目的: 探讨门静脉栓塞术在二期精准肝切除的应用。方法: 分析7例在超声扫描及X线数字减影血管造影引导下,经皮经肝穿刺门静脉栓塞术后,行二期精准肝切除术的肝癌病人临床资料。分成肝硬化组3例和无肝硬化组4例,分别检测门静脉栓塞术前和术后肝功能指标及肝体积变化,总结二期手术切除。结果: 7例病人均成功实施经皮经肝穿刺门静脉栓塞术,其中6例病人达到肝脏体积代偿增大的预期效果,顺利完成二期精准肝切除术。1例结肠直肠癌肝转移病人在门静脉栓塞8周后,未栓塞肝脏代偿性增大体积未达到精准肝切除的条件,转外院顺利行拯救性联合肝脏离断和门静脉结扎的二步肝切除术。两组经皮经肝穿刺门静脉栓塞术后1 d,肝功能指标较术前升高（P<0.05）,予护肝治疗3~7 d后降至术前水平。未发生严重并发症。结论: 门静脉栓塞技术成功率高、安全可行。剩余肝脏代偿性增大明显,可显著提高二期精准肝切除手术率。
金圣杰, 范逸群, 柏斗胜, 蒋国庆, 钱建军, 姚捷, 王小东, 高志慧, 张弛
. 门静脉栓塞术在二期精准肝切除中的应用[J]. 外科理论与实践, 2018
, 23(03)
: 247
-251
.
DOI: 10.16139/j.1007-9610.2018.03.013
Objective: To discuss the application of portal vein embolization in two-stage precise hepatectomy. Methods: Clinical data of 7 patients who underwent two-stage precise hepatectomy after percutaneous transhepatic portal vein embolization guided by ultrasound and digital subtraction angiography were analyzed in this study. There were 3 cases in liver cirrhosis group and 4 cases in without liver cirrhosis group. Liver function and liver volume were detected in each group before and after portal vein embolization, and the effect of two-stage surgical resection was examined. Results: Percutaneous transhepatic portal vein embolization was successfully performed in all 7 patients. Future liver remnant increased and hepatic hypertrophy was found in 6 patients who completed two-stage precise hepatectomy afterward. Non-embolized liver hypertrophy was not enough to the conditions for two-stage hepatectomy after 8 weeks in the other patient of colorectal cancer with liver metastases. The patient underwent the therapy of associating liver partition and portal vein ligation for staged hepatectomy in other hospital. In both groups liver function was abnormal at the first day after the percutaneous transhepatic portal vein embolization (P<0.05) and recovered to normal 3-7 days later. No severe complication was found in this study. Conclusions: Portal vein embolization is safe and feasible, and increases the volume of future liver remnant significantly. It can provide the opportunity of two-stage precise hepatectomy.
[1] Huang B, Yu Y, Zhao S, et al.Precise hepatectomy based on the optimized technique of hepatic blood flow occlusion combined with the curettage and cut technique by electrotome[J]. Minerva Chir,2016,72(1):1-9.
[2] 徐安书, 傅朝春, 韦萍, 等. 3D打印技术在精准切除治疗肝脏肿瘤中的应用[J]. 中国普通外科杂志,2018,27(1):29-34.
[3] Kinoshita H, Sakai K, Hirohashi K, et al.Preoperative portal vein embolization for hepatocellular carcinoma[J]. World J Surg,1986,10(5):803-808.
[4] Makuuchi M, Thai BL, Takayasu K, et al.Preoperative portal embolization to increase safety of major hepatectomy for hilar bile duct carcinoma: a preliminary report[J]. Surgery,1990,107(5):521-527.
[5] Orcutt ST, Kobayashi K, Sultenfuss M, et al.Portal vein embolization as an oncosurgical strategy prior to major hepatic resection: anatomic, surgical, and technical considerations[J]. Front Surg,2016,3:14.
[6] Wu H, Zeng Y, Li J, et al.Application of PVE in hepatic surgery[M]//Yan L. Operative Techniques in Liver Resection. Dordrecht: Springer Netherlands,2016:245-248.
[7] Rous P, Larimore LD.Relation of the portal blood to li-ver maintenance: a demonstration of liver atrophy conditional on compensation[J]. J Exp Med,1920,31(5):609-632.
[8] Madoff DC, Hicks ME, Abdalla EK, et al.Portal vein embolization with polyvinyl alcohol particles and coils in preparation for major liver resection for hepatobiliary malignancy: safety and effectiveness--study in 26 patients[J]. Radiology,2003,227(1):251-260.
[9] de Baere T, Roche A, Elias D, et al. Preoperative portal vein embolization for extension of hepatectomy indications[J]. Hepatology,1996,24(6):1386-1391.
[10] Tsuge H, Mimura H, Kawata N, et al.Right portal embolization before extended right hepatectomy using laparoscopic catheterization of the ileocolic vein: a prospective study[J]. Surg Laparosc Endosc,1994,4(4):258-263.
[11] Matela J, Zabavnik Z, Jukic T, et al.Selective portal vein embolization as introduction in major surgery[J]. Coll Antropol,2005,29(1):163-167.
[12] Takayama T, Makuuchi M.Preoperative portal vein embolization: is it useful?[J]. J Hepatobiliary Pancreat Surg,2004,11(1):17-20.
[13] Gruttadauria S, Luca A, Mandala L, et al.Sequential preoperative ipsilateral portal and arterial embolization in patients with colorectal liver metastases[J]. World J Surg,2006,30(4):576-578.
[14] 荚卫东. 精准肝切除治疗肝细胞癌关键技术[J]. 中国普通外科杂志,2014,23(1):1-5.
[15] Yokoyama Y, Ebata T, Igami T, et al.The predictive va-lue of indocyanine green clearance in future liver remnant for posthepatectomy liver failure following hepatectomy with extrahepatic bile duct resection[J]. World J Surg,2016,40(6):1440-1447.
[16] Lodge JPA.Taking “Play-Doh” to the kids: using the ALPPS approach to prevent postoperative liver failure[J]. Ann Surg,2017,266(2):e18.
[17] 周俭, 王征, 孙健, 等. 联合肝脏离断和门静脉结扎的二步肝切除术[J]. 中华消化外科杂志,2013,12(7):485-489.
[18] 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.
[19] 张宁, 卢实春, 冯玉泉. 联合肝实质离断及门静脉结扎的分期肝切除术研究进展[J]. 中华肝胆外科杂志,2015,21(6):421-423.
[20] Wu H, Pan G.Associating liver partition and portal vein ligation for staged hepatectomy[M]//Yan L. Operative Techniques in Liver Resection. Dordrecht: Springer Netherlands,2016:249-254.
