Fortner J G, Papachristou D N
Int Adv Surg Oncol. 1979;2:251-75.
Hepatic neoplasms, primary and metastatic, are best treated with surgery. The present report summarizes the results of various surgical procedures used during the last eight years in the management of 310 patients with liver neoplasms. Exploratory laparotomy was the ultimate diagnostic test, determining resectability of the lesion. Percutaneous liver biopsy was discouraged and was used only in the presence of obvious distant metastasis. Primary and metastatic neoplasms confined to the liver were managed with lobectomy, hepatic trisegmentectomy, or left lateral segmentectomy whether they were solitary or multifocal; the choice of procedure depended on their location. Tumors invading major vascular structures were resected using a new method of hepatic isolation/hypothermic perfusion. Neoplasms involving the entire liver were managed with intrahepatic infusion chemotherapy administered directly into the hepatic circulation through percutaneous catheters. Selected individuals with unresectable lesions were treated with vascular isolation and perfusion of the liver with chemotherapeutic agents. Budd-Chiari syndrome caused by malignant obstruction of hepatic outflow was managed either with isolation/hypothermic perfusion and resection or with hepatic artery ligation and infusion of chemotherapeutic agents. Total hepatectomy with orthotopic liver transplantation was reserved for a few highly selected individuals. The results obtained with these procedures were encouraging. Major hepatic resection was performed with a 9% operative mortality and resulted in an 81% 3-year actuarial survival if the disease was limited to the liver. Palliative major resection in a 31% 3-year actuarial survival. Intrahepatic infusion of chemotherapeutic agents was effective when the dosage was adequate and proved superior to peripheral intravenous treatment. Isolation perfusion of the liver permitted resection of lesions which could not have been managed by conventional procedures. The effectiveness of isolation chemotherapy perfusion of the liver was tempered by leakage of Actinomycin-D into the systemic circulation. The results is this series of patients encourage the judicious use of these procedures in the management of the patient with liver cancer. A pessimistic attitude often based on preoperative evaluation alone without the benefit of exploratory laparotomy ought to be discouraged.
原发性和转移性肝脏肿瘤最好通过手术治疗。本报告总结了过去八年中用于治疗310例肝脏肿瘤患者的各种手术方法的结果。剖腹探查术是最终的诊断性检查，用于确定病变的可切除性。不提倡经皮肝活检，仅在存在明显远处转移时使用。局限于肝脏的原发性和转移性肿瘤，无论为单发还是多发，均采用肝叶切除术、肝三段切除术或左外叶切除术进行治疗；手术方式的选择取决于肿瘤的位置。侵犯主要血管结构的肿瘤采用一种新的肝隔离/低温灌注方法进行切除。累及整个肝脏的肿瘤通过经皮导管直接注入肝循环的肝内灌注化疗进行治疗。部分无法切除病变的患者接受了肝脏血管隔离和化疗药物灌注治疗。由肝流出道恶性梗阻引起的布加综合征，采用隔离/低温灌注及切除术或肝动脉结扎并灌注化疗药物进行治疗。少数经过严格挑选的患者接受了原位肝移植的全肝切除术。这些手术取得的结果令人鼓舞。如果疾病局限于肝脏，进行大肝切除的手术死亡率为9%，三年实际生存率为81%。姑息性大切除的三年实际生存率为31%。当化疗药物剂量充足时，肝内灌注化疗有效，且证明优于外周静脉治疗。肝脏隔离灌注使一些原本无法通过传统手术治疗的病变得以切除。放线菌素-D漏入体循环降低了肝脏隔离化疗灌注的效果。本系列患者的结果鼓励在肝癌患者的治疗中明智地使用这些手术方法。仅基于术前评估而未进行剖腹探查的悲观态度应予以摒弃。
