Feasibility of laparoscopic isolated caudate lobe resection for rare hepatic mesenchymal neoplasms

BACKGROUND Mesenchymal tumors such as perivascular epithelioid cell neoplasm(PEComa)and inflammatory pseudotumor-like follicular dendritic cell sarcoma(IPT-like FDC sarcoma)are relatively uncommon in the liver and are particularly rare in the caudate lobe.The clinical manifestations and available imaging tests lack specificity for hepatic mesenchymal tumors.To the best of our knowledge,no caudate PEComa or IPT-like FDC sarcoma has been completely resected by laparoscopy.The standard laparoscopic technique,surgical approaches,and tumor margins for potentially malignant or malignant caudate mesenchymal tumors are still being explored.AIM To assess both the safety and feasibility of laparoscopic resection for rare caudate mesenchymal neoplasms.METHODS Eleven patients who underwent isolated caudate lobe resection from 2003 to 2017 were identified from a prospective database.Three consecutive patients with rare caudate mesenchymal tumors underwent laparoscopic resection.Patient demographic data,intraoperative parameters,and postoperative outcomes were assessed and compared with the open surgery group.RESULTS All procedures for the three resection patients with caudate mesenchymal tumors were completed using a total laparoscopic technique by two different approaches.The average operative time was 226 min,and the estimated blood loss was 133 mL.The average length of postoperative hospital stay was 6.3±0.3 d for the laparoscopy group and 15.5±2.3 d for the open surgery group(P<0.05).There were no perioperative complications or patient deaths in this series.CONCLUSION Laparoscopic isolated caudate lobe resection for rare mesenchymal neoplasms is a feasible and curative surgical option in selected patients.

Transarterial chemoembolization vs. liver resection as initial treatment for hepatocellular carcinoma occurring exclusively in caudate lobe: A retrospective propensity matching analysis

Treatment of hepatocellular carcinoma(HCC)in the caudate lobe is technically challenging.This retrospective study was designed to evaluate the clinical outcome of both superselective transcatheter arterial chemoembolization(TACE)and liver resection(LR)for HCC occurring exclusively in the caudate lobe.From January 2008 to September 2021,a total of 129 patients were diagnosed with HCC of the caudate lobe.The Cox proportional hazard model was used to analyze the potential clinical factors and established prognostic nomograms with interval validation.Of the total number of patients,78 received TACE and 51 received LR.The overall survival(OS)rates(TACE vs.LR)at 1,2,3,4,and 5 years were 83.9%vs.71.0%;74.2%vs.61.3%;58.1%vs.48.4%;45.2%vs.45.2%;and 32.3%vs.25.0%,respectively.However,subgroup analysis revealed that TACE was superior to LR for treating patients with stage IIb Chinese liver cancer(CNLC-IIb)in the entire cohort(p=0.002).Interestingly,no difference was found between TACE and LR in the treatment outcomes of CNLC-IIa HCC(p=0.6).Based on Child-Pugh A and B calculations,TACE tended to lead to a better OS than LR(p=0.081 and 0.16,respectively).Multivariate analysis showed that Child-Pugh score,CNLC stage,ascites,alpha fetoprotein(AFP),tumor size,and anti-HCV are related to OS.Predictive nomograms for 1,2,and 3 years were performed.Based on this study,TACE may provide a longer OS than liver resection for patients with CNLC-IIb HCC of the caudate lobe.Because this suggestion is limited by the study design and relatively small sample size,additional randomized controlled trials are needed.

Predictors of long term survival after hepatic resection for hilar cholangiocarcinoma:A retrospective study of 5-year survivors

AIM:To determine predictors of long term survival after resection of hilar cholangiocarcinoma(HC) by comparing patients surviving > 5 years with those who survived < 5 years.METHODS:This is a retrospective study of patients with pathologically proven HC who underwent surgical resection at the Gastroenterology Surgical Center,Mansoura University,Egypt between January 2002 and April 2013.All data of the patients were collected from the medical records.patients were divided into two groups according to their survival:patients surviving less than 5 years and those who survived > 5 years.RESULTS:There were 34(14%) long term survivors(5 year survivors) among the 243 patients.Fiveyear survivors were younger at diagnosis than those surviving less than 5 years(mean age,50.47 ± 4.45 vs 54.59 ± 4.98,p = 0.001).Gender,clinical presentation,preoperative drainage,preoperative serum bilirubin,albumin and serum glutamic-pyruvic transaminase were similar between the two groups.The level of CA 19-9 was significantly higher in patients surviving < 5 years(395.71 ± 31.43 vs 254.06 ± 42.19,p = 0.0001).Univariate analysis demonstrated nine variables to be significantly associated with survival > 5 year,includingyoung age(p = 0.001),serum CA19-9(p = 0.0001),non-cirrhotic liver(p = 0.02),major hepatic resection(p = 0.001),caudate lobe resection(p = 0.006),well differentiated tumour(p = 0.03),lymph node status(0.008),R0 resection margin(p = 0.0001) and early postoperative liver cell failure(p = 0.02).CONCLUSION:Liver status,resection of caudate lobe,lymph node status,R0 resection and CA19-9 were demonstrated to be independent risk factors for long term survival.

Bismuth Ⅲ型肝门胆管癌的外科治疗

目的：研究肝Ｂｉｓｍｕｔｈ Ⅲ型肝门胆管癌根治性切除时，需要伴同切除肝脏的范围。方法：对两家医院近两年半来收治的ＢｉｓｍｕｔｈⅢ型肝门胆管癌３１例进行分析。其中２１例行根治性切除者，伴同左半肝切除１１例，伴同右半肝切除５例，伴同右三叶切除２例，伴同Ⅳ肝段切除３例。与上述各种肝切除合并作尾叶切除者９例。结果：全组无手术死亡，并发膈下脓肿２例，经穿刺置管引流治愈；并发肝衰腹水８例，其中右半肝切除后３例，左半肝切除后３例，右三叶切除后２例，均经强化护肝治疗、反复多次输注血浆和白蛋白治愈；并发胆漏３例，经保守引流而愈。施行Ⅳ肝段＋尾叶切除的３例顺利恢复，无并发症。结论： ＢｉｓｍｕｔｈⅢ型肝门胆管癌根治性切除伴同肝切除的范围应根据肿瘤所在的确切部位以及同侧门静脉有无受侵犯而定，尽量避免大范围的肝切除。

肝尾状叶肿瘤的切除(附5例报道)

目的:探讨肝尾状叶肿瘤的手术切除经验。方法:对我院2001年11月～2002年6月收治的5例累及肝脏尾状叶肿瘤的手术方式作回顾性分析。结果:本组5例均采用右侧路径切断尾状静脉,2例其中游离部分腔静脉,切断尾状静脉4～5支,2例血管瘤和1例肝转移癌患者游离全部肝段下腔静脉,切断全部尾状静脉。5例患者均好转出院。结论:尾状静脉的离断是手术安全的保障。另外解剖肝门板,离断尾状叶的动、静脉分支可以减少手术中的出血量。

单纯全尾状叶切除术治疗巨块型肝癌(直径≥10 cm)的疗效

目的:探讨尾状叶巨块型肝癌(直径≥10 cm)行单纯全尾状叶切除手术的可行性及疗效。方法:回顾性分析2001年1月至2011年12月27例单纯全尾状叶切除的巨块型肝癌患者的临床资料。结果:27例患者均顺利手术,无死亡病例,平均手术时间288 min,平均出血量2 260 mL,44%的患者出现了术后并发症,经积极处理均顺利出院。术后1,3,5年的总生存率分别是80.2%,52.1%,27.1%。结论:尾状叶巨块型肝癌行单纯全尾状叶切除安全有效。

机器人辅助前正中入路肝尾状叶肿瘤切除

目的:探讨机器人辅助前正中入路肝尾状叶肿瘤切除的手术技术及临床应用,提出微创肝脏手术的新入路。方法:分析2012年11月我院于机器人手术系统(da Vinci S)辅助下完成的1例前正中入路肝尾状叶肿瘤切除术,术前CT血管造影图像建立肝脏3D模型,确定经肝正中裂前入路行尾状叶肿瘤切除的手术方案。结果:病人男性,78岁。完全机器人辅助顺利完成手术。完整切除肿瘤。手术时间360 min,术中出血300 mL,无术中、术后输血。术后病理为肝细胞癌。未发生术后并发症,术后28天出院,随访至今1年余,恢复良好。结论:肝正中裂前入路可提高肝尾状叶肿瘤的手术切除率,保留更多的正常肝组织。在精确的术前评估后,机器人手术系统下肝尾状叶肿瘤切除术安全、可行。

肝脏尾状叶巨大肿瘤切除手术经验

施行肝脏尾状叶巨大肿瘤手术４例．其中２例为肝脏多发性海绵状血管瘤．２例为原发性肝癌．术式：左或右半肝切除并肝尾叶切除２例；肝尾叶切除并肝左叶血管瘤剥除１例；巨大左肝尾状叶肿瘤切除、并左肝外叶切除、右肝小癌灶无水乙醇注射１例。１例出院后因癌复发转移．术后２．５个月死亡；３例治愈出院．经６～１７个月随访健在．肝尾状叶巨大瘤块切除是难度大、风险大的手术．本文介绍了具体操作的几点体会．并对难以切除的肝肿瘤行一期或二期手术问题提出自己的看法．

常温下全肝血流分步阻断行肝左尾叶切除术

采用常温下全肝血流分步阻断法对3例左肝尾叶原发性肝癌患者行肝左尾叶切除,其中1例肿瘤侵及左肺内叶者同时行左半肝切除术。结果手术顺利,疗效满意。认为该术式的优点为:1对全身血流动力学影响不大。2提高了切除率。3可在直视下显示和切除肝左尾叶及肿瘤,并可修复大血管损伤。

肝尾状叶血管瘤的手术切除

目的 :总结该院肝尾状叶血管瘤手术的临床经验。方法 :目前该院共实施肝尾状叶手术 2例 ,对术中止血 ,切口的选择 ,手术入路等方面的经验进行了回顾性分析。结果 :2例患者中 ,均采用肋脉下屋顶状切口 ,1例出现肝短静脉损伤。结论 :切口选择、手术入路。

肝尾叶切除

肝尾叶深藏于肝门结构与下腔静脉之间，具有独立的管道系统，手术切除风险较大，作者结合２例肝尾叶切除的体会，复习文献，对肝尾叶的解剖、影像学特征、切除指征及手术方法进行了讨论。

87例肝门部胆管癌手术切除的诊疗分析

目的分析手术切除治疗肝门部胆管癌的疗效及技术要点。方法回顾性分析87例肝门部胆管癌患者行肝管高位切除及联合肝切除、肝肠吻合术及姑息性手术的临床资料。总结患者的手术方式,并发症发生情况,观察患者术后5年生存率。结果手术切除率为72.4%(63/87),姑息性引流率为27.6%(24/87)。术后病理结果均回报为胆管细胞癌,63例患者行手术切除,其中根治性切除(R0)占69.8%(44/63),姑息性切除(R1、R2)占30.2%(19/63),姑息性引流24例。围手术期死亡患者3例(2.3%),术后发生胆漏的患者13例(14.9%),术后发生应激性上消化道出血4例(4.6%),其他并发症如发生腹腔出血3例(3.4%),腹腔感染5例(5.7%),肝性脑病8例(9.2%),胸腔积液7例(8.0%),切口感染或裂开者6例(6.9%)。随访患者5年,根治性切除术组的患者5年生存率(28.4%)明显高于姑息性切除组(14.1%)及姑息性引流组(0)。结论肝门部胆管癌手术复杂,连同尾状叶的左、右半肝切除治疗肝门部胆管癌有助于提高根治性手术切除率,并能明显提高患者5年生存率。

10例尾状叶肝肿瘤切除术患者的护理研究

目的分析10例尾状叶肝肿瘤切除术患者的护理经验。方法选择行尾状叶肝肿瘤切除术的10例患者。围术期给予患者严密护理,总结患者术中临床护理经验和方法。结果 10例患者均顺利完成不同入路单独尾状叶肿瘤切除术;术后未见腹腔出血者,出现1例肝功能异常,1例肺部感染,1例切口轻度感染;术后随访3个月患者预后良好。结论尾状叶肝肿瘤切除术应强化术中护理,积极采取并发症预防性措施,以控制术后并发症风险,改善患者预后。

肝尾状叶应用解剖学的研究进展

近年来,肝尾状叶的解剖在外科领域受到的关注越来越多,但目前仍缺乏针对其解剖结构的深入研究,肝尾状叶的手术方式和策略亟待改善。肝尾状叶的手术一直是肝脏外科最具有挑战性的手术之一,只有熟知肝尾状叶的位置、形态、毗邻及血管、胆管的结构,才能安全地进行肝尾状叶手术。本文主要对肝尾状叶的解剖学特点、外科及介入治疗相关的研究进展进行综述。

循肝静脉入路的腹腔镜肝中叶上区肿瘤切除

目的:探讨腹腔镜循肝静脉入路在肝中叶上区(2区)肿瘤治疗中的疗效及安全性。方法:回顾2018~2021年行肝中叶切除的肝肿瘤患者临床资料,根据分型选取中2型共27例,对其手术的安全性及有效性进行评估。结果:所有患者均顺利完成手术,术中出血量(303.70±210.35)mL,手术时长(263±90.25)min,术后住院时间(8.00±3.65)d,术后通气时间(3.52±1.73)d,无围手术期死亡。术后出现并发症5例,其中胸腔积液3例,肺不张1例,腹腔积液1例。结论:通过对肝中叶肿瘤的分型后,肝中叶上区的肿瘤选择循肝静脉入路的手术方式,有助于术者控制术中出血,提高手术安全性。

尾叶原发性肝癌的手术切除(附12例报告)

总结１２例尾叶原发性肝癌手术切除的经验，应用ＰＭＯＤ采取刮吸法断肝，可清楚解剖出管道结构，便于可靠结扎并节省时间；肝正中裂完全切开，有利于尾叶的显露。介绍了左侧尾叶切除、右侧尾叶切除。

全尾叶切除治疗肝尾状叶肿瘤

目的探讨肝尾叶肿瘤的全尾叶切除技巧及其疗效。方法１６例肝尾叶肿瘤病人，其中肝细胞癌１１例，胆管癌１例，直肠癌术后肝尾状叶转移１例，巨大良性肿瘤３例。均行全尾叶或全尾叶＋左外叶或左半肝或左三叶切除术，平均手术时间（２２７±５２）分钟，术中平均失血（５９２±９４０）ｍｌ，输血（１５１７±６４１）ｍｌ。无手术死亡及术后并发症。结果１１例肝细胞癌病人术后１、３、５年生存率分别为５５．６％、５５．６％及４０％，１例胆管癌病人术后４月死亡，１例肝尾叶转移癌病人术后４年仍存活，３例良性肿瘤病人均健在。结论虽然肝尾叶手术难度高、风险大，但尾叶切除仍应作为治疗肝尾叶肿瘤的首选方法。

经中央入路肝全尾状叶肿瘤切除术

尾状叶肿瘤切除是肝脏外科的难点，因肿瘤多压迫肝静脉、下腔静脉和第一肝门，且肿瘤显露困难，术中易发生大出血。大部分尾状叶肿瘤常需联合肝部分切除，而对于尾状叶腔静脉旁部的肿瘤，联合右半肝或左半肝切除均无法很好地显露肿瘤，并且切除过多正常肝脏组织易导致术后肝功能衰竭。

肝尾区肿瘤的现代外科治疗

目的总结肝尾区肿瘤的现代外科治疗经验。方法对1989-2003年收治的9例肝尾区肿瘤病人的治疗情况进行回顾性分析。结果除1例晚期肝癌行肝移植术外,其余7例均接受肝尾区肿瘤切除术,全部病例手术及术后恢复顺利。6例肝癌病人中,2例分别于术后10个月、17个月死亡,1例术后24个月失访,另3例术后3、15、99个月仍健在。3例良性肝占位病人术前均曾误诊为肝癌,及时手术方才明确诊断。结论剖腹探查是明确肝尾区肿瘤诊断和避免误诊的最佳方法,肝移植、肝尾区切除等现代外科治疗手段给肝尾区肿瘤病人带来了新的希望,积极治疗、慎重对待、合理术中处理及术后综合治疗是肝尾区肿瘤治疗的基本原则及取得成功的主要经验。