影响二步肝切除术肝脏再生的主要因素研究
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摘要
目的联合肝脏分割和门静脉结扎的二步肝切除术(ALPPS)可促进未来残余肝脏(FLR)的快速再生,其原因之一是患侧门静脉的结扎可以使残余肝脏的门静脉血供显著增加,原因之二是肝脏离断带来的刺激,但是尚不明确何种因素起主导作用。通过回顾性研究,拟探究残余肝脏血供是否在这一过程中起关键作用。方法选择2014年6月—2016年6月浙江省肿瘤医院收治的13例接受ALPPS治疗的患者,根据肝脏离断程度,分成完全性ALPPS组(5例)和部分性ALPPS组(8例);并对不同方法所致的FLR再生速率进行对比;通过观察阶段-1 ALPPS术后门静脉变化以及患者接受肝动脉栓塞后残余肝脏的再生情况,判断入肝血流与残余肝脏再生的关系。结果完全性ALPPS组中有1例中度肝硬化患者接受阶段-1 ALPPS后,由于门静脉再通而无FLR再生,经反复经动脉化疗栓塞(TACE)后,FLR再生明显。阶段-1 ALPPS后,其他12名患者的FLR均有显著再生;部分性ALPPS促进FLR的再生所需时间更长,阶段-1 ALPPS和阶段-2 ALPPS之间的时间间隔分别为(10.0±1.6)d(完全性ALPPS组)和(31.3±5.2)d(部分性ALPPS组),比较差异有统计学意义(P<0.001)。结论阶段-1 ALPPS术后门静脉的再通,部分性ALPPS肝内门静脉分流可以导致残余肝脏血供增加不足因而减缓FLR的再生;阶段-1 ALPPS失败的患者接受经肝动脉栓塞(TAE)可增加对FLR的动脉血供,促进FLR的再生。增加残余肝脏血供是促进ALPPS术后FLR再生的关键因素。
Objective As seen in literature, associating liver partition and portal vein ligation for staged hepatectomy(ALPPS) could promote the rapid regeneration of the future liver remnant(FLR). One reason is that occluded portal ligation could significantly increase the portal blood supply of the remaining liver. Another reason is that it might be provoked by dividing liver. Yet, the leading reason remains unclear. By retrospective study, we aim to find out whether it is the hepatic blood inflow that plays key role in this process. Methods From June 2014 to June 2016, thirteen patients received ALPPS at our department, among whom 5 patients accepted complete ALPPS(complete ALPPS group), and 8 patients accepted partial ALPPS. The correlation with the regeneration of the FLR was evaluated. The time interval between stage-1 ALPPS and stage-2 ALPPS and other clinical data were compared between partial ALPPS and complete ALPPS. Results One patient with moderate cirrhosis in the complete ALPPS group had absent hypertrophy of FLR due to recanalization of the ligated right portal vein but his FLR augmented significantly after repeated transcatheter arterial chemoembolization(TACE). After stage-1 ALPPS, the FLR of other twelve patients increased significantly; partial ALPPS promotes the regeneration of FLR much slower than complete ALPPS, and the time interval between stage-1 ALPPS and stage-2 ALPPS was(10.0±1.6) days for complete ALPPS and(31.3±5.2) days for partial ALPPS respectively, indicating statistical significance(P<0.001). Conclusion Recanalization of the portal vein, the intrahepatic portal collaterals after partial ALPPS that divert portal blood from FLR could slow down the augment of FLR; transcatheter arterial embolization(TAE) could increase arterial blood supply to FLR and promote the regeneration of FLR. Less invasive portal vein occlusion and TAE might replace ALPPS to promote the regeneration of the FLR. Hepatic blood supply is probably the key factor that influences the regeneration of the FLR after ALPPS.
Objective As seen in literature, associating liver partition and portal vein ligation for staged hepatectomy(ALPPS) could promote the rapid regeneration of the future liver remnant(FLR). One reason is that occluded portal ligation could significantly increase the portal blood supply of the remaining liver. Another reason is that it might be provoked by dividing liver. Yet, the leading reason remains unclear. By retrospective study, we aim to find out whether it is the hepatic blood inflow that plays key role in this process. Methods From June 2014 to June 2016, thirteen patients received ALPPS at our department, among whom 5 patients accepted complete ALPPS(complete ALPPS group), and 8 patients accepted partial ALPPS. The correlation with the regeneration of the FLR was evaluated. The time interval between stage-1 ALPPS and stage-2 ALPPS and other clinical data were compared between partial ALPPS and complete ALPPS. Results One patient with moderate cirrhosis in the complete ALPPS group had absent hypertrophy of FLR due to recanalization of the ligated right portal vein but his FLR augmented significantly after repeated transcatheter arterial chemoembolization(TACE). After stage-1 ALPPS, the FLR of other twelve patients increased significantly; partial ALPPS promotes the regeneration of FLR much slower than complete ALPPS, and the time interval between stage-1 ALPPS and stage-2 ALPPS was(10.0±1.6) days for complete ALPPS and(31.3±5.2) days for partial ALPPS respectively, indicating statistical significance(P<0.001). Conclusion Recanalization of the portal vein, the intrahepatic portal collaterals after partial ALPPS that divert portal blood from FLR could slow down the augment of FLR; transcatheter arterial embolization(TAE) could increase arterial blood supply to FLR and promote the regeneration of FLR. Less invasive portal vein occlusion and TAE might replace ALPPS to promote the regeneration of the FLR. Hepatic blood supply is probably the key factor that influences the regeneration of the FLR after ALPPS.
引文
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[14] MATSUO K,MURAKAMI T,KAWAGUCHI D,et al.Histologic features after surgery associating liver partition and portal vein ligation for staged hepatectomy versus those after hepatectomy with portal vein embolization[J].Surgery,2016,159(5):1289-1298.
[15] RATTI F,SCHADDE E,MASETTI M,et al.Strategies to increase the resectability of patients with colorectal liver metastases:a multi-center case-match analysis of ALPPS and conventional two-stage hepatectomy[J].Ann Surg Oncol,2015,22(6):1933-1942.
[16] SCHADDE E,ARDILES V,SLANKAMENAC K,et al.ALPPS offers a better chance of complete resection in patients with primarily unresectable liver tumors compared with conventional-staged hepatectomies:results of a multicenter analysis[J].World J Surg,2014,38(6):1510-1519.
[17] PENG S Y,WANG X A,HUANG C Y,et al.Evolution of associating liver partition and portal vein ligation for staged hepatectomy:simpler,safer and equally effective methods[J].World J Gastroenterol,2017,23(23):4140-4145.
[18] HONG DE F,ZHANG Y B,PENG S Y,et al.Percutaneous microwave ablation liver partition and portal vein embolization for rapid liver regeneration:a minimally invasive first step of ALPPS for hepatocellular carcinoma[J].Ann Surg,2016,264(1):e1-2.
[19] ROBLES R,PARRILLA P,LóPEZ-CONESA A,et al.Tourniquet modification of the associating liver partition and portal ligation for staged hepatectomy procedure[J].Br J Surg,2014,101(9):1129-1134.
[20] CAI X,PENG S,DUAN L,et al.Completely laparoscopic ALPPS using round-the-liver ligation to replace parenchymal transection for a patient with multiple right liver cancers complicated with liver cirrhosis[J].J Laparoendosc Adv Surg Tech A,2014,24(12):883-886.
[21] CHUNG B M,PARK H J,PARK S B,et al.Differentiation of small arterial enhancing hepatocellular carcinoma from non-tumorous arterioportal shunt with an emphasis on the precontrast CT scan[J].Abdom Imaging,2015,40(7):2200-2209.
[22] HOSHIAI S,MORI K,ISHIGURO T,et al.Balloon-assisted chemoembolization using a micro-balloon catheter alongside a microcatheter for a hepatocellular carcinoma with a prominent arterioportal shunt:a case report[J].Cardiovasc Intervent Radiol,2017,40(4):625-628.
[2] LAUBER D T,TIHANYI D K,CZIGáNY Z,et al.Liver regeneration after different degrees of portal vein ligation[J].J Surg Res,2016,203(2):451-458.
[3] GIGLIO MC,GIAKOUSTIDIS A,DRAZ A,et al.Oncological outcomes of major liver resection following portal vein embolization:a systematic review and meta-analysis[J].Ann Surg Oncol,2016,23(11):3709-3717.
[4] BERTENS K A,HAWEL J,LUNG K,et al.ALPPS:challenging the concept of unresectability--a systematic review[J].Int J Surg,2015,13:280-287.
[5] KATAYAMA H,KUROKAWA Y,NAKAMURA K,et al.Extended Clavien-Dindo classification of surgical complications:Japan Clinical Oncology Group postoperative complications criteria[J].Surg Today,2016,46(6):668-685.
[6] KAMBAKAMBA P,STOCKER D,REINER C S,et al.Liver kinetic growth rate predicts postoperative liver failure after ALPPS[J].HPB (Oxford),2016,18(10):800-805.
[7] SCHADDE E,RAPTIS D A,SCHNITZBAUER A A.et al.Prediction of mortality after ALPPS stage-1:an analysis of 320 patients from the international ALPPS registry[J].Ann Surg,2015,262(5):780-785.
[8] CHIA D K A,YEO Z,LOH S E K,et al.Greater hypertrophy can be achieved with associating liver partition with portal vein ligation for staged hepatectomy compared to conventional staged hepatectomy,but with a higher price to pay[J].Am J Surg,2018,215(1):131-137.
[9] DEAL R,FREDERIKS C,WILLIAMS L,et al.Rapid liver hypertrophy after portal vein occlusion correlates with the degree of collateralization between lobes-a study in pigs[J].J Gastrointest Surg,2018,22(2):203-213.
[10] LAU W Y,LAI E C.Modifications of ALPPS - from complex to more complex or from complex to less complex operations[J].Hepatobiliary Pancreat Dis Int,2017,16(4):346-352.
[11] LINECKER M,KAMBAKAMBA P,REINER C S,et al.How much liver needs to be transected in ALPPS?A translational study investigating the concept of less invasiveness[J].Surgery,2017,161(2):453-464.
[12] CHAN A C Y,CHOK K,DAI J W C,et al.Impact of split completeness on future liver remnant hypertrophy in associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in hepatocellular carcinoma:complete-ALPPS versus partial-ALPPS[J].Surgery,2017,161(2):357-364.
[13] TRUANT S,SCATTON O,DOKMAK S,et al.Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS):Impact of the inter-stages course on morbimortality and implications for management[J].Eur J Surg Oncol,2015,41(5):674-682.
[14] MATSUO K,MURAKAMI T,KAWAGUCHI D,et al.Histologic features after surgery associating liver partition and portal vein ligation for staged hepatectomy versus those after hepatectomy with portal vein embolization[J].Surgery,2016,159(5):1289-1298.
[15] RATTI F,SCHADDE E,MASETTI M,et al.Strategies to increase the resectability of patients with colorectal liver metastases:a multi-center case-match analysis of ALPPS and conventional two-stage hepatectomy[J].Ann Surg Oncol,2015,22(6):1933-1942.
[16] SCHADDE E,ARDILES V,SLANKAMENAC K,et al.ALPPS offers a better chance of complete resection in patients with primarily unresectable liver tumors compared with conventional-staged hepatectomies:results of a multicenter analysis[J].World J Surg,2014,38(6):1510-1519.
[17] PENG S Y,WANG X A,HUANG C Y,et al.Evolution of associating liver partition and portal vein ligation for staged hepatectomy:simpler,safer and equally effective methods[J].World J Gastroenterol,2017,23(23):4140-4145.
[18] HONG DE F,ZHANG Y B,PENG S Y,et al.Percutaneous microwave ablation liver partition and portal vein embolization for rapid liver regeneration:a minimally invasive first step of ALPPS for hepatocellular carcinoma[J].Ann Surg,2016,264(1):e1-2.
[19] ROBLES R,PARRILLA P,LóPEZ-CONESA A,et al.Tourniquet modification of the associating liver partition and portal ligation for staged hepatectomy procedure[J].Br J Surg,2014,101(9):1129-1134.
[20] CAI X,PENG S,DUAN L,et al.Completely laparoscopic ALPPS using round-the-liver ligation to replace parenchymal transection for a patient with multiple right liver cancers complicated with liver cirrhosis[J].J Laparoendosc Adv Surg Tech A,2014,24(12):883-886.
[21] CHUNG B M,PARK H J,PARK S B,et al.Differentiation of small arterial enhancing hepatocellular carcinoma from non-tumorous arterioportal shunt with an emphasis on the precontrast CT scan[J].Abdom Imaging,2015,40(7):2200-2209.
[22] HOSHIAI S,MORI K,ISHIGURO T,et al.Balloon-assisted chemoembolization using a micro-balloon catheter alongside a microcatheter for a hepatocellular carcinoma with a prominent arterioportal shunt:a case report[J].Cardiovasc Intervent Radiol,2017,40(4):625-628.