原发性肝癌病人的肝血流量和肝功能对肝切除率的术前预测

目的 探讨99mTcECT动态扫描和断层扫描预测肝癌手术切除安全性的价值。方法 采用99mTc 植酸钠胶体肝再摄取和首次通过斜率原理 ,运用自编程序 ,检测 2 0例肝癌和 10例正常健康人的HBF、HAF、PVF。 16例肝癌再行断层扫描。划出手术预切除区 ,计算出功能肝切除率。结果 肝癌病人和正常人的HBF分别为 :142 4 9± 431ml/min ,15 0 7 5± 36 4 3ml/min ,(P >0 0 5 ) ;HAF为 :6 4 2 %± 2 3 6 %,35 7%± 6 2 %,(P <0 0 5 ) ;PVF为 :33 8%± 14 5 %,6 4 3%± 8 7%(P <0 0 5 ) )。 16例功能肝切除率 :10 %～ 2 0 %6例 ,2 1%～ 30 %7例 ,31%～ 40 %1例 ,41%～ 5 0 %1例 ,5 0 %以上者 1例 ,术后因肝功能衰竭死亡 1例。结论 99mTc 植酸钠动态及断层扫描能确定肝血流量和各种不规则肝切除术的功能肝切除率 ,预测切除术的风险。

完全性左侧卧位在腹腔镜下肝Ⅶ段切除术中的临床应用

目的探讨完全性左侧卧位在腹腔镜下肝Ⅶ段切除术中的临床应用价值。方法选择本院收治的肝Ⅶ段肝细胞癌患者60例,按照随机数字表法分为观察组和对照组,每组30例。观察组行完全性左侧卧位腹腔镜下肝Ⅶ段切除术,对照组实施左侧倾斜30°~60°大字斜坡卧位腹腔镜下肝Ⅶ段切除术。比较2组患者手术时间、术中出血量、术后引流量、术后留置引流时间、摆放体位耗时、术中手术床调整频次、中转开腹率及术中解剖性肝切除率;分析2组患者手术前后肝功能指标变化;统计围术期并发症发生率。结果观察组患者手术时间及术后留置引流时间均短于对照组(P<0.05),术中出血量及术后引流量均低于对照组(P<0.05),观察组患者术中手术床调整频次少于对照组(P<0.05),术中解剖性肝切除率显著高于对照组(P<0.05);观察组患者术后肝功能指标水平低于对照组(P<0.05);观察组患者围术期并发症发生率低于对照组(P<0.05)。结论完全性左侧卧位下腹腔镜肝Ⅶ段切除术可缩短手术时间,减少术中出血量,提高解剖性肝切除率,改善术后肝功能,降低手术并发症发生率。

CT测量保留肝容积率对肝癌切除术前肝储备功能的评估价值

目的探讨CT测量保留肝容积率评估肝癌术前肝储备功能的价值。方法前瞻性研究原发性肝癌手术病人59例。所有病人均行肝脏双期增强CT扫描。术前用CT测量保留肝容积率,与术后切除容积和生存率进行级间差异性分析。结果保留肝容积率≤50%和>50%之间的生存率差异有统计学意义(χ2=4·9881,P<0·05);而肝切除率≤50%和>50%之间差异无统计学意义(χ2=0·0154,P>0·05)。结论保留肝容积率可以作为临床肝癌术前评估肝储备功能的重要指标之一。

Orthotopic liver transplantation as a rescue operation for recurrent hepatocellular carcinoma after partial hepatectomy

AIM: To compare post-orthotopic liver transplantation (OLT) survival between patients with recurrent hepatocellular carcinoma (HCC) after partial hepatectomy and those who received de novo OLT for HCC and to assess the risk factors associated with post-OLT mortality. METHODS: From July 2003 to August 2005, 77 consecutive HCC patients underwent OLT, including 15 patients with recurrent HCC after partial hepatectomy for tumor resection (the rescue OLT group) and 62 patients with de novo OLT for HCC (the de novo OLT group). Thirty-three demographic, clinical, histological, laboratory, intra-operative and post-operative variables were analyzed. Survival was calculated by the Kaplan- Meier method. Univariable and multivariable analyses were also performed. RESULTS: The median age of the patients was 49.0 years. The median follow-up was 20 mo. Three patients (20.0%) in the rescue OLT group and 15 patients (24.2%) in the de novo OLT group died during the follow-up period (P = 0.73). The 30-day mortality of OLT was 6.7% for the rescue OLT group vs 1.6% for the de novo OLT group (P = 0.27). Cox proportional hazards model showed that pre-OLT hyperbilirubinemia, the requirement of post-OLT transfusion, the size of the tumor, and family history of HCC were significantly associated with a higher hazard for mortality. CONCLUSION: There are no significant differences in survival/mortality rates between OLT as de novo therapy and OLT as a rescue therapy for patients with hcc. Pre-OLT hyperbilirubinemia, post-OLT requirement of transfusion, large tumor size and family history of HCC are associated with a poor survival outcome.

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.

Efficacy of surgical resection in management of isolated extrahepatic metastases of hepatocellular carcinoma

AIM:To clarify the benefit of surgical excision for patients with extrahepatic metastases of hepatocellular carcinoma(HCC). METHODS:We retrospectively reviewed the medical records of 140 patients with pathologically proven extrahepatic metastases of HCC and evaluated the outcomes of those who had undergone surgical resection(SR)for extrahepatic metastatic lesions.Prognoses made on the basis of extrahepatic metastatic sites were also examined. RESULTS:The survival rates of patients who underwent SR of extrahepatic metastases were significantly better than those of patients who did not receive SR. For the SR group,1-and 3-year survival rates were 24%and 7%,respectively,while for the non-resection group,the survival rates were 8%and 0%,respec- tively(P<0.0001).Survival rates related to metastatic sites were also significantly superior after SR of extrahepatic metastases:median survivals were 32 mo with lung metastasis,10 mo with bone metastasis,6.1 mo with brain metastasis. CONCLUSION:SR can provide survival benefits forpatients with 1 or 2 isolated extrahepatic metastases and who concurrently exhibit good hepatic functional reserve and general performance status as well as successful treatment of intrahepatic HCC.

Estimating glomerular filtration rate preoperatively for patients undergoing hepatectomy

AIM:To compare creatinine clearance(Ccr) with estimated glomerular filtration rate(eGFR) in preoperative renal function tests in patients undergoing hepatectomy.METHODS:The records of 197 patients undergoing hepatectomy between August 2006 and August 2008 were studied,and preoperative Ccr,a three-variable equation for eGFR(eGFR3) and a five-variable equation for eGFR(eGFR5) were calculated.Abnormal values were defined as Ccr < 50 mL/min,eGFR3 and eGFR5 < 60 mL/min per 1.73 m2.The maximum increases in the postoperative serum creatinine(post Cr) level and postoperative rate of increase in the serum Cr level(post Cr rate) were compared.RESULTS:There were 37 patients(18.8%) with abnormal Ccr,31(15.7%) with abnormal eGFR3,and 40(20.3%) with abnormal eGFR5.Although there were no significant differences in the post Cr rate between patients with normal and abnormal Ccr,eGFR3 and eGFR5 values,the post Cr level was significantly higher in patients with eGFR3 and eGFR5 abnormality than in normal patients(P < 0.0001).Post Cr level tended to be higher in patients with Ccr abnormality(P = 0.0936 and P = 0.0875,respectively).CONCLUSION:eGFR5 and the simpler eGFR3,rather than Ccr,are recommended as a preoperative renal function test in patients undergoing hepatectomy.