肝癌联合脾切除与肝癌切除在肝癌合并门静脉高压病例中的对比研究

发布时间：2018-03-19 21:01

本文选题：肝细胞性肝癌　切入点：门静脉高压　出处：《山东大学》2017年硕士论文　论文类型：学位论文

【摘要】：背景原发性肝癌(肝癌)是我国常见癌症,而慢性乙型病毒性肝炎、肝硬化仍然是肝癌的的重要发病因素。众所周知,在乙肝、肝硬化、肝癌患者中,肝癌病人常有急性肝炎→慢性肝炎→肝硬化-→肝癌病史,而在肝炎、肝硬化的发展过程当中,由于肝窦结构改建及假小叶形成,往往导致门静脉压力不同程度升高,进而导致不同程度的脾肿大及脾功能亢进。传统上一般认为,肝癌合并肝硬化、脾功能亢进患者,手术风险较高,多主张采用非手术治疗,但效果很差;少数只作肝癌切除治疗的患者,术中门静脉压力较高、脾脏肿大等,限制了手术视野,高门静脉压力增加了出血风险及门静脉阻断时间,术后持续存在并逐渐加重的脾功能亢进,严重影响了患者的预后。通过回顾性研究可知,肝硬化门静脉高压时,切除功能亢进的脾脏可以促进肝脏再生,减缓肝硬化的进展,进而可能降低肝癌的发生风险;有动物实验证明,门静脉高压、脾功能亢进可促进诱导动物肝癌发生及肝脏纤维化。门静脉高压、脾功能亢进对于肝癌切除术后近期恢复是显而易见的,对远期预后的影响缺乏明确研究。脾切除对肝癌切除患者并发症和预后的影响,可有以下几方面的原因:①脾功能亢进对于血小板、白细胞的破坏作用,导致患者血小板、白细胞降低,从而对手术产生相关影响;②正常脾脏作为免疫器官,对于肿瘤存在正性免疫作用,门脉高压情况下脾脏可能逆转为负性免疫作用?③门静脉高压对于术中出血及肝门阻断的影响;④门静脉高压对于肝肿瘤转移是否起到了推动作用?鉴于以上几点考虑,对于乙肝肝硬化后肝细胞性肝癌(以下简称肝癌)合并门静脉高压患者,肝癌联合脾切除是否有积极意义仍需进一步探索研究。目的对比研究肝癌合并门静脉高压、脾功能亢进患者,肝癌联合脾切除效果是否优于单纯肝癌切除术。方法总结2006-2016山东大学齐鲁医院手术治疗肝癌合并门静脉高压患者123例,其中63例肝癌联合脾脏切除、60例行单纯肝肿瘤切除术,分为两组(A组联合脾切除,B组单纯肝肿瘤切除),比较两组术中出血量、门静脉阻断情况、术后引流管引流量、血小板、白细胞、胆红素、间接胆红素、术后出院时间、术后并发症、无瘤生存期、生存期等相关指标。结果肝癌联合脾切除手术创伤大,手术时间(217.76±65.05min)较肝癌切除术组手术时间(174.75±75.4min)长,但两组患者术中出血量、输血情况无统计学差异,而肝门阻断次数及时间较单纯肝癌切除组要少(p=0.02)。肝癌联合脾切除组及肝癌切除组患者住院时间、术后并发症情况无统计学差异,术后7天白细胞、血小板计数明显高于单纯肝癌切除组;而术后2天、7天胆红素及间接胆红素明显低于肝癌切除组(p0.01)。肝癌联合脾切除组的平均无瘤生存期(45.07 ±3.66个月)显著长于单纯肝癌切除组(31.41 ±3.49个月)(p0.01);平均生存期(67.36 ±4.05个月)显著长于单纯肝癌切除组(49.83 ±3.95个月)(p0.01)。结论尽管肝癌联合脾切除术手术创伤大、手术时间长,但并没有显著延长住院时间及增加围手术期并发症发生率。肝癌联合脾切除术有利于降低门静脉压力,纠正脾功能亢进,有利于降低术中及术后出血风险,促进肝功能恢复,有利于肝细胞代谢及机体营养代谢,有助于降低胆红素负荷,有助于血小板及白细胞的数目恢复正常。肝癌联合脾切除术对肿瘤复发有一定抑制作用,并能一定程度上延长患者的无瘤生存期及生存期。
[Abstract]:Background hepatocellular carcinoma (HCC) is the most common cancer and chronic hepatitis B, cirrhosis is still the important factors in the pathogenesis of HCC. As everyone knows, in hepatitis B, liver cirrhosis, liver cancer patients, cancer patients often have acute hepatitis, chronic hepatitis, liver cirrhosis, liver cancer - history, and in the development process of hepatitis. Liver cirrhosis, liver sinus formed due to structural remodeling and pseudolobuli, often leads to portal vein pressure increased, resulting in splenomegaly and hypersplenism in different degrees. It is traditionally thought that, liver cancer complicated with liver cirrhosis, hypersplenism, the higher the risk of surgery, advocate the use of non surgical treatment, but the effect is poor only few; liver cancer treated with high pressure of portal vein, spleen enlargement, limiting the surgical field, high venous pressure increases the risk of bleeding and portal vein occlusion time, surgery After the continued existence of hypersplenia and gradually aggravated, serious impact on the prognosis of the patients. By retrospective study, liver cirrhosis and portal hypertension, splenectomy can promote liver regeneration, slowing the progression of liver cirrhosis, and may reduce the incidence of liver cancer risk; animal experiment proved that portal hypertension, spleen hyperthyroidism can promote the induction of animal liver cancer and liver fibrosis. Portal hypertension, hypersplenism is obviously to recent recovery after resection of hepatocellular carcinoma, clear influence on long-term prognosis. The lack of effect of splenectomy on the complications and prognosis of patients with liver cancer, may have the following reasons: 1 for hypersplenism platelet damage of white blood cells, resulting in decreased white blood cells, platelets, and then produce influence on the normal operation; as for the spleen immune organ. There is a positive role in tumor immunity, portal hypertension cases of spleen may reverse the negative immune effect? The portal hypertension for bleeding effect and hepatic portal occlusion during operation; the portal hypertension for liver metastasis is to play a role in promoting? In view of the above considerations, for hepatocellular carcinoma in patients with hepatitis B cirrhosis after (HCC) patients with portal vein hypertension, liver cancer resection combined with splenectomy is of positive significance still need further study. Objective to study the liver cancer with portal hypertension and hypersplenism in patients with liver cancer resection combined with splenectomy, the effect is better than that of liver resection. Methods 123 cases of the 2006-2016 surgical treatment of hepatocellular carcinoma with portal of Qilu Hospital of Shandong University in patients with portal hypertension, including 63 cases of hepatocellular carcinoma combined with splenectomy, 60 cases underwent liver resection, were divided into two groups (group A, splenectomy, B group liver swelling Tumor resection, bleeding) were compared between the two groups, portal vein occlusion, drainage tube drainage, postoperative platelet, leukocyte, bilirubin, indirect bilirubin, postoperative discharge time, postoperative complications, disease-free survival, survival and other related indicators. The results of liver cancer resection combined with splenectomy in surgical trauma surgery. Time (217.76 + 65.05min) with liver resection group operation time (174.75 + 75.4min), but the two groups of patients with intraoperative bleeding, no significant difference in blood transfusion, and hepatic portal occlusion times and time compared with hepatectomy group less (p=0.02). Liver cancer resection combined with splenectomy group and liver resection group in hospitalized patients time, there was no significant difference in postoperative complications, after 7 days of white blood cell, platelet count was significantly higher than that in hepatectomy group; and after 2 days, 7 days of bilirubin and indirect bilirubin was significantly lower than that of the liver resection group (P0.01). The average liver cancer resection combined with splenectomy group The disease-free survival (45.07 + 3.66 months) was significantly longer in hepatectomy group (31.41 + 3.49 months) (P0.01); the average survival period (67.36 + 4.05 months) was significantly longer in hepatectomy group (49.83 + 3.95 months) (P0.01). Conclusion although the surgical trauma and splenectomy for hepatocellular carcinoma, the operation time is long, but did not significantly prolong hospitalization time and increase the incidence of perioperative complications. Liver cancer with splenectomy can reduce portal vein pressure, correct hypersplenism, to reduce the risk of bleeding during and after surgery, promote liver function recovery, is conducive to liver cell metabolism and nutritional metabolism, have help to reduce bilirubin load, contribute to the number of platelets and leukocytes returned to normal. Liver cancer combined with splenectomy has a certain inhibitory effect on tumor recurrence, and to some extent prolong disease-free survival and survival.

【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R735.7

【相似文献】