Haddad F F, Chapman W C, Wright J K, Blair T K, Pinson C W
Division of Hepatobiliary Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.
J Surg Res. 1998 Mar;75(2):103-8. doi: 10.1006/jsre.1998.5280.
There have been reports that suggest cryosurgical techniques may be a useful adjunct to surgical resection or even a viable alternative treatment for hepatobiliary malignancies. Our objective was to evaluate the clinical results following cryoablation in conjunction with surgical resection for advanced hepatic tumors.
Thirty-two consecutive procedures in 31 patients with advanced liver tumors treated with cryosurgical ablation were evaluated. Cryosurgery was applied: (1) to achieve a > 1-cm tumor-free margin when standard surgical margins were close (2) with or without standard surgical resection to manage multiple tumors (3) with hepatic arterial portocath placement to increase tumor response. Cryoablation was applied to 47 of 105 lesions--independently in 4 patients and in combination with hepatic resection in 28 procedures.
Cryoablation was used in 11 procedures because of close surgical margins. In 21 operations cryosurgery was used for primary ablation. In 17 of these 21 patients both cryosurgery and resection were used for different lesions; in 4 cryosurgery alone was used. Transient changes in hepatic enzymes, PT, PTT, and platelets were at maximum on Postoperative Days 1-3. Surgical mortality and morbidity rates were 6 and 60%, respectively. Coagulation abnormalities were common: at least 30% reduction in platelets occurred in all patients and greater than a 50% reduction occurred in 19 of 32 (59%). Twenty patients had a PT > 15 s and 6 of these 20 also had a platelet count < 50,000. Associated complications included one wound hematoma, two GI hemorrhages, one intracranial hemorrhage, and one hepatic hemorrhage from the cryosurgical site. The actuarial patient survivals were 90, 59, 33, and 22% at 6, 12, 24, and 36 months, respectively.
This report helps define the risks and results of cryosurgical ablation as a complement to surgical resection for advanced hepatobiliary tumors. Management of lesions contiguous to major blood vessels may include either the Pringle maneuver or total vascular isolation. Since these procedures can have significant morbidity, we urge cautious application of cryosurgery for advanced hepatobiliary tumors in selected otherwise unresectable patients.
有报告表明，冷冻外科技术可能是手术切除的有用辅助手段，甚至是肝胆恶性肿瘤的一种可行替代治疗方法。我们的目的是评估冷冻消融联合手术切除治疗晚期肝肿瘤后的临床结果。
对31例接受冷冻消融治疗的晚期肝肿瘤患者连续进行的32例手术进行了评估。应用冷冻手术：（1）当标准手术切缘较窄时，实现>1 cm的无瘤切缘；（2）联合或不联合标准手术切除以处理多个肿瘤；（3）放置肝动脉导管以提高肿瘤反应。105个病灶中的47个接受了冷冻消融——4例单独进行，28例与肝切除联合进行。
11例手术因手术切缘较窄而使用冷冻消融。21例手术中冷冻手术用于初次消融。在这21例患者中，17例冷冻手术和切除用于不同病灶；4例仅使用冷冻手术。肝酶、PT、PTT和血小板的短暂变化在术后第1 - 3天达到最大值。手术死亡率和发病率分别为6%和60%。凝血异常很常见：所有患者血小板至少减少30%，32例中的19例（59%）减少超过50%。20例患者PT>15 s，其中6例血小板计数<50,000。相关并发症包括1例伤口血肿、2例胃肠道出血、1例颅内出血和1例冷冻手术部位的肝出血。患者6个月、12个月、24个月和36个月的精算生存率分别为90%、59%、33%和22%。
本报告有助于明确冷冻消融作为晚期肝胆肿瘤手术切除补充手段的风险和结果。处理与主要血管相邻的病灶可能包括Pringle手法或完全血管隔离。由于这些手术可能有显著的发病率，我们敦促在选定的其他无法切除的患者中谨慎应用冷冻手术治疗晚期肝胆肿瘤。
