Polacco M, Vitale A, Valmasoni M, D'Amico F, Gringeri E, Brolese A, Zanus G, Neri D, Carraro A, Pauletto A, Romanelli E, Lo Bello S, Cillo U
Unità di Chirurgia Epatobiliare e Trapianto Epatico, Dipartimento assistenziale di Chirurgia Generale e Trapianti d'Organo, Università degli Studi di Padova, Padova, Italy.
Transplant Proc. 2010 May;42(4):1378-80. doi: 10.1016/j.transproceed.2010.03.090.
Tumor progression before orthotopic liver transplantation (OLT) is the main cause of dropouts from waiting lists among patients with hepatocellular carcinoma (HCC). Performing a porto-caval shunt (PCS) before parenchymal liver transection has the potential to allow an extended hepatectomy in patients with decompensated liver cirrhosis, reducing portal hyperflow and therefore the sinusoidal shear-stress on the remnant liver. We report the case of a 59-year-old man affected by hepatitis C virus (HCV)-related decompensated liver cirrhosis (Child Pugh score presentation, C-10; Model for End Stage Liver Disease score, 18) and HCC (2 lesions of 2 and 2.8 cm). The patient began the evaluation to join the OLT waiting list, but, in the 3 months required to complete the evaluation, he developed tumor progression: 3 HCC lesions, the largest 1 with a diameter of about 4.4 cm. These findings excluded transplantation criteria and the patient was referred to our center. After appropriate preoperative studies, the patient underwent a major liver resection (trisegmentectomy) after side-to-side PCS by interposition of an iliac vein graft from a cadaveric donor. The patient overcame the worsened severity of cirrhosis. After 6 months of follow-up, he developed 2 other HCC nodules. He was then included on the waiting list at our center, undergoing OLT from a cadaveric donor at 8 months after salvage treatment. At 36 months after OLT, he is alive and free from HCC recurrence. Associating a partial side-to-side PCS with hepatic resection may represent a potential salvage therapy for patients with decompensated cirrhosis and HCC progression beyond listing criteria for OLT.
原位肝移植（OLT）前肿瘤进展是肝细胞癌（HCC）患者从等待名单中退出的主要原因。在肝实质离断前进行门腔分流术（PCS）有可能使失代偿期肝硬化患者接受扩大肝切除术，减少门静脉高流量，从而降低残余肝脏的窦状切应力。我们报告了一例59岁男性患者，患有丙型肝炎病毒（HCV）相关的失代偿期肝硬化（Child Pugh评分C-10；终末期肝病模型评分18）和HCC（两个病灶，直径分别为2 cm和2.8 cm）。该患者开始接受评估以加入OLT等待名单，但在完成评估所需的3个月内，他出现了肿瘤进展：出现3个HCC病灶，最大的一个直径约为4.4 cm。这些发现排除了移植标准，该患者被转诊至我们中心。经过适当的术前检查后，患者在通过插入尸体供体的髂静脉移植物进行侧侧PCS后接受了扩大肝切除术（三段切除术）。患者克服了肝硬化严重程度的恶化。经过6个月的随访，他又出现了2个HCC结节。然后他被列入我们中心的等待名单，在挽救治疗8个月后接受了尸体供体的OLT。OLT后36个月，他存活且无HCC复发。将部分侧侧PCS与肝切除术相结合可能是失代偿期肝硬化和HCC进展超过OLT列入标准的患者的一种潜在挽救治疗方法。
