腹腔镜肝脏手术作为肝硬化患者肝癌标准治疗方法的演变?
Evolution of laparoscopic liver surgery as standard procedure for HCC in cirrhosis?
作者信息
Seehofer Daniel, Sucher Robert, Schmelzle Moritz, Öllinger Robert, Lederer Andri, Denecke Timm, Schott Eckart, Pratschke Johann
机构信息
Klinik für Allgemein-, Visceral- und Transplantationschirurgie, Charité-Universitätsmedizin Berlin, Campus Virchow Klinikum, Berlin.
Klinik für Radiologie, Charité-Universitätsmedizin Berlin, Campus Virchow Klinikum, Berlin.
出版信息
Z Gastroenterol. 2017 May;55(5):453-460. doi: 10.1055/s-0043-100021. Epub 2017 Feb 27.
Patients with hepatocellular carcinoma (HCC) in cirrhosis have an increased risk for postoperative complications including liver failure. However, there is some evidence that the use of laparoscopy markedly decreases this risk. Between 2010 - 2015, a total of 21 laparoscopic liver resections were performed for HCC in Child-A cirrhosis at our center. Mean MELD score was 9 (6 - 12), and the mean LiMAx was 261 µg/h/kg (101 - 489). All resections were performed by conventional laparoscopy using 4 - 6 trocars. Liver parenchyma was transected using ultrasonic shears. Hilar occlusion was used on demand. In the earlier years, laparoscopic resections were performed occasionally and mainly if tumors were easily accessible. With increasing experience, currently most HCC in cirrhosis are resected laparoscopically. Likewise, 12 out of the 21 resections were performed within the last 12 months, including 2 anatomic left hemihepatectomies. Conversion rate, postoperative mortality, and operative revision rate were all 0 %. Four patients (19 %) developed mild complications Clavien-Dindo grade 1 or 2 (ascites, transfusion, pneumonia, renal impairment). One patient (4.8 %) developed a grade 3 event (bile leak, percutaneous drainage). All but 1 early patient underwent R0 resection (95 %). The mean duration of hospital stay was 10.5 days (5 - 21), and the mean duration of ICU stay was 1.8 days (1 - 7). No case of decompensation of liver cirrhosis was observed. In 1 case, a prolonged production of ascites evolved. Even in patients with severely impaired liver function, no severe complications and especially no decompensation of cirrhosis was observed. Therefore, in accordance with other single center experiences, liver resection for HCC in cirrhosis should be performed preferentially by laparoscopy.
肝硬化合并肝细胞癌(HCC)患者术后发生包括肝衰竭在内的并发症风险增加。然而,有证据表明,腹腔镜手术的应用可显著降低这一风险。2010年至2015年期间,我们中心共对Child-A级肝硬化合并HCC患者实施了21例腹腔镜肝切除术。平均终末期肝病模型(MELD)评分为9分(6 - 12分),平均吲哚菁绿15分钟滞留率(LiMAx)为261μg/h/kg(101 - 489μg/h/kg)。所有手术均采用传统腹腔镜技术,使用4 - 6个套管针。肝实质采用超声刀离断。按需进行肝门阻断。在早期,腹腔镜手术偶尔进行,主要针对易于切除的肿瘤。随着经验的增加,目前大多数肝硬化合并HCC患者采用腹腔镜手术切除。同样,2例解剖性左半肝切除术在内的21例手术中有12例是在过去12个月内完成的。中转率、术后死亡率和手术修正率均为0%。4例患者(19%)发生轻度Clavien-Dindo 1级或2级并发症(腹水、输血、肺炎、肾功能损害)。1例患者(4.8%)发生3级事件(胆漏,经皮引流)。除1例早期患者外,所有患者均实现R0切除(95%)。平均住院时间为10.5天(5 - 21天),平均重症监护病房(ICU)停留时间为1.8天(1 - 7天)。未观察到肝硬化失代偿病例。1例患者出现腹水持续时间延长。即使在肝功能严重受损的患者中,也未观察到严重并发症,尤其是未发生肝硬化失代偿。因此,与其他单中心经验一致,肝硬化合并HCC患者的肝切除应优先采用腹腔镜手术。