肝膽手術(shù)大膽創(chuàng)新二步肝切除術(shù)

1、相關(guān)疾?。?腫瘤 肝硬化本文是剛發(fā)表在中華消化外科雜志的一篇文章，介紹了一種很新的肝臟手術(shù)方式，復(fù)旦中山周檢團(tuán)隊(duì)報(bào)道了亞洲第一例。附件為文章全文及劉院士的述評。希望對手術(shù)感興趣的戰(zhàn)友一閱！因有戰(zhàn)友指出，華西也報(bào)道了一例。故更改了標(biāo)題。對“聯(lián)合肝臟離斷和門靜脈結(jié)扎的二步肝切除術(shù)”的述評劉允怡 劉曉欣 【摘要】 聯(lián)合肝臟離斷和門靜脈結(jié)扎的二步肝切除術(shù)(ALPPS)是 一 個 非 常 新 的 外 科 手 術(shù) 。 該 手 術(shù) 主 要 針 對 因 未來剩余肝臟體積較小而不能接受大范圍肝切除術(shù)的 T分期較晚的肝癌患者而設(shè)計(jì)的。ALPPS第 1步手術(shù)后,患者剩余肝臟對手術(shù)的反應(yīng)非常強(qiáng)烈,使得肝臟體積急劇增生

2、。因而可在第 1步手術(shù)后 1周左右施行第 2步手術(shù)以切除所有肝內(nèi)腫瘤(R0 切除)。本文追溯 ALPPS的發(fā)展歷史,描述該手術(shù)的傳統(tǒng)步驟和手術(shù)的偏離等情況,分析該手術(shù)的短期療效。盡管 ALPPS后零死亡已有報(bào)道,但初步的研究結(jié)果表明:ALPPS的手術(shù)死亡率和并發(fā)癥發(fā)生率仍然較高。ALPPS后尚沒有明確的長遠(yuǎn)治療腫瘤效果的報(bào)道。該手術(shù)在肝硬化肝癌患者中能否安全施行尚有疑問。但是還是認(rèn)為選擇門脈介入栓塞這一微創(chuàng)的方法更好，且風(fēng)險(xiǎn)更小。支持，外科的進(jìn)步有些就是來源于一些意外發(fā)現(xiàn)及治療過程中無法解釋的現(xiàn)象。減肥手術(shù)被發(fā)現(xiàn)能夠治療糖尿病也是這種情況。這種方法為無法切除的肝臟腫瘤提供了一個治療的途徑，值得

3、學(xué)習(xí)。期待著能有中長期患者生存率的報(bào)道。相關(guān)疾病： 肝癌 腫瘤相關(guān)疾?。焊伟┠[瘤修改來源：中國新聞網(wǎng)7月18日，四川省人民醫(yī)院器官移植中心成功實(shí)施了一種全新的肝癌切除手術(shù)，目前患者病情穩(wěn)定。這標(biāo)志著我國晚期肝腫瘤的根治性手術(shù)取得新的進(jìn)展。據(jù)了解，這種手術(shù)于2012年在德國首創(chuàng)，正式名稱為聯(lián)合肝臟分割和門靜脈結(jié)扎的分階段肝切除術(shù)，簡稱ALPPS，是晚期肝腫瘤的根治性手術(shù)。據(jù)院方介紹，49歲的男性患者劉應(yīng)奎是全國第一個接受此術(shù)式的患者，他近日因右上腹脹痛，進(jìn)行CT檢查后發(fā)現(xiàn)肝臟有巨大腫瘤，腫瘤原發(fā)于右肝，并在左肝發(fā)現(xiàn)了轉(zhuǎn)移跡象。經(jīng)過四川省人民醫(yī)院醫(yī)生的全面評估后，7月5日該患者實(shí)施了一期手術(shù)?！霸?/p>

4、第一階段手術(shù)中，外科醫(yī)生先將患者肝臟的左右葉徹底劈開”，四川省人民醫(yī)院器官移植中心主任楊洪吉表示，肝臟劈開后通過結(jié)扎右側(cè)門靜脈，切斷右側(cè)的血液供應(yīng)，然后再切除左側(cè)肝臟腫瘤部分，保留正常肝組織。患者的右側(cè)肝臟因?yàn)闆]有血液供給而萎縮，同時，左側(cè)肝臟由于過量的血液供給而成倍增大。等到左側(cè)肝臟增長到一定程度后，外科醫(yī)生對病人進(jìn)行第二階段手術(shù)，切除右肝腫瘤。“這樣所有的肝臟腫瘤全部就切除了”，楊洪吉說，不能一次性切除肝臟面積在65%以上，而是通過肝臟分離切除，保障患者的功能和生命安全。同時，為了保證腫瘤不蔓延到肝臟其他部位，手術(shù)的兩階段需要十天左右。一期手術(shù)后一周復(fù)查，患者的左肝已經(jīng)代償性增生了50%，

5、并保持完好的肝功能，因此7月18日成功實(shí)施了二期手術(shù)。據(jù)楊洪吉介紹，這次新型手術(shù)的原理就在于肝臟有很強(qiáng)的再生功能。過去醫(yī)學(xué)界一直認(rèn)為一小瓣肝臟在體內(nèi)長大50%需要半年或者更長的時間。現(xiàn)在研究表明，一小瓣肝臟在7至10天就可以長大50%。由于，患者必須短期內(nèi)接受兩次手術(shù)，這家要求患者的身體狀態(tài)足夠好才能承受這種手術(shù)。術(shù)前需要對患者進(jìn)行一次全面的醫(yī)療評估，包括心臟功能和病史，肺功能以及麻醉師的評估。associating liver partition and portal vein ligation for staged hepatectomy (ALPPS)英意譯中:肝臟分隔加門靜脈結(jié)扎后二步

6、肝切除術(shù)下面的這篇或是國際上該領(lǐng)域的第一篇處女作,爾后人們稱之ALPPSAnn Surg.2012 Mar;255(3):405-14. doi: 10.1097/SLA.0b013e31824856f5.Right portal vein ligation combined with in situ splitting induces rapid left lateral liver lobe hypertrophy enabling 2-staged extended right hepatic resection in small-for-size settings.Schnitzbau

7、er AA,Lang SA,Goessmann H,Nadalin S,Baumgart J,Farkas SA,Fichtner-Feigl S,Lorf T,Goralcyk A,H?rbelt R,Kroemer A,Loss M,Rmmele P,Scherer MN,Padberg W,K?nigsrainer A,Lang H,Obed A,Schlitt HJ.SourceDepartment of Surgery, University Hospital Regensburg, Regensburg, Germany.AbstractOBJECTIVE:To evaluate

8、a new 2-step technique for obtaining adequate but short-term parenchymal hypertrophy in oncologic patients requiring extended right hepatic resection with limited functional reserve.BACKGROUND:Patients presenting with primary or metastatic liver tumors often face the dilemma that the remaining liver

9、 tissue may not be sufficient. Preoperative portal vein embolization has thus far been established as the standard procedure for achieving resectability.METHODS:Two-staged hepatectomy was performed in patients who preoperatively appeared to be marginally resectable but had a tumor-free left lateral

10、lobe. Marginal respectability was defined as a left lateral lobe to body weight ratio of less than 0.5. In the first step, surgical exploration, right portal vein ligation (PVL), and in situ splitting (ISS) of the liver parenchyma along the falciform ligament were performed. Computed tomographic vol

11、umetry was performed before ISS and before completion surgery.RESULTS:The study included 25 patients with primary liver tumors (hepatocellular carcinoma: n = 3, intrahepatic cholangiocarcinoma: n = 2, extrahepatic cholangiocarcinoma: n = 2, malignant epithelioid hemangioendothelioma: n = 1, gallblad

12、der cancer: n = 1 or metastatic disease [colorectal liver metastasis: n = 14, ovarian cancer: n = 1, gastric cancer: n = 1). Preoperative CT volumetry of the left lateral lobe showed 310 mL in median (range = 197-444 mL). After a median waiting period of 9 days (range = 5-28 days), the volume of

13、 the left lateral lobe had increased to 536 mL (range = 273-881 mL), representing a median volume increase of 74% (range = 21%-192%) (P 0.001). The median left lateral liver lobe to body weight ratio was increased from 0.38% (range = 0.25%-0.49%) to 0.61% (range = 0.35-0.95). Ten of 25 patients (40%

14、) required biliary reconstruction with hepaticojejunostomy. Rapid perioperative recovery was reflected by normalization of International normalized ratio (INR) (80% of patients), creatinine (84% of patients), nearly normal bilirubin (56% of patients), and albumin (64% of patients) values by day 14 a

15、fter completion surgery. Perioperative morbidity was classified according to the Dindo-Clavien classification of surgical complications: grade I (12 events), grade II (13 events), grade III (14 events, III a: 6 events, III b: 8 events), grade IV (8 events, IV a: 3 events, IV b: 5 events), and grade

16、V (3 events). Sixteen patients (68%) experienced perioperative complications. Follow-up was 180 days in median (range: 60-776 days) with an estimated overall survival of 86% at 6 months after resection.CONCLUSIONS:Two-step hepatic resection performing surgical exploration, PVL, and ISS results in a

17、marked and rapid hypertrophy of functional liver tissue and enables curative resection of marginally resectable liver tumors or metastases in patients that might otherwise be regarded as palliative.Ann Surg.2012 Sep;256(3):e5; author reply e16-9. doi: 10.1097/SLA.0b013e318265fbbe.Long-term results w

18、ith associating liver partition and portal vein ligation for staged hepatectomy (ALPPS).Andriani OC.Comment on Playing Play-Doh to prevent postoperative liver failure: the ALPPS approach.[Ann Surg. 2012Playing Play-Doh to prevent postoperative liver failure: the ALPPS approach.de Santiba?es E, C

19、lavien PA. Ann Surg. 2012 Mar; 255(3):415-7. Right portal vein ligation combined with in situ splitting induces rapid left lateral liver lobe hypertrophy enabling 2-staged extended right hepatic resection in small-for-size settings.Ann Surg. 2012Right portal vein ligation combined with in situ split

20、ting induces rapid left lateral liver lobe hypertrophy enabling 2-staged extended right hepatic resection in small-for-size settings.Schnitzbauer AA, Lang SA, Goessmann H, Nadalin S, Baumgart J, Farkas SA, Fichtner-Feigl S, Lorf T, Goralcyk A, H?rbelt R, et al. Ann Surg. 2012 Mar; 255(3):405-14.” 現(xiàn)在

21、研究表明，一小瓣肝臟在7至10天就可以長大50%“。我想知道誰做的什么研究表明 “一小瓣肝臟在7至10天就可以長大50%” ？Preoperative CT volumetry of the left lateral lobe showed 310 mL in median (range = 197-444 mL). After a median waiting period of 9 days (range = 5-28 days), the volume of the left lateral lobe had increased to 536 mL (range = 273-881 mL

22、),representing a median volume increase of 74%(range = 21%-192%) (P 0.001).The median left lateral liver lobe to body weight ratio was increased from 0.38% (range = 0.25%-0.49%) to 0.61% (range = 0.35-0.95). Ten of 25 patients (40%) required biliary reconstruction with hepaticojejunostomy.1, 且不管其用何種

23、方式測量的，也不管準(zhǔn)確性如何，確實(shí)是增大了。2，從病理的角度講這種增大的基礎(chǔ)是什么？細(xì)胞數(shù)量增多了？還是每個細(xì)胞增大了？還是由于肝右門脈結(jié)扎后肝左葉血流量增多充血引起？最好有病理解釋。3，另外，肝臟增大的同時有沒有肝功檢查支持其功能改善？和門靜脈栓塞比如何？曲 度: 對肝臟分隔加門靜脈結(jié)扎后二步肝切除術(shù)之利弊初步分析associating liver partition and portal vein ligation for staged hepatectomy (ALPPS)肝臟分隔加門靜脈結(jié)扎后二步肝切除術(shù)優(yōu)點(diǎn):1.因在二步切肝術(shù)中可直視下測量欲保留肝大小,故殘肝組織急速再生事實(shí)應(yīng)不是問

24、題.這是一種突破!2.該術(shù)或許能部分解決巨大肝癌或位置不佳肝癌,施行一步肝切除術(shù)后急性肝衰等問題.3.或許在二步肝十指腸切除術(shù)膽道重建時,考慮到殘肝已急速再生其重建位置更趨正常.缺點(diǎn):1.二步切肝術(shù)圍術(shù)期併發(fā)癥問題仍是大問題.Sixteen patients/25 (68%) experienced perioperative complications.2.二步切肝術(shù)后與一步切肝術(shù)相比,其生存率難以樂觀;因肝臟腫瘤切除術(shù)后生存長短主要與病人肝腫瘤細(xì)胞惡性程度高低相關(guān).3.在肝腫瘤伴隨廣泛肝硬化的病人中恐同樣難于施行.4.或許尚未等到二步切肝術(shù)時,因肝臟分隔加門靜脈結(jié)扎一步術(shù)中人為擠壓與牽拉肝

25、組織之故,肝腫瘤細(xì)胞已經(jīng)廣泛轉(zhuǎn)移.個人初步看法:基本上可以這么判斷這是該術(shù)另兩大優(yōu)點(diǎn).但尚須前瞻性分組對照研究結(jié)果去證實(shí)之.同時祝賀上海中山醫(yī)院周檢團(tuán)隊(duì)與四川省人民醫(yī)院楊洪吉團(tuán)隊(duì)在國內(nèi)率先引進(jìn)這種針對晚期肝癌的國際新術(shù)式!1. 關(guān)于這點(diǎn)本人對其毫不置疑;一是有CT對比,二是在二步術(shù)中可直接測量;2.一步術(shù)中門脈右支結(jié)扎后,整個門脈系統(tǒng)向肝營養(yǎng)血流均流向待保留左肝,故其快速肝再生;3.未看全文,不知細(xì)節(jié).但推理判斷,如做自身一步術(shù)與二步術(shù)對照,肝功能應(yīng)該改善.-關(guān)鍵問題:該術(shù)如何預(yù)防術(shù)中術(shù)后肝癌細(xì)胞血道等途轉(zhuǎn)移?該術(shù)能否提高這類晚期肝癌的遠(yuǎn)期生存率?在web of science，pubmed上

26、檢索，一年之內(nèi)已經(jīng)有32次引用阿根廷的10例手術(shù)Our initial experience with ALPPS technique: encouraging results.Sala S,Ardiles V,Ulla M,Alvarez F,Pekolj J,de Santiba?es E.SourceLiver Transplant Unit and General Surgery Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.AbstractSurgical resection is the

27、 best option for prolonged survival in patients with primary or secondary liver tumors. A sufficient future liver remnant (FLR) volume is needed to prevent post-hepatectomy liver failure (PHLF). With the aim of increasing FLR, a new two-step technique has been recently developed. Our aim is to repor

28、t our initial experience with associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) technique. Analysis was conducted of ten patients previously considered locally unresectable because of small FLR. During first surgical step liver parenchymal partition and portal vein

29、ligation was performed. Seven days after the first procedure, once volumetric and functional studies have demonstrated an appropriate FLR volume, the resection of the deportalized hemiliver was achieved. This technique was successfully performed in all ten patients (feasibility 100 %). Six were male

30、 with mean age of 55.2 years (range 39-77). Mean preoperative FLR volume and FLR/total liver volume were 408.4 ml and 27.8 %. Mean postoperative FLR volume was 733 ml representing a mean volume increase of 325 ml or 82 % (range 31-140) (p 0.0001). All resections were R0 (4 right hepatectomies, 5 rig

31、ht trisectionectomies and 1 left trisectionectomy). There were two grade A post-hepatectomy liver failures. Morbidity was 40 % and mortality 0 %. With a mean follow-up of 187 days, disease-free survival and overall survival were 80 and 100 %, respectively. ALPPS induces a great and fast FLR hypertro

32、phy allowing R0 resections in patients otherwise considered unresectable because of small FLR volume, without severe PHLF and low mortality in experience centers. Further experience is needed to determine long-term outcomes.PMID: 22903531 [PubMed - indexed for MEDLINE美國的合并肝纖維化，門脈高壓的Using ALPPS t

33、o induce rapid liver hypertrophy in a patient with hepatic fibrosis and portal vein thrombosis.Cavaness KM,Doyle MB,Lin Y,Maynard E,Chapman WC.SourceDepartment of Surgery, Section of Abdominal Transplantation, Washington University School of Medicine, St. Louis, MO, USA.PMID: 22996934 [PubMed -

34、indexed for MEDLINE阿根廷的另一篇 病例上升到15例J Gastrointest Surg.2013 Apr;17(4):814-21. doi: 10.1007/s11605-012-2092-2. Epub 2012 Nov 27.Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS): tips and tricks.Alvarez FA,Ardiles V,Sanchez Claria R,Pekolj J,de Santiba?es E.SourceGen

35、eral Surgery Service, Hospital Italiano de Buenos Aires, Juan D. Pern 4190, C1181ACH, Buenos Aires, Argentina.AbstractBACKGROUND:Posthepatectomy liver failure is the most severe complication after major hepatectomies and it is associated with an insufficient future liver remnant (FLR). Associating l

36、iver partition and portal vein ligation (PVL) has recently been described as a revolutionary strategy to induce a rapid and large FLR volume increase. We aim to describe our surgical technique, patient management, and preliminary results with this new two-stage approach.TECHNIQUE:During the first st

37、age, liver partition and PVL of the diseased hemiliver are performed. The completion surgery is carried out after volumetric studies have demonstrated a sufficient FLR and provided the patient is in good condition. This is usually achieved after 7 days. In the second step, the patient undergoes a co

38、mpletion surgery with right hepatectomy, right trisectionectomy, or left trisectionectomy.RESULTS:Fifteen patients with advanced liver tumors were treated. Nine patients were males and the mean age was 54 years old. The mean difference between the preoperative and postoperative FLR volume was 303 ml

39、 (p?0.001), which represented a mean volume increase of 78.4 %. All resections were R0. Morbidity and mortality rates were 53 and 0 %, respectively. The average hospital stay was 19 days.CONCLUSIONS:The presented technique was feasible and safe in the hands of experienced hepatobiliary surgeons, wit

40、h satisfactory short-term results. It induces rapid liver hypertrophy and at the same time it offers the possibility of cure to patients previously declared unresectable.德國的九例J Gastrointest Surg.2013 May;17(5):956-61. doi: 10.1007/s11605-012-2132-y. Epub 2013 Jan 4.ALPPS in right trisectionectomy: a

41、 safe procedure to avoid postoperative liver failure?Li J,Girotti P,K?nigsrainer I,Ladurner R,K?nigsrainer A,Nadalin S.SourceGeneral, Visceral and Transplantation Surgery, University Hospital Tuebingen, Tuebingen, Germany. j.liuke.deAbstractINTRODUCTION:To induce rapid hepatic hypertrophy and to red

42、uce post-hepatectomy liver failure (PHLF), associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been recently developed for patients with a limited future liver remnant. The aim of this study was to further assess the perioperative risk of this procedure and its sp

43、ecific indications.PATIENTS AND METHODS:The study was performed between November 2010 and April 2012 for patients undergoing right trisectionectomy by the ALPPS approach. Liver volume, intra- and postoperative complications, including PHLF, and residual tumour status were compared for patients with

44、different diagnoses.RESULTS:The interval between two operations in nine patients undergoing ALPPS was 13 days (median). Sufficient hepatic hypertrophy was achieved with a volume gain of 87.2 % (median). All patients underwent right trisectionectomy without residual tumours. In contrast to six patien

45、ts with uneventful intra- and postoperative course, bile leak, vancomycin-resistant enterococcus infection, PHLF and sepsis developed in two of three patients with hilar cholangiocarcinoma as the preoperative diagnosis.CONCLUSION:ALPPS leads to sufficient hepatic hypertrophy within 2 weeks, avoiding

46、 PHLF in most patients. In patients with hilar cholangiocarcinoma, ALPPS should be applied with extreme caution due to high morbidity and mortality.匈牙利的Magy Seb.2013 Feb;66(1):21-6. doi: 10.1556/MaSeb.66.2013.1.3.ALPPS (Associated Liver Partition and Portal vein ligation for Staged hepatectomy) - fa

47、ster and greater growth of liver.Article in HungarianHahn O,Duds I,Pajor P,Gy?rke T,Korom C,Zsirka-Klein A,Kupcsulik P,Harsnyi L.SourceSemmelweis Egyetem ?ltalnos Orvostudomnyi Kar I. sz. Sebszeti Klinika 1082 Budapest. Hahn.oszkarmed.semmelweis-univ.huAbstractCase report: 75 years old female patien

48、t was referred with large, multifocal colorectal liver metastasis. Prior to this consultation she received chemotherapies of various protocols and series. Liver metastasis, however, increased at about 3 times of the original size during the 5 months of the oncological treatment. A right extended hep

49、atectomy was planned to remove the tumor, but the residual liver (FLR) was found to be too small. Portal occlusion technique was necessary to induce the hypertrophy of the FLR. Due to rapid tumor progression we decided to perform the first ALPPS (PVL + in situ split) procedure in Hungary. After a ve

50、ry fast (9 days) and significant (94%) hypertrophy of the FLR the planned liver resection was successfully performed.PMID: 23428724 [PubMed - indexed for MEDLINE巴西Ann Surg Oncol.2013 May;20(5):1491-3. doi: 10.1245/s10434-013-2920-y. Epub 2013 Mar 7.ALPPS procedure with the use of pneumoperitoneu

51、m.Machado MA,Makdissi FF,Surjan RC.SourceDepartment of Surgery, Sirio Libanes Hospital, Sao Paulo, Brazil. dr.brAbstractBACKGROUND:A new method for liver hypertrophy was recently introduced, the so-called associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure.

52、We present a video of an ALPPS procedure with the use of pneumoperitoneum.METHODS:A 29-year-old woman with colon cancer and synchronous liver metastasis underwent a two-stage liver resection by the ALPPS technique because of an extremely small future liver remnant.RESULTS:The first operation began w

53、ith 30 min pneumoperitoneum. Anatomical resection of segment 2 was performed, followed by multiple enucleations on the left liver. The right portal vein was ligated and the liver partitioned. The abdominal cavity was partially closed, and a 10 mm trocar was left to create a pneumoperitoneum for addi

54、tional 30 min. The patient had an adequate future liver remnant volume after 7 days, but she was not clinically fit for the second stage of therapy, so it was postponed. She was discharged on day 7 after surgery. The second stage took place 3 weeks later and consisted of an en-bloc right trisectione

55、ctomy extended to segment 1. The patient recovered and was discharged 9 days after second-stage surgery. Postoperative CT scan revealed an enlarged remnant liver.CONCLUSIONS:The ALPPS procedure is a new revolutionary technique that permits R0 resection even in patients with massive liver metastasis.

56、 The use of pneumoperitoneum during the first stage is an easy tool that may prevent hard adhesions, allowing an easier second stage. This video may help oncological surgeons to perform and standardize this challenging procedure.法國的4例Updates Surg.2013 Jun;65(2):141-8. doi: 10.1007/s13304-013-0214-3.

57、 Epub 2013 May 21.The ALPPS technique for bilateral colorectal metastases: three variations on a theme.Gauzolino R,Castagnet M,Blanleuil ML,Richer JP.SourceUnit of Liver and Pancreatic Surgery, University Hospital, Poitiers, France, Riccardo.GAUZOLINOchu-poitiers.fr.AbstractThe aim of this study was to assess feasibility of technical variations of the associating liver partition and port