腹腔镜再次肝切除术是否可行？三机构分析。
Is laparoscopic repeat hepatectomy feasible? A tri-institutional analysis.
机构信息
Department of Digestive Diseases, Institut Mutualiste Montsouris, University Paris V, Paris, France.
出版信息
J Am Coll Surg. 2011 Feb;212(2):171-9. doi: 10.1016/j.jamcollsurg.2010.10.012.
BACKGROUND
A laparoscopic approach has not been advocated for repeat hepatectomy on a large scale. This report analyzes the experience of 3 institutions pioneering laparoscopic repeat liver resection (LRLR). The aim of this study was to evaluate the feasibility, safety, oncologic integrity, and outcomes of LRLR.
STUDY DESIGN
All patients undergoing LRLR were identified. Since 1997, 76 LRLRs have been attempted. Operative indications were metastasis (n = 63), hepatocellular carcinoma (n = 3), and benign tumors (n = 10). All patients had 1 or more earlier liver resections (28 open, 44 laparoscopic), including 16 major resections (en bloc removal of 3 or more Couinaud segments).
RESULTS
Eight conversions (11%) to open resections (n = 7) or radiofrequency ablation (n = 1) were required due to technical difficulties or hemorrhage. LRLRs included 49 wedge or segmental resections and 19 major hepatectomies. Median blood loss and operative time were 300 mL and 180 minutes. Patients with previous open liver resection (group B) experienced more intraoperative blood loss and transfusion requirements than those with earlier laparoscopic resections (group A) (p = 0.02; p = 0.01, respectively). R0 resection was achieved in 58 of 64 (91%) patients with malignant tumor. The incidence of postoperative complications and duration of hospital stay were not statistically different between the 2 groups. Bile leakages developed in 5 (6.6%) patients, including 1 requiring reoperation. There was no perioperative death. Median tumor size was 25 mm (range 5 to 125 mm) and the median number of tumors was 2 (range 1 to 7). Median follow-up was 23.5 months (range 0 to 86 months). There was no port-site metastasis. The 3- and 5-year actuarial survivals for patients with colorectal metastases were 83% and 55%, respectively.
CONCLUSIONS
Laparoscopic repeat hepatic resections can be performed safely and with good results, particularly in patients with earlier laparoscopic resections.
背景
腹腔镜方法尚未被广泛用于大规模的肝切除术重复进行。本报告分析了 3 家开创性地进行腹腔镜肝切除重复手术（LRLR）的机构的经验。本研究的目的是评估 LRLR 的可行性、安全性、肿瘤学完整性和结果。
研究设计
所有接受 LRLR 的患者均被识别。自 1997 年以来，已尝试了 76 例 LRLR。手术适应证为转移瘤（n = 63）、肝细胞癌（n = 3）和良性肿瘤（n = 10）。所有患者均有 1 次或更多次先前的肝切除术（28 例开腹手术，44 例腹腔镜手术），其中包括 16 例大切除术（整块切除 3 个或更多的 Couinaud 段）。
结果
由于技术困难或出血，有 8 例（11%）需要转为开腹手术（n = 7）或射频消融（n = 1）。LRLR 包括 49 例楔形或节段性切除术和 19 例大肝切除术。中位出血量和手术时间分别为 300 毫升和 180 分钟。有先前开腹肝切除术史的患者（B 组）术中出血量和输血需求均高于有先前腹腔镜切除术史的患者（A 组）（p = 0.02；p = 0.01）。58 例恶性肿瘤患者（91%）达到了 R0 切除。两组患者术后并发症发生率和住院时间无统计学差异。5 例（6.6%）患者发生胆漏，其中 1 例需要再次手术。无围手术期死亡。中位肿瘤大小为 25 毫米（范围 5 至 125 毫米），中位肿瘤数为 2 个（范围 1 至 7 个）。中位随访时间为 23.5 个月（范围 0 至 86 个月）。无切口转移。结直肠癌转移患者的 3 年和 5 年总生存率分别为 83%和 55%。
结论
腹腔镜肝切除重复手术是安全可行的，且效果良好，特别是在有先前腹腔镜切除术史的患者中。
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