發(fā)布時(shí)間：2018-07-02 13:09

  本文選題：原發(fā)性肝癌 + 聯(lián)合肝臟分隔和門靜脈結(jié)扎的二步肝切除術(shù)�。� 參考：《第三軍醫(yī)大學(xué)》2017年碩士論文

【摘要】：背景與目的:手術(shù)切除仍然是目前肝癌根治性治療手段之一,但是對(duì)于BCLC分期較晚的B、C期的患者,目前主張的治療方式為以TACE為主的姑息治療。這類患者實(shí)施手術(shù)的最主要的限制因素為預(yù)留剩余肝體積(FLR)不足。近年來出現(xiàn)的聯(lián)合肝臟分隔和門靜脈結(jié)扎的二步肝切除術(shù)(ALPPS)可在較短時(shí)間內(nèi)促進(jìn)FLR顯著增長,為既往無法手術(shù)的患者提供了手術(shù)機(jī)會(huì)。但是經(jīng)典的ALPPS具有較高的手術(shù)并發(fā)癥和死亡率,射頻消融輔助的ALPPS(RALPPS)是針對(duì)經(jīng)典ALPPS上述弊端進(jìn)行改良的一種術(shù)式。我們將RALPPS應(yīng)用在進(jìn)展期的肝硬化肝癌患者上,分析其圍手術(shù)期各項(xiàng)指標(biāo),評(píng)估該術(shù)式的臨床效果,并探討射頻消融在促進(jìn)肝硬化肝癌患者RALPPS一期術(shù)后肝組織再生中的作用。方法:對(duì)于預(yù)留剩余肝體積(FLR)不足(40%)的原發(fā)性肝癌患者實(shí)施RALPPS,在一期術(shù)中利用RFA在患側(cè)和健側(cè)肝葉間燒灼出一條無血凝固帶,然后結(jié)扎右側(cè)門靜脈。術(shù)后每周行CT掃描了解FLR的增長情況,待FLR超過40%并且患者全身情況良好即實(shí)施二期手術(shù)切除腫瘤。對(duì)于FLR一期術(shù)后2-3周后仍未達(dá)到40%的患者,在超聲引導(dǎo)下行補(bǔ)充性經(jīng)皮RFA(即補(bǔ)救性RFA)。針對(duì)患者的圍手術(shù)期手術(shù)并發(fā)癥發(fā)生率、死亡率、FLR增長率、手術(shù)時(shí)間和術(shù)中出血、二期手術(shù)完成率、總體生存率(OS)、無瘤生存率(DFS)、實(shí)施補(bǔ)救性RFA前后FLR的變化及其他指標(biāo)進(jìn)行評(píng)估。結(jié)果:從2014年7月至2016年8月,共有21例肝癌患者實(shí)施RALPPS,其中15例合并有肝硬化。5例患者因各種原因未行手術(shù)切除,二期手術(shù)脫失率為23.8%。1例患者院內(nèi)死亡,院內(nèi)死亡率為4.8%(1/21);嚴(yán)重并發(fā)癥(Clavien-Dindo≥Ⅲb)的發(fā)生率是23.8%(5/21)。FLR在25.2±14.8天的間隔期內(nèi)由372.5±93.4ml(29.0±6.8%)增長至616.4±92.3ml(48.6±6.1%)。兩期的手術(shù)出血量分別為190.5±115.8 ml和513.1±240.7ml,手術(shù)時(shí)間分別為224.5±58.3分鐘和309.0±83.8分鐘。經(jīng)過中位期為16月(2-30月)的隨訪,總體生存率為45.7%,無腫瘤生存率是44.4%。共有4例患者在一期術(shù)后2-3周后FLR體積增長不足,實(shí)施補(bǔ)救性經(jīng)皮RFA。在實(shí)施補(bǔ)救措施前FLR的增長率為0.3-7.5%,實(shí)施補(bǔ)救措施后FLR的增長率為9.7-12.1%。結(jié)論:和經(jīng)典術(shù)式相比,RALPPS是一種較為安全、有效、簡化的手術(shù)方式;經(jīng)過嚴(yán)格篩選病例,對(duì)于肝功能良好的進(jìn)展期肝硬化肝癌患者,其FLR也可以較好的增長,盡管有一定的二期手術(shù)未完成率。為提高二期手術(shù)完成率,可在RALPPS一期術(shù)后FLR增長不良時(shí)行“補(bǔ)救性”射頻消融,但其確切效果仍需大樣本的研究來證實(shí)。此外,探索并篩選肝硬化肝癌患者FLR增長不良的危險(xiǎn)因素進(jìn)而建立風(fēng)險(xiǎn)預(yù)測模型對(duì)于RALPPS術(shù)式的推廣應(yīng)用很有必要。
[Abstract]:Background & objective: surgical resection is still one of the methods of radical treatment for hepatocellular carcinoma, but for patients with BCLC stage, TACE is the main palliative treatment. The main limiting factor for surgery in this group of patients was insufficient reserved residual liver volume (FLR). In recent years, combined hepatic septum and portal vein ligation with two-step hepatectomy (ALPPS) can significantly increase FLR in a short period of time, and provide surgical opportunities for patients who have been unable to operate before. But the classical ALPPS has higher operative complications and mortality. Radiofrequency Ablation assisted ALPPS (RALPPS) is a modified procedure for the above disadvantages of classical ALPPS. We applied RALPPS to liver cancer patients with advanced liver cirrhosis, analyzed its perioperative indexes, evaluated the clinical effect of this procedure, and discussed the role of radiofrequency ablation in promoting liver tissue regeneration in patients with liver cirrhosis after primary operation of RALPPS. Methods: RALPPSs were performed in patients with primary liver cancer with insufficient residual liver volume (FLR) (40%). RFA was used to cauterize a blood free coagulation zone between the affected and healthy hepatic lobes during one stage operation, and then ligated the right portal vein. Ct scans were performed weekly after operation to find out the growth of FLR. The tumor was resected after secondary operation when the FLR was more than 40% and the patient was in good condition. In 40% of the patients with FLR who were still not up to 40% 2-3 weeks after primary operation, complementary percutaneous RFA (remedial RFA) was performed under ultrasound guidance. According to the incidence of perioperative complications, mortality rate of FLR, operative time and intraoperative bleeding, secondary operation completion rate, Overall survival rate (OS), tumor-free survival rate (DFS), changes in FLR and other indicators before and after the implementation of remedial RFA were evaluated. Results: from July 2014 to August 2016, a total of 21 patients with liver cancer were treated with RALPPS. Among them, 15 patients with liver cirrhosis were not resected for various reasons. The rate of second stage operation loss was 23.8.1 patients died in hospital. The incidence of severe complications (Clavien-Dindo 鈮，

本文編號(hào)：2090228