Pocard Marc, Sauvanet Alain, Regimbeau Jean-Marc, Duwat Olivier, Farges Olivier, Belghiti Jacques
Department of Digestive Surgery, Hôpital Beaujon, Clichy, France.
Hepatogastroenterology. 2002 Jan-Feb;49(43):32-5.
BACKGROUND/AIMS: The purpose of this study was to evaluate the results of liver resection in cirrhotic patients for liver hepatocellular carcinoma located near the diaphragm through an exclusive transthoracic approach.
Between 1995 and 1999, 19 cirrhotic patients with hepatocellular carcinoma underwent a liver resection through an exclusive transthoracic approach. This approach was indicated in 11 cases for previous upper abdominal surgery, including hepatobiliary surgery in 3 and before liver transplantation in 8. Results of the transthoracic approach were compared to 84 cirrhotic patients who underwent transabdominal limited resection of hepatocellular carcinoma matched for age, sex and localization of the tumor.
Resection was feasible by an exclusive transthoracic approach in 18 (95%) cases with a mean operating time of 201 +/- 53 min. In 8 (44%) patients a Pringle maneuver was performed. No postoperative deaths were observed after the transthoracic approach. Pulmonary complications rate was significantly higher (P < 0.001) after transthoracic resection compared to transabdominal resection (67% vs. 25%, P < 0.001). In contrast, ascites were observed in only one (5%) of the transthoracic group compared to 35 (42%) in the transabdominal group (P < 0.01). The resection margin was positive in 3 (17%) after transthoracic approch and in 1 (2%) patient after the transabdominal resection (P < 0.02). In patients who underwent liver transplantation after the transthoracic approach, total hepatectomy was performed without increasing difficulties.
The transthoracic approach is a safe procedure for resection of hepatocellular carcinoma located under the right diaphragm in cirrhotic patients. However, this approach allows only limited resection with a high risk of positive margin, resulting in a restriction of indications either for patients with previous major abdominal surgery than before liver transplantation.
背景/目的：本研究旨在评估通过单纯经胸入路对位于膈肌附近的肝硬化患者肝细胞癌进行肝切除的效果。
1995年至1999年间，19例肝硬化肝细胞癌患者通过单纯经胸入路进行了肝切除。该入路适用于11例既往有上腹部手术史的患者，其中3例有肝胆手术史，8例有肝移植术前手术史。将经胸入路的结果与84例年龄、性别和肿瘤位置相匹配的经腹局限性肝细胞癌切除术的肝硬化患者进行比较。
18例（95%）患者通过单纯经胸入路可行肝切除，平均手术时间为201±53分钟。8例（44%）患者进行了Pringle手法。经胸入路术后未观察到死亡病例。与经腹切除相比，经胸切除术后肺部并发症发生率显著更高（P<0.001）（67%对25%，P<0.001）。相比之下，经胸组仅1例（5%）出现腹水，而经腹组为35例（42%）（P<0.01）。经胸入路后3例（17%）切缘阳性，经腹切除术后1例（2%）患者切缘阳性（P<0.02）。经胸入路后接受肝移植的患者，进行全肝切除时未增加难度。
经胸入路对肝硬化患者右膈下肝细胞癌切除是一种安全的手术方法。然而，该入路仅允许进行有限切除，切缘阳性风险高，导致对于既往有重大腹部手术史或肝移植术前患者的适应证受限。
