Inoue Yosuke, Hasegawa Kiyoshi, Ishizawa Takeaki, Aoki Taku, Sano Keiji, Beck Yoshifumi, Imamura Hiroshi, Sugawara Yasuhiko, Kokudo Norihiro, Makuuchi Masatoshi
Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan.
Surgery. 2009 Jan;145(1):9-19. doi: 10.1016/j.surg.2008.09.005.
Although portal venous tumor thrombus (PVTT) is regarded as an ominous prognostic factor in patients with hepatocellular carcinoma (HCC), the optimal treatment method for maximizing both safety and long-term outcome has not yet been discussed. We describe a surgical technique in which the venous wall is peeled off from the PVTT.
In the peeling off (PO) technique, the portal venotomy was placed after adequate vascular control of portal flow. The PVTT was dissected from the portal venous wall and removed through the opening. Macroscopically residual PVTTs intruding into tiny branches were meticulously extracted. This procedure was compared with the en bloc resection of PVTT. Between 1995 and 2006, 49 patients underwent curative hepatic resections for HCC with macroscopic PVTT; these patients were classified according to whether the PO technique (n = 20) or the en bloc technique (n = 29) had been utilized. Both the short- and long-term results were compared between the 2 groups.
No mortalities occurred in either group. Both the 5-year overall survival and the recurrence-free survival rates of the PO group were comparable with those of the en bloc group (39% vs 41% [P = .90] and 23% vs 18% [P = .89], respectively). No local recurrences or regrowth of the PVTT occurred in either group.
Our procedure is useful for removing PVTT extending beyond the bifurcation or into other sectors that should be preserved in terms of liver function and enables a more conservative resection than an en bloc technique without sacrificing curability.
尽管门静脉癌栓（PVTT）被视为肝细胞癌（HCC）患者预后不良的因素，但尚未讨论过能使安全性和长期疗效最大化的最佳治疗方法。我们描述了一种从PVTT上剥离静脉壁的手术技术。
在剥离（PO）技术中，在充分控制门静脉血流后进行门静脉切开术。将PVTT从门静脉壁上剥离并通过开口取出。肉眼可见侵入小分支的残留PVTT被仔细取出。将该手术与PVTT整块切除进行比较。1995年至2006年期间，49例患有肉眼可见PVTT的HCC患者接受了根治性肝切除术；这些患者根据是否采用PO技术（n = 20）或整块技术（n = 29）进行分类。比较两组的短期和长期结果。
两组均未发生死亡。PO组的5年总生存率和无复发生存率与整块切除组相当（分别为39%对41% [P = 0.90]和23%对18% [P = 0.89]）。两组均未发生PVTT的局部复发或再生长。
我们的手术方法有助于切除延伸至分叉以外或进入其他应保留肝功能的肝段的PVTT，并且能够比整块切除技术进行更保守的切除，同时不牺牲根治性。
