Spolverato Gaya, Pawlik Timothy M
From the Department of Surgery, Division of Surgical Oncology, The Johns Hopkins University School of Medicine, Baltimore, MD.
Am Soc Clin Oncol Educ Book. 2014:101-10. doi: 10.14694/EdBook_AM.2014.34.101.
When feasible, surgical resection is typically the preferred therapeutic option in patients with both primary and secondary hepatic malignancies. Improved patient selection, preoperative management, and advances in perioperative care have had a considerable effect on short-term and long-term outcomes following hepatic resection. Parenchymal transection of the liver can be performed using many different techniques such as digitoclasia, clamp crushing, vessel sealing system, harmonic scalpel, water-jet, Cavitron Ultrasonic Surgical Aspirator, or radiofrequency dissecting sealer. At the time of surgery, one of the main factors that influences postoperative morbidity and mortality is blood loss. Different techniques are used to decrease blood loss, such as the Pringle maneuver, selective ligation of the right, left, or smaller branches of the portal system; extrahepatic dissection; isolation; and transection of the hepatic artery and portal vein and the total vascular exclusion. Liver resection is on occasion accompanied by a concomitant procedure. Given that colorectal liver metastasis is a common indication for liver resection, colon resection is one of the more common concurrent procedures, but also surgical management of other disease in the lung or pancreas may sometimes be indicated. A subset of patients with primary or secondary liver malignancies may also require the addition of an ablative therapy to treat the extent of disease in the liver. Moreover, occasionally, hepatic resection takes place following intra-arterial therapy administration to the liver. Although many of these patients may benefit from surgical therapy, a multidisciplinary team approach remains critical.
在可行的情况下，手术切除通常是原发性和继发性肝恶性肿瘤患者的首选治疗方案。患者选择的改善、术前管理以及围手术期护理的进展对肝切除术后的短期和长期结果产生了相当大的影响。肝脏实质离断可采用多种不同技术进行，如指捏法、钳夹破碎法、血管封闭系统、超声刀、水刀、超声外科吸引器或射频解剖密封器。手术时，影响术后发病率和死亡率的主要因素之一是失血。可采用不同技术减少失血，如Pringle手法、选择性结扎门静脉系统的右支、左支或较小分支；肝外解剖；隔离；肝动脉和门静脉离断以及全血管阻断。肝切除有时会伴有同期手术。鉴于结直肠癌肝转移是肝切除的常见适应证，结肠切除是较常见的同期手术之一，但有时也可能需要对肺部或胰腺的其他疾病进行手术治疗。一部分原发性或继发性肝恶性肿瘤患者可能还需要联合消融治疗以处理肝脏内的病变范围。此外，偶尔会在对肝脏进行动脉内治疗后进行肝切除。虽然这些患者中的许多人可能从手术治疗中获益，但多学科团队方法仍然至关重要。
