Haddad F F, Wright J K, Blair T K, Chapman W C, Pinson C W
Department of Surgery, Vanderbilt University School of Medicine, Nashville, USA.
Tenn Med. 1998 Sep;91(9):357-60.
There are reports that suggest cryosurgical techniques may be a useful adjunct or even a viable alternative to surgical resection for hepatobiliary malignancies. Our objective was to evaluate the clinical results following cryoablation in conjunction with surgical resection for advanced hepatic tumors. Cryosurgical techniques were used in 25 consecutive patients with advanced liver tumors (1) to achieve a > 1-cm tumor-free margin when standard surgical margins were close, (2) to manage multiple tumor nodules with or without standard surgical resection, or (3) to increase chemotherapy response rates in conjunction with hepatic arterial portocath placement. In these 25 patients cryoablation was applied to 44 of 91 lesions--independently in four patients and in combination with hepatic resection in 21 patients. Cryoablation was used in seven patients because of close surgical margins. In 18 patients cryosurgery was used for complete lesion ablation. In 14 of the 18 patients cryosurgery and resection were used for different lesions; in four cryosurgery alone was used. Transient changes in hepatic enzymes, PT, PTT, and platelets were at maximum on postoperative days 1 to 3. Surgical mortality and morbidity rates were 4% and 68% respectively. Coagulation abnormalities were common; at least 30% reduction in platelets occurred in all patients and a > 50% reduction occurred in 15 of 25 (60%). Sixteen patients had a PT > 15 sec and five of these 16 also had platelet count < 50,000. Associated complications included one wound hematoma, one GI hemorrhage, one intracranial hemorrhage, and one hepatic hemorrhage from the cryosurgical site. 96%, 66%, 49%, 35%, and 20% of patients were surviving respectively at 6, 12, 18, 24, and 36 months. This report helps define the risks and results of cryosurgical ablation in conjunction with surgical resection for very advanced hepatobiliary tumors. Management of lesions contiguous to major blood vessels can include the Pringle maneuver or total hepatic vascular isolation. Cryoablation can be applied carefully as a complement to resection to achieve total tumor ablation in selected otherwise unresectable patients.
有报告表明，对于肝胆恶性肿瘤，冷冻外科技术可能是手术切除的有用辅助手段，甚至是可行的替代方法。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。25例晚期肝肿瘤患者接受了冷冻外科技术治疗，（1）当标准手术切缘较窄时，实现大于1厘米的无瘤切缘；（2）处理有或无标准手术切除的多个肿瘤结节；或（3）联合肝动脉植入导管药盒系统提高化疗反应率。在这25例患者中，91个病灶中的44个接受了冷冻消融，其中4例单独进行冷冻消融，21例与肝切除联合进行。7例患者因手术切缘较窄而采用冷冻消融。18例患者采用冷冻手术完全消融病灶。18例患者中有14例冷冻手术和切除术用于不同病灶，4例仅采用冷冻手术。肝酶、凝血酶原时间（PT）、部分凝血活酶时间（PTT）和血小板的短暂变化在术后第1至3天达到最大值。手术死亡率和发病率分别为4%和68%。凝血异常很常见，所有患者血小板至少减少30%，25例中有15例（60%）减少超过50%。16例患者PT>15秒，这16例中有5例血小板计数<50,000。相关并发症包括1例伤口血肿、1例胃肠道出血、1例颅内出血和1例冷冻手术部位肝出血。6个月、12个月、18个月、24个月和36个月时分别有96%、66%、49%、35%和20%的患者存活。本报告有助于明确冷冻消融联合手术切除治疗极晚期肝胆肿瘤的风险和结果。处理与主要血管相邻的病灶可包括Pringle手法或全肝血管隔离。冷冻消融可谨慎应用作为切除术的补充，以在选定的其他无法切除的患者中实现肿瘤完全消融。
