Qian Xinye, Hu Wang, Gao Lu, Xu Jingyi, Wang Bo, Song Jiyong, Yang Shizhong, Lu Qian, Zhang Lin, Yan Jun, Dong Jiahong
Center of Hepatobiliary Pancreatic Disease, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China.
School of Clinical Medicine, Tsinghua University, Beijing, China.
Front Oncol. 2022 Jul 22;12:966626. doi: 10.3389/fonc.2022.966626. eCollection 2022.
Anatomical liver resection is the optimal treatment for patients with resectable hepatocellular carcinoma (HCC). Laparoscopic Couinaud liver segment resection could be performed easily as liver segments could be stained by ultrasound-guided indocyanine green (ICG) injection into the corresponding segment portal vein. Several smaller liver anatomical units (liver watersheds) have been identified (such as S8v, S8d, S4a, and S4b). However, since portal veins of liver watersheds are too thin to be identified under ultrasound, the boundaries of these liver watersheds could not be stained intraoperatively, making laparoscopic resection of these liver watersheds demanding. Digital subtraction angiography (DSA) could identify arteries of liver watersheds with a diameter of less than 2 mm. Yet, its usage for liver watershed staining has not been explored so far.
The aim of this study is to explore the possibility of positive liver watershed staining trans-arterial ICG injection under DSA examination for navigating laparoscopic watershed-oriented hepatic resection.
We describe, in a step-by-step approach, the application of trans-arterial ICG injection to stain aimed liver watershed during laparoscopic anatomical hepatectomy. The efficiency and safety of the technique are illustrated and discussed in comparison with the laparoscopic anatomical liver resection ultrasound-guided liver segment staining.
Eight of 10 HCC patients received successful trans-arterial liver watershed staining. The success rate of the trans-artery staining approach was 80%, higher than that of the ultrasound-guided portal vein staining approach (60%). Longer surgical duration was found in patients who underwent the trans-artery staining approach (305.3 ± 23.2 min vs. 268.4 ± 34.7 min in patients who underwent the ultrasound-guided portal vein staining approach, = 0.004). No significant difference was found in major morbidity, reoperation rate, hospital stay duration, and 30-day and 90-day mortality between the 2 groups.
Trans-arterial ICG staining is safe and feasible for staining the aimed liver watershed, navigating watershed-oriented hepatic resection under fluorescence laparoscopy for surgeons.
解剖性肝切除是可切除肝细胞癌（HCC）患者的最佳治疗方法。腹腔镜下库氏肝段切除术可以轻松实施，因为通过超声引导将吲哚菁绿（ICG）注入相应肝段门静脉能够对肝段进行染色。已识别出几个较小的肝解剖单位（肝分水岭）（如S8v、S8d、S4a和S4b）。然而，由于肝分水岭的门静脉过细，在超声下无法识别，这些肝分水岭的边界在术中无法染色，使得腹腔镜下切除这些肝分水岭颇具挑战性。数字减影血管造影（DSA）能够识别直径小于2mm的肝分水岭动脉。然而，其在肝分水岭染色方面的应用迄今尚未得到探索。
本研究旨在探讨在DSA检查下经动脉注射ICG进行肝分水岭阳性染色，以指导腹腔镜下以分水岭为导向的肝切除术的可能性。
我们逐步描述了在腹腔镜解剖性肝切除术中经动脉注射ICG对目标肝分水岭进行染色的应用。与腹腔镜解剖性肝切除超声引导肝段染色相比，阐述并讨论了该技术的有效性和安全性。
10例HCC患者中有8例成功进行了经动脉肝分水岭染色。经动脉染色方法的成功率为80%，高于超声引导门静脉染色方法（60%）。接受经动脉染色方法的患者手术时间更长（305.3±23.2分钟，而接受超声引导门静脉染色方法的患者为268.4±34.7分钟，P = 0.004）。两组在主要并发症、再次手术率、住院时间以及30天和90天死亡率方面未发现显著差异。
经动脉ICG染色对目标肝分水岭进行染色是安全可行的，可为外科医生在荧光腹腔镜下进行以分水岭为导向的肝切除术提供指导。
