肝Ⅷ段大肝癌手术切除安全性及疗效分析
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摘要
目的探讨肝Ⅷ段大肝癌手术切除治疗的安全性和疗效。方法回顾性分析2008年1月至2012年12月在东方肝胆外科医院行肝Ⅷ段大肝癌切除的17例患者临床资料。其中男15例,女2例;年龄30～62岁,中位年龄49岁。患者均签署知情同意书,符合医学伦理学规定。术中采用低中心静脉压,合理应用各种血流阻断法,控制肝静脉和下腔静脉大出血,以完整切除肿瘤为原则。生存分析采用Kaplan-Meier法和Log-rank检验。结果 17例患者均顺利完成手术,手术时间中位数133(80～190)min,术中出血量150(50～800)ml。输血3例,分别输血600、800、600 ml。无围手术期死亡。术后9例出现并发症,其中胸腔积液7例,肺不张1例,腹腔积液+胸腔积液1例,无术中大出血、空气栓塞等严重并发症发生。16例术后行辅助性TACE治疗。患者无瘤生存时间12(1～116)个月,总体生存时间30(12～116)个月;1、3、5年无瘤生存率分别为58.8%、40.3%、30.3%,1、3、5年总体生存率分别为100.0%、48.1%、41.3%。结论肝切除仍是肝Ⅷ段大肝癌首选治疗方案,手术以完整切除肿瘤为主要目标,可获得良好疗效。术中采用多种措施控制出血,保护主要管道结构,避免损伤肝静脉和下腔静脉,预防空气栓塞,妥善处理好肝脏创面,可保证手术安全。
Objective To evaluate the safety and clinical efficacy of surgical resection in patients with large liver cancer in segment Ⅷ. Methods Clinical data of 17 patients who underwent resection of segment Ⅷ large liver cancer from January 2008 to December 2012 in Eastern Hepatobiliary Surgery Hospital were retrospectively analyzed. Among them, 15 patients were male and 2 female, aged 30-62 years, with a median age of 49 years. The informed consents of all patients were obtained and the local ethical committee approval was received. Intraoperatively, low central venous pressure was adopted, and different vascular occlusions were reasonably applied to control the massive hemorrhage of the hepatic vein and inferior vena cava. Radical resection of the tumor was the principle of operation. Survival analysis were conducted with Kaplan-Meier method and Log-rank test. Results All 17 patients underwent the operation successfully. The median operation time was 133(80-190) min. Intraoperative blood loss was 150(50-800) ml. Blood transfusion was performed in 3 cases(600, 800 and 600 ml). No perioperative death occurred. Postoperative complications were noted in 9 cases, including pleural effusion in 7 cases, atelectasis in 1 and peritoneal effusion combined with pleural effusion in 1. No serious complications, such as intraoperative hemorrhage and air embolism, were observed. Adjuvant TACE was performed in 16 cases after operation. The tumor-free survival time was 12(1-116) months and the overall survival time was 30(12-116) months. The 1-, 3-, and 5-year tumor-free survival rates were 58.8%, 40.3% and 30.3%, respectively. The 1-, 3-, and 5-year overall survival rates were 100.0%,48.1% and 41.3%, respectively. Conclusions Hepatectomy is still the primary choice for the treatment of large liver cancer in segment Ⅷ. The main objective of operation is radical resection of tumors, which yields good clinical efficacy. Intraoperatively, hemorrhage control with different measures, to protect the main vascular structures, to avoid the hepatic vein and inferior vena cava damage, to prevent the incidence of air embolism and to properly manage the liver section, can ensure the safety of operation.
Objective To evaluate the safety and clinical efficacy of surgical resection in patients with large liver cancer in segment Ⅷ. Methods Clinical data of 17 patients who underwent resection of segment Ⅷ large liver cancer from January 2008 to December 2012 in Eastern Hepatobiliary Surgery Hospital were retrospectively analyzed. Among them, 15 patients were male and 2 female, aged 30-62 years, with a median age of 49 years. The informed consents of all patients were obtained and the local ethical committee approval was received. Intraoperatively, low central venous pressure was adopted, and different vascular occlusions were reasonably applied to control the massive hemorrhage of the hepatic vein and inferior vena cava. Radical resection of the tumor was the principle of operation. Survival analysis were conducted with Kaplan-Meier method and Log-rank test. Results All 17 patients underwent the operation successfully. The median operation time was 133(80-190) min. Intraoperative blood loss was 150(50-800) ml. Blood transfusion was performed in 3 cases(600, 800 and 600 ml). No perioperative death occurred. Postoperative complications were noted in 9 cases, including pleural effusion in 7 cases, atelectasis in 1 and peritoneal effusion combined with pleural effusion in 1. No serious complications, such as intraoperative hemorrhage and air embolism, were observed. Adjuvant TACE was performed in 16 cases after operation. The tumor-free survival time was 12(1-116) months and the overall survival time was 30(12-116) months. The 1-, 3-, and 5-year tumor-free survival rates were 58.8%, 40.3% and 30.3%, respectively. The 1-, 3-, and 5-year overall survival rates were 100.0%,48.1% and 41.3%, respectively. Conclusions Hepatectomy is still the primary choice for the treatment of large liver cancer in segment Ⅷ. The main objective of operation is radical resection of tumors, which yields good clinical efficacy. Intraoperatively, hemorrhage control with different measures, to protect the main vascular structures, to avoid the hepatic vein and inferior vena cava damage, to prevent the incidence of air embolism and to properly manage the liver section, can ensure the safety of operation.
引文
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[9]李倩,杜佳,关鹏,等.中国2008年肝癌发病、死亡和患病情况的估计与预测[J].中华流行病学杂志,2012,33(6):554-557.
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[12]何慧梁,吴健,金旭东,等.4%琥珀酰明胶急性高容血液稀释联合低中心静脉压用于肝脏手术的观察[J].中华麻醉学杂志,2004,24(2):158-159.
[13]Melendez JA,Arslan V,Fischer ME,et al.Perioperative outcomes of major hepatic resections under low central venous pressure anesthesia:blood loss,blood transfusion,and the risk of postoperative renal dysfunction[J].J Am Coll Surg,1998,187(6):620-625.
[14]隋承军,张敏峰,戴炳华,等.半肝血流完全阻断法在肝细胞癌肝切除术中的应用:前瞻性随机对照研究[J].第二军医大学学报,2016,37(10):1230-1238.
[15]周伟平,李爱军,傅思源,等.肝静脉阻断技术在肝切除术中的应用[J].中华普通外科杂志,2006,21(8):573-576.
[16]宋平辉,周牛蕾.不同肝血流阻断方案对大肝癌手术治疗效果的影响[J/CD].中华普外科手术学杂志(电子版),2016,10(2):168-170.
[17]李川江,邹衍泰,林建华,等.保留半肝动脉血流的肝门阻断在肝细胞癌肝切除术中的应用[J/CD].中华肝脏外科手术学电子杂志,2014,3(6):31-34.
[18]何尹韬,陈应军,甄作均.半肝血流阻断在腹腔镜肝细胞癌切除中的应用[J/CD].中华肝脏外科手术学电子杂志,2017,6(5):384-388.
[19]杨连粤,黄耿文,黄建华,等.不阻断肝门的大肝癌切除术[J].中华肝胆外科杂志,2003,9(6):331-333.
[2]Wang FS,Fan JG,Zhang Z,et al.The global burden of liver disease:the major impact of China[J].Hepatology,2014,60(6):2099-2108.
[3]杨广顺,付雍.原发性肝癌手术方式选择与原则[J/CD].中华普外科手术学杂志(电子版),2014,8(1):8-11.
[4]Torre LA,Bray F,Siegel RL,et al.Global cancer statistics,2012[J].CA Cancer J Clin,2015,65(2):87-108.
[5]Chen W,Zheng R,Baade PD,et al.Cancer statistics in China,2015[J].CA Cancer J Clin,2016,66(2):115-132.
[6]中华人民共和国卫生和计划生育委员会医政医管局.原发性肝癌诊疗规范(2017年版)[J].中华消化外科杂志,2017,16(7):635-647.
[7]Qi X,Guo X.Sorafenib for the treatment of hepatocellular carcinoma with portal vein tumour thrombosis:a systematic review of comparative studies[J].Prz Gastroenterol,2015,10(3):142-147.
[8]张尊义,董汉华.肝切除术后联合肝动脉化疗栓塞综合治疗大肝癌中长期生存率[J].武汉大学学报(医学版),2016,37(5):794-796,806.
[9]李倩,杜佳,关鹏,等.中国2008年肝癌发病、死亡和患病情况的估计与预测[J].中华流行病学杂志,2012,33(6):554-557.
[10]高纪东,邵永孚,吴健雄,等.肝细胞癌肝切除术后预后影响因素分析[J].中华肝胆外科杂志,2005,11(8):515-517.
[11]耿小平,张宗耀.第Ⅷ肝段切除治疗肝细胞癌[J].中华肝胆外科杂志,1999,5(1):26-28.
[12]何慧梁,吴健,金旭东,等.4%琥珀酰明胶急性高容血液稀释联合低中心静脉压用于肝脏手术的观察[J].中华麻醉学杂志,2004,24(2):158-159.
[13]Melendez JA,Arslan V,Fischer ME,et al.Perioperative outcomes of major hepatic resections under low central venous pressure anesthesia:blood loss,blood transfusion,and the risk of postoperative renal dysfunction[J].J Am Coll Surg,1998,187(6):620-625.
[14]隋承军,张敏峰,戴炳华,等.半肝血流完全阻断法在肝细胞癌肝切除术中的应用:前瞻性随机对照研究[J].第二军医大学学报,2016,37(10):1230-1238.
[15]周伟平,李爱军,傅思源,等.肝静脉阻断技术在肝切除术中的应用[J].中华普通外科杂志,2006,21(8):573-576.
[16]宋平辉,周牛蕾.不同肝血流阻断方案对大肝癌手术治疗效果的影响[J/CD].中华普外科手术学杂志(电子版),2016,10(2):168-170.
[17]李川江,邹衍泰,林建华,等.保留半肝动脉血流的肝门阻断在肝细胞癌肝切除术中的应用[J/CD].中华肝脏外科手术学电子杂志,2014,3(6):31-34.
[18]何尹韬,陈应军,甄作均.半肝血流阻断在腹腔镜肝细胞癌切除中的应用[J/CD].中华肝脏外科手术学电子杂志,2017,6(5):384-388.
[19]杨连粤,黄耿文,黄建华,等.不阻断肝门的大肝癌切除术[J].中华肝胆外科杂志,2003,9(6):331-333.