Lo C M, Lai E C, Liu C L, Fan S T, Wong J
Department of Surgery, The University of Hong Kong, Queen Mary Hospital, China.
Ann Surg. 1998 Apr;227(4):527-32. doi: 10.1097/00000658-199804000-00013.
This prospective study evaluates the value of laparoscopy and laparoscopic ultrasonography (USG) in avoiding exploratory laparotomy in patients with hepatocellular carcinoma (HCC).
Laparotomy and intraoperative USG is the gold standard to determine the resectability of HCC. No palliation can be offered to patients found to have unresectable disease, and the surgical exploration causes morbidity.
From June 1994 to June 1996, 110 of 370 patients (30%) with HCC were considered candidates for possible hepatic resection. Preoperative liver function was assessed using Child-Pugh grading and indocyanine green retention test. The extent of disease was evaluated with radiologic studies, including percutaneous USG, computerized tomography scan, and hepatic angiogram. Nineteen patients were excluded from the study because of previous upper abdominal surgery (n = 12), ruptured tumors (n = 4), refusal by patients (n = 2), and instrument failure (n = 1). Laparoscopy and laparoscopic USG was performed on 91 patients immediately before a planned laparotomy aiming at hepatic resection. Laparotomy was aborted when definite evidence of unresectable disease was found on laparoscopic examination.
The median time required for laparoscopy and laparoscopic USG was 30 minutes (range, 10 to 120 minutes). Fifteen patients had evidence of unresectable disease on laparoscopic examination. Among the remaining 76 patients who underwent laparotomy, 9 had exploration only and 67 underwent hepatic resection. Thus, exploratory laparotomy was avoided in 63% of patients with unresectable disease. The laparoscopic examination failed to confirm unresectable disease more often when the tumor was >10 cm in diameter. The procedure accurately assessed the adequacy of the liver remnant and the presence of intrahepatic metastases, but it was less sensitive in determining the presence of tumor thrombi in major vascular structures and the extent of invasion of adjacent organs. When unresectable disease was detected without the need for a laparotomy, the postoperative recovery was faster, and the nonoperative treatment for the tumor could be initiated earlier.
Laparoscopy with laparoscopic USG avoids unnecessary laparotomy in patients with HCC and should precede a planned laparotomy aiming at hepatic resection.
本前瞻性研究评估腹腔镜检查及腹腔镜超声检查（USG）在避免肝细胞癌（HCC）患者进行剖腹探查术中的价值。
剖腹术及术中USG是确定HCC可切除性的金标准。对于被发现患有不可切除疾病的患者无法提供姑息治疗，且手术探查会导致发病。
1994年6月至1996年6月，370例HCC患者中有110例（30%）被认为有可能进行肝切除。术前使用Child-Pugh分级和吲哚菁绿滞留试验评估肝功能。通过包括经皮USG、计算机断层扫描和肝血管造影在内的放射学检查评估疾病范围。19例患者因既往上腹部手术（n = 12）、肿瘤破裂（n = 4）、患者拒绝（n = 2）和器械故障（n = 1）而被排除在研究之外。对91例计划进行旨在肝切除的剖腹术的患者在即将进行剖腹术之前立即进行腹腔镜检查及腹腔镜USG。当在腹腔镜检查中发现不可切除疾病的确切证据时，取消剖腹术。
腹腔镜检查及腹腔镜USG所需的中位时间为30分钟（范围10至120分钟）。15例患者在腹腔镜检查中有不可切除疾病的证据。在其余76例接受剖腹术的患者中，9例仅进行了探查，67例进行了肝切除。因此，63%患有不可切除疾病的患者避免了剖腹探查术。当肿瘤直径>10 cm时，腹腔镜检查更常无法确认不可切除疾病。该手术准确评估了肝残余量的充足性及肝内转移的存在，但在确定主要血管结构中肿瘤血栓的存在及相邻器官的侵犯范围方面敏感性较低。当无需进行剖腹术而检测到不可切除疾病时，术后恢复更快，并且可以更早开始对肿瘤进行非手术治疗。
腹腔镜检查及腹腔镜USG可避免HCC患者进行不必要的剖腹术，并且应在计划进行旨在肝切除的剖腹术之前进行。
