihepatectomy, KICG≥0.10 for bisegmentectomy, KCG≥0.08 for monosegmentectomy, and KICG≥ 0.06 for nonanatomic hepatectomy. The hepatectomies were categorized into three types： major hepatectomy （hemihepatectomy or a more extensive procedure）, bisegmentectomy, and limited hepatectomy. Univariate （Fishers exact test） and multivariate （the logistic regression model） analyses were used. RESULTS： Postoperative mortality was 5% after major hepatectomy, 3% after bisegmentectomy, and 3% after limited hepatectomy. The bhree percentages were comparable （P = 0.876）. The platelet count of ≤ 10× 10^4/μL was the strongest independent factor for postoperative mortality on univariate （P = 0.001） and multivariate （risk ratio, 12.5; P= 0.029） analyses. No patient with a platelet count of 〉7.3× 10^4/μL died of postoperative morbidity, whereas 25% （6/24 patients） of patients with a platelet count of ≤7.3×10^4/μL died （P〈0.001）. CONCLUSION： The selection criteria for hepatectomy procedures based on KICG are generally considered valid, because of the acceptable morbidity and mortality with these criteria. The preoperative platelet count independently affects morbidity and mortality after hepatectomy, suggesting that a combination of KICG and platelet count would further reduce postoperative mortality.

Liver transplantation for polycystic liver with massive hepatomegaly: A case report

A previous study has shown that liver or combined liver-kidney transplantation can be a valuable surgical technique for the treatment of polycystic liver disease. Herein, we present the case of a 35-year-old woman with polycystic liver disease, who underwent orthotopic liver transplantation (OLT) on November 11, 2008. The whole-size graft was taken from a deceased donor (a 51-year-old man who died of a heart attack). Resection in a patient with massive hepatomegaly is very difficult. Thus, after intercepting the portal hepatic vein, left hepatectomy was performed, then the vena cava was intercepted, the second and third porta hepatic isolated, and fi nally, right hepatectomy was performed. OLT was performed successfully. The recipient did well after transplantation. This case suggested that OLT is an effective therapeutic option for polycystic liver disease and left hepatectomy can be performed fi rst during OLT if the liver is over enlarged.

Therapeutic options for intermediate-advanced hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most common malignancies, ranking the sixth in the world, with 55% of cases occurring in China. Usually, patients with HCC did not present until the late stage of the disease, thus limiting their therapeutic options. Although surgical resection is a potentially curative modality for HCC, most patients with intermediate-advanced HCC are not suitable candidates. The current therapeutic modalities for intermediate-advanced HCC include: (1) surgical procedures, such as radical resection, palliative resection, intraoperative radiofrequency ablation or cryosurgical ablation, intraoperative hepatic artery and portal vein chemotherapeutic pump placement, two-stage hepatectomy and liver transplantation; (2) interventional treatment, such as transcatheter arterial chemoembolization, portal vein embolization and image-guided locoregional therapies; and (3) molecularly targeted therapies. So far, how to choose the therapeutic modalities remains controversial. Surgeons are faced with the challenge of providing the most appropriate treatment for patients with intermediate-advanced HCC. This review focuses on the optional therapeutic modalities for intermediateadvanced HCC.

Antiviral therapy for hepatitis B virus-related hepatocellular carcinoma after radical hepatectomy

Objective： To assess the effect of antiviral therapy for hepatitis B virus （HBV）-related hepatocellular carcinoma （HCC） after radical hepatectomy. Methods： A total of 478 HBV-related HCC patients treated by radical hepatectomy were retrospectively collected. Patients in the treatment group （n=141） received postoperative lamivudine treatment （100 rag/d）, whereas patients in the control group （n=337） did not. Recurrence-free survival （RFS） rates, overall survival （OS） rates, treatments for recurrent HCC and cause of death were compared between the two groups. Propensity score matching （PSM） analysis was also conducted to reduce confounding bias between the two groups. Results： The 1-, 3-, and 5-year RFS rates didn＇t significantly differ between the two groups （P=0.778）; however, the 1-, 3-, and 5-year OS rates in the treatment group were significantly higher than those in the control group （P=0.002）. Similar results were observed in the matched data. Subgroup analysis showed that antiviral treatment conferred a significant survival benefit for Barcelona Clinical Liver Cancer stage A/B patients. Following HCC recurrence, more people in the treatment group were able to choose curative treatments than those in the control group （P=0.031）. For cause of death, fewer people in the treatment group died of liver failure than those in the control group （P=0.041）. Conclusion： Postoperative antiviral therapy increases chances of receiving curative treatments for recurrent HCC and prevents death because of liver failure, thereby significantly prolonging OS, especially in early- or intermedian-stage tumors.

Resection of Hilar Liver Cancer, Close to Major Vessels

Objective To study the surgical experience with resection of a hilar liver cancer close to major vessels and how to improve the therapeutic result.Methods From January 1990 to June 1997, 58 hilar liver tumors (segment I , IV , V , VI ) were resected. The tumors in these 58 patients were within a distance of 1 cm to major hepatic vessels (retrothepatic inferior vena cava, root of hepatic veins, and left or right trunk of portal vein) . The diameter of the tumors was > 5 cm in 42 cases and < 5 cm in 16 cases, respectively. The size of the largest tumor was 20 cm ×18 cm×18 cm. The surgical techniques are summarized, and the prevention and treatment of postoperative complications are discussed.Results All operations have been carried out successfully and had a regular follow-up until now with 1-, 3- and 5-year survival rate of 71%, 38% and 25%, respectively.Conclusion While hilar liver surgery is quite difficult and risky, the safety and therapeutic results of surgery could be improved by observing a meticulous surgical technique, and by preventing and treating postoperative complications by multimodal measures.

Radiotherapy combined with transcatheter arterial chemoembolization for unresectable hepatocellular carcinoma–a prospective clinical trial

Objective: This study evaluated the therapeutic effect of external beam radiotherapy (RT) combined with trans- catheter arterial chemoembolization (TACE) on the patients with unresectable hepatocellular carcinoma (HCC). Methods: From June 1994 to April 2002, 114 patients with unresectable HCC were nonrandomized prospectively stepped into our study. All patients received TACE as initial therapy, except 54 also received combination therapy with external beam therapy. Sur- vival failure patterns were analyzed and compared between the two groups. Results: Overall survival rates in the patients in the radiotherapy group were 65%, 47%, 38% at 1, 2, 3 years, respectively, improved over the non-radiotherapy group rates of 54%, 36.5%, 18% at 1, 2, 3 years, respectively. There was significant difference between two groups (P < 0.05). The survival rates correlated with tumor size, number of tumors, and portal vein embolus. Conclusion: TACE combined with RT is a more effective treatment than TACE alone in patients with unresectable HCC.