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
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
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DOI：
10.1097/sla.0b013e31824856f5
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发表时间：
2012-03-01
影响因子：
9
通讯作者：
Schlitt, Hans J.
中科院分区：
文献类型：
--
作者：
Schnitzbauer, Andreas A.;Lang, Sven A.;Schlitt, Hans J.
目的：为了评估一种新的两步技术，以获得足够的，但短期的实质肥大的肿瘤患者需要扩大右肝切除有限的functionalreserve.Background：原发性或转移性肝肿瘤的患者往往面临的困境，剩余的肝组织可能不够。术前门静脉栓塞迄今已被确立为标准的程序，为实现可切除性。方法：两阶段肝切除术的患者术前似乎是边缘切除，但有一个无肿瘤的左外侧叶。边缘可切除性定义为左外叶与体重之比小于0.5。在第一步，手术探查，右门静脉结扎（PVL），并在原位分裂（ISS）肝实质沿着镰状韧带。在ISS前和手术完成前进行CT容积测定。结果：研究包括25例原发性肝肿瘤患者（肝细胞癌：n = 3，肝内胆管细胞癌：n = 2，肝外胆管细胞癌：n = 2，恶性上皮样血管内皮瘤：n = 1，胆囊癌：n = 1或转移性疾病[结直肠肝转移]：卵巢癌14例，胃癌1例。左外叶术前CT容积测定显示中位数为310 mL（范围= 197-444 mL）。经过9天（范围= 5-28天）的中位等待期后，左外叶体积增加至536 mL（范围= 273-881 mL），表示中位体积增加74%（范围= 21%-192%）（P < 0.001）。左外侧肝叶与体重的中位比值从0.38%（范围= 0.25%-0.49%）增加至0.61%（范围= 0.35-0.95）。25例患者中有10例（40%）需要肝管空肠吻合术进行胆道重建。完成手术后第14天，国际标准化比值（INR）（80%的患者）、肌酐（84%的患者）、接近正常的胆红素（56%的患者）和白蛋白（64%的患者）值恢复正常，反映了围手术期快速恢复。根据手术并发症的Dindo-Clavien分类对围手术期发病率进行分类：I级（12起事件）、II级（13起事件）、III级（14起事件，III a：6起事件，III B：8起事件）、IV级（8起事件，IV a：3起事件，IV B：5起事件）和V级（3起事件）。16例患者（68%）发生围手术期并发症。随访中位数为180天（范围：60-776天），估计总生存率为86%，在6个月后surveillance.Conclusions：两步肝切除术进行手术探查，PVL，和ISS的结果在一个显着的和快速的功能性肝组织肥大，使治愈性切除边缘可切除的肝肿瘤或转移的患者，否则可能被视为姑息性。
Objective: To evaluate 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 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 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 volumetry 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, gallbladder 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 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%) 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 after 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 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 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.