Kim R D, Nazarey P, Katz E, Chari R S
Department of Surgery, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01655, USA.
Surg Endosc. 2004 Jan;18(1):39-44. doi: 10.1007/s00464-002-8778-x. Epub 2003 Nov 21.
Surgical resection and liver transplantation remain the only treatments that offer cure for hepatoma, but are limited to those with early stage disease. Prelisting radiological staging is not always definitive. In this study, we sought to delineate the role of laparoscopy for clarification of staging in advanced cirrhotic patients when radiological assessment during evaluation for orthotopic liver transplants (OLTx) is equivocal.
Over a 3-year period, 18 patients with advanced liver insufficiency being evaluated for OLTx listing underwent laparoscopic staging when the following criteria were met: (1) lesion(s) with indeterminate size/borders, (2) an indeterminate number of lesions, or (3) lesion(s) and alpha-fero protein (AFP) less than 100 ng/ml. Patients underwent exploratory laparoscopy and laparoscopic ultrasound with biopsy, with or without ablation of lesion(s).
Laparoscopic staging was initiated in 18 patients; four of the first six patients were converted to open procedures. Twelve patients were restaged as a result of the procedure: six down-staged and six up-staged. Stage changes were based on laparoscopic visualization of advanced disease in two, ultrasonographic clarification of tumor size/number in seven, and biopsy in three. Twelve of the 14 laparoscopic procedures included laparoscopic radiofrequency ablation while one received ethanol ablation. One patient required 2 units of red blood cells. One patient died on postoperative day 7 because of gastrointestinal bleeding. Four of the six down-staged patients underwent liver transplant, and pathological staging of the explants agreed with laparoscopic staging in all cases.
Laparoscopic staging for HCC in advanced cirrhosis can clearly characterize tumor burden when preoperative radiological assessment is equivocal.
手术切除和肝移植仍然是仅有的能够治愈肝癌的治疗方法，但仅限于早期疾病患者。术前影像学分期并不总是明确的。在本研究中，我们试图明确当原位肝移植（OLTx）评估期间的影像学评估不明确时，腹腔镜检查在晚期肝硬化患者分期明确中的作用。
在3年的时间里，18例因肝移植评估而患有晚期肝功能不全的患者在满足以下标准时接受了腹腔镜分期：（1）病变大小/边界不确定；（2）病变数量不确定；（3）病变和甲胎蛋白（AFP）低于100 ng/ml。患者接受了探索性腹腔镜检查和腹腔镜超声检查并活检，有或没有对病变进行消融。
18例患者开始进行腹腔镜分期；前6例患者中有4例转为开放手术。12例患者因该手术而重新分期：6例分期降低，6例分期升高。分期改变的依据是：2例通过腹腔镜观察到晚期疾病，7例通过超声明确肿瘤大小/数量，3例通过活检。14例腹腔镜手术中有12例包括腹腔镜射频消融，1例接受乙醇消融。1例患者需要2单位红细胞。1例患者术后第7天因胃肠道出血死亡。6例分期降低的患者中有4例接受了肝移植，所有病例中切除肝脏的病理分期与腹腔镜分期一致。
当术前影像学评估不明确时，晚期肝硬化患者肝癌的腹腔镜分期能够清楚地确定肿瘤负荷。
