射频辅助的ALPPS治疗肝硬化肝癌的临床研究

发布时间：2018-07-02 13:09

  本文选题：原发性肝癌 + 联合肝脏分隔和门静脉结扎的二步肝切除术　； 参考：《第三军医大学》2017年硕士论文

【摘要】：背景与目的:手术切除仍然是目前肝癌根治性治疗手段之一,但是对于BCLC分期较晚的B、C期的患者,目前主张的治疗方式为以TACE为主的姑息治疗。这类患者实施手术的最主要的限制因素为预留剩余肝体积(FLR)不足。近年来出现的联合肝脏分隔和门静脉结扎的二步肝切除术(ALPPS)可在较短时间内促进FLR显著增长,为既往无法手术的患者提供了手术机会。但是经典的ALPPS具有较高的手术并发症和死亡率,射频消融辅助的ALPPS(RALPPS)是针对经典ALPPS上述弊端进行改良的一种术式。我们将RALPPS应用在进展期的肝硬化肝癌患者上,分析其围手术期各项指标,评估该术式的临床效果,并探讨射频消融在促进肝硬化肝癌患者RALPPS一期术后肝组织再生中的作用。方法:对于预留剩余肝体积(FLR)不足(40%)的原发性肝癌患者实施RALPPS,在一期术中利用RFA在患侧和健侧肝叶间烧灼出一条无血凝固带,然后结扎右侧门静脉。术后每周行CT扫描了解FLR的增长情况,待FLR超过40%并且患者全身情况良好即实施二期手术切除肿瘤。对于FLR一期术后2-3周后仍未达到40%的患者,在超声引导下行补充性经皮RFA(即补救性RFA)。针对患者的围手术期手术并发症发生率、死亡率、FLR增长率、手术时间和术中出血、二期手术完成率、总体生存率(OS)、无瘤生存率(DFS)、实施补救性RFA前后FLR的变化及其他指标进行评估。结果:从2014年7月至2016年8月,共有21例肝癌患者实施RALPPS,其中15例合并有肝硬化。5例患者因各种原因未行手术切除,二期手术脱失率为23.8%。1例患者院内死亡,院内死亡率为4.8%(1/21);严重并发症(Clavien-Dindo≥Ⅲb)的发生率是23.8%(5/21)。FLR在25.2±14.8天的间隔期内由372.5±93.4ml(29.0±6.8%)增长至616.4±92.3ml(48.6±6.1%)。两期的手术出血量分别为190.5±115.8 ml和513.1±240.7ml,手术时间分别为224.5±58.3分钟和309.0±83.8分钟。经过中位期为16月(2-30月)的随访,总体生存率为45.7%,无肿瘤生存率是44.4%。共有4例患者在一期术后2-3周后FLR体积增长不足,实施补救性经皮RFA。在实施补救措施前FLR的增长率为0.3-7.5%,实施补救措施后FLR的增长率为9.7-12.1%。结论:和经典术式相比,RALPPS是一种较为安全、有效、简化的手术方式;经过严格筛选病例,对于肝功能良好的进展期肝硬化肝癌患者,其FLR也可以较好的增长,尽管有一定的二期手术未完成率。为提高二期手术完成率,可在RALPPS一期术后FLR增长不良时行“补救性”射频消融,但其确切效果仍需大样本的研究来证实。此外,探索并筛选肝硬化肝癌患者FLR增长不良的危险因素进而建立风险预测模型对于RALPPS术式的推广应用很有必要。
[Abstract]:Background & objective: surgical resection is still one of the methods of radical treatment for hepatocellular carcinoma, but for patients with BCLC stage, TACE is the main palliative treatment. The main limiting factor for surgery in this group of patients was insufficient reserved residual liver volume (FLR). In recent years, combined hepatic septum and portal vein ligation with two-step hepatectomy (ALPPS) can significantly increase FLR in a short period of time, and provide surgical opportunities for patients who have been unable to operate before. But the classical ALPPS has higher operative complications and mortality. Radiofrequency Ablation assisted ALPPS (RALPPS) is a modified procedure for the above disadvantages of classical ALPPS. We applied RALPPS to liver cancer patients with advanced liver cirrhosis, analyzed its perioperative indexes, evaluated the clinical effect of this procedure, and discussed the role of radiofrequency ablation in promoting liver tissue regeneration in patients with liver cirrhosis after primary operation of RALPPS. Methods: RALPPSs were performed in patients with primary liver cancer with insufficient residual liver volume (FLR) (40%). RFA was used to cauterize a blood free coagulation zone between the affected and healthy hepatic lobes during one stage operation, and then ligated the right portal vein. Ct scans were performed weekly after operation to find out the growth of FLR. The tumor was resected after secondary operation when the FLR was more than 40% and the patient was in good condition. In 40% of the patients with FLR who were still not up to 40% 2-3 weeks after primary operation, complementary percutaneous RFA (remedial RFA) was performed under ultrasound guidance. According to the incidence of perioperative complications, mortality rate of FLR, operative time and intraoperative bleeding, secondary operation completion rate, Overall survival rate (OS), tumor-free survival rate (DFS), changes in FLR and other indicators before and after the implementation of remedial RFA were evaluated. Results: from July 2014 to August 2016, a total of 21 patients with liver cancer were treated with RALPPS. Among them, 15 patients with liver cirrhosis were not resected for various reasons. The rate of second stage operation loss was 23.8.1 patients died in hospital. The incidence of severe complications (Clavien-Dindo 鈮，

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