本文選題：肝細胞性肝癌　切入點：門靜脈高壓　出處：《山東大學》2017年碩士論文　論文類型：學位論文

【摘要】：背景原發(fā)性肝癌(肝癌)是我國常見癌癥,而慢性乙型病毒性肝炎、肝硬化仍然是肝癌的的重要發(fā)病因素。眾所周知,在乙肝、肝硬化、肝癌患者中,肝癌病人常有急性肝炎→慢性肝炎→肝硬化-→肝癌病史,而在肝炎、肝硬化的發(fā)展過程當中,由于肝竇結(jié)構(gòu)改建及假小葉形成,往往導致門靜脈壓力不同程度升高,進而導致不同程度的脾腫大及脾功能亢進。傳統(tǒng)上一般認為,肝癌合并肝硬化、脾功能亢進患者,手術(shù)風險較高,多主張采用非手術(shù)治療,但效果很差;少數(shù)只作肝癌切除治療的患者,術(shù)中門靜脈壓力較高、脾臟腫大等,限制了手術(shù)視野,高門靜脈壓力增加了出血風險及門靜脈阻斷時間,術(shù)后持續(xù)存在并逐漸加重的脾功能亢進,嚴重影響了患者的預后。通過回顧性研究可知,肝硬化門靜脈高壓時,切除功能亢進的脾臟可以促進肝臟再生,減緩肝硬化的進展,進而可能降低肝癌的發(fā)生風險;有動物實驗證明,門靜脈高壓、脾功能亢進可促進誘導動物肝癌發(fā)生及肝臟纖維化。門靜脈高壓、脾功能亢進對于肝癌切除術(shù)后近期恢復是顯而易見的,對遠期預后的影響缺乏明確研究。脾切除對肝癌切除患者并發(fā)癥和預后的影響,可有以下幾方面的原因:①脾功能亢進對于血小板、白細胞的破壞作用,導致患者血小板、白細胞降低,從而對手術(shù)產(chǎn)生相關(guān)影響;②正常脾臟作為免疫器官,對于腫瘤存在正性免疫作用,門脈高壓情況下脾臟可能逆轉(zhuǎn)為負性免疫作用?③門靜脈高壓對于術(shù)中出血及肝門阻斷的影響;④門靜脈高壓對于肝腫瘤轉(zhuǎn)移是否起到了推動作用?鑒于以上幾點考慮,對于乙肝肝硬化后肝細胞性肝癌(以下簡稱肝癌)合并門靜脈高壓患者,肝癌聯(lián)合脾切除是否有積極意義仍需進一步探索研究。目的對比研究肝癌合并門靜脈高壓、脾功能亢進患者,肝癌聯(lián)合脾切除效果是否優(yōu)于單純肝癌切除術(shù)。方法總結(jié)2006-2016山東大學齊魯醫(yī)院手術(shù)治療肝癌合并門靜脈高壓患者123例,其中63例肝癌聯(lián)合脾臟切除、60例行單純肝腫瘤切除術(shù),分為兩組(A組聯(lián)合脾切除,B組單純肝腫瘤切除),比較兩組術(shù)中出血量、門靜脈阻斷情況、術(shù)后引流管引流量、血小板、白細胞、膽紅素、間接膽紅素、術(shù)后出院時間、術(shù)后并發(fā)癥、無瘤生存期、生存期等相關(guān)指標。結(jié)果肝癌聯(lián)合脾切除手術(shù)創(chuàng)傷大,手術(shù)時間(217.76±65.05min)較肝癌切除術(shù)組手術(shù)時間(174.75±75.4min)長,但兩組患者術(shù)中出血量、輸血情況無統(tǒng)計學差異,而肝門阻斷次數(shù)及時間較單純肝癌切除組要少(p=0.02)。肝癌聯(lián)合脾切除組及肝癌切除組患者住院時間、術(shù)后并發(fā)癥情況無統(tǒng)計學差異,術(shù)后7天白細胞、血小板計數(shù)明顯高于單純肝癌切除組;而術(shù)后2天、7天膽紅素及間接膽紅素明顯低于肝癌切除組(p0.01)。肝癌聯(lián)合脾切除組的平均無瘤生存期(45.07 ±3.66個月)顯著長于單純肝癌切除組(31.41 ±3.49個月)(p0.01);平均生存期(67.36 ±4.05個月)顯著長于單純肝癌切除組(49.83 ±3.95個月)(p0.01)。結(jié)論盡管肝癌聯(lián)合脾切除術(shù)手術(shù)創(chuàng)傷大、手術(shù)時間長,但并沒有顯著延長住院時間及增加圍手術(shù)期并發(fā)癥發(fā)生率。肝癌聯(lián)合脾切除術(shù)有利于降低門靜脈壓力,糾正脾功能亢進,有利于降低術(shù)中及術(shù)后出血風險,促進肝功能恢復,有利于肝細胞代謝及機體營養(yǎng)代謝,有助于降低膽紅素負荷,有助于血小板及白細胞的數(shù)目恢復正常。肝癌聯(lián)合脾切除術(shù)對腫瘤復發(fā)有一定抑制作用,并能一定程度上延長患者的無瘤生存期及生存期。
[Abstract]:Background hepatocellular carcinoma (HCC) is the most common cancer and chronic hepatitis B, cirrhosis is still the important factors in the pathogenesis of HCC. As everyone knows, in hepatitis B, liver cirrhosis, liver cancer patients, cancer patients often have acute hepatitis, chronic hepatitis, liver cirrhosis, liver cancer - history, and in the development process of hepatitis. Liver cirrhosis, liver sinus formed due to structural remodeling and pseudolobuli, often leads to portal vein pressure increased, resulting in splenomegaly and hypersplenism in different degrees. It is traditionally thought that, liver cancer complicated with liver cirrhosis, hypersplenism, the higher the risk of surgery, advocate the use of non surgical treatment, but the effect is poor only few; liver cancer treated with high pressure of portal vein, spleen enlargement, limiting the surgical field, high venous pressure increases the risk of bleeding and portal vein occlusion time, surgery After the continued existence of hypersplenia and gradually aggravated, serious impact on the prognosis of the patients. By retrospective study, liver cirrhosis and portal hypertension, splenectomy can promote liver regeneration, slowing the progression of liver cirrhosis, and may reduce the incidence of liver cancer risk; animal experiment proved that portal hypertension, spleen hyperthyroidism can promote the induction of animal liver cancer and liver fibrosis. Portal hypertension, hypersplenism is obviously to recent recovery after resection of hepatocellular carcinoma, clear influence on long-term prognosis. The lack of effect of splenectomy on the complications and prognosis of patients with liver cancer, may have the following reasons: 1 for hypersplenism platelet damage of white blood cells, resulting in decreased white blood cells, platelets, and then produce influence on the normal operation; as for the spleen immune organ. There is a positive role in tumor immunity, portal hypertension cases of spleen may reverse the negative immune effect? The portal hypertension for bleeding effect and hepatic portal occlusion during operation; the portal hypertension for liver metastasis is to play a role in promoting? In view of the above considerations, for hepatocellular carcinoma in patients with hepatitis B cirrhosis after (HCC) patients with portal vein hypertension, liver cancer resection combined with splenectomy is of positive significance still need further study. Objective to study the liver cancer with portal hypertension and hypersplenism in patients with liver cancer resection combined with splenectomy, the effect is better than that of liver resection. Methods 123 cases of the 2006-2016 surgical treatment of hepatocellular carcinoma with portal of Qilu Hospital of Shandong University in patients with portal hypertension, including 63 cases of hepatocellular carcinoma combined with splenectomy, 60 cases underwent liver resection, were divided into two groups (group A, splenectomy, B group liver swelling Tumor resection, bleeding) were compared between the two groups, portal vein occlusion, drainage tube drainage, postoperative platelet, leukocyte, bilirubin, indirect bilirubin, postoperative discharge time, postoperative complications, disease-free survival, survival and other related indicators. The results of liver cancer resection combined with splenectomy in surgical trauma surgery. Time (217.76 + 65.05min) with liver resection group operation time (174.75 + 75.4min), but the two groups of patients with intraoperative bleeding, no significant difference in blood transfusion, and hepatic portal occlusion times and time compared with hepatectomy group less (p=0.02). Liver cancer resection combined with splenectomy group and liver resection group in hospitalized patients time, there was no significant difference in postoperative complications, after 7 days of white blood cell, platelet count was significantly higher than that in hepatectomy group; and after 2 days, 7 days of bilirubin and indirect bilirubin was significantly lower than that of the liver resection group (P0.01). The average liver cancer resection combined with splenectomy group The disease-free survival (45.07 + 3.66 months) was significantly longer in hepatectomy group (31.41 + 3.49 months) (P0.01); the average survival period (67.36 + 4.05 months) was significantly longer in hepatectomy group (49.83 + 3.95 months) (P0.01). Conclusion although the surgical trauma and splenectomy for hepatocellular carcinoma, the operation time is long, but did not significantly prolong hospitalization time and increase the incidence of perioperative complications. Liver cancer with splenectomy can reduce portal vein pressure, correct hypersplenism, to reduce the risk of bleeding during and after surgery, promote liver function recovery, is conducive to liver cell metabolism and nutritional metabolism, have help to reduce bilirubin load, contribute to the number of platelets and leukocytes returned to normal. Liver cancer combined with splenectomy has a certain inhibitory effect on tumor recurrence, and to some extent prolong disease-free survival and survival.

【學位授予單位】：山東大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R735.7

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