Hepatic vein reconstruction for resection of hepatic tumors
Hepatic vein reconstruction for resection of hepatic tumors
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DOI：
10.1097/00000658-200206000-00013
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发表时间：
2002-06-01
影响因子：
9
通讯作者：
Howard, RJ
中科院分区：
文献类型：
--
作者：
Hemming, AW;Reed, AI;Howard, RJ
总结。背景资料由于手术风险高且长期预后差，传统上认为晚期肝肿瘤切除术的禁忌症是累及肝静脉需要重建。从劈离式和活体肝移植中收集到的肝外科最新进展中，肝静脉重建在某些情况下可以应用于肝切除术，方法回顾性分析1996-2001年16例肝切除术后需要肝静脉重建的患者。平均年龄为43岁（范围2-61岁）。9例患者因肝细胞癌（HCC）切除，5例患者因结直肠转移切除，1例患者因肝母细胞瘤和胆管癌切除。在6例HCC和肝硬化患者中，重建了右肝静脉，为剩余主要肝静脉未充分引流的肝段提供静脉流出。这6例患者中有4例需要使用Gore-Tex（W. L.戈尔联合公司，纽瓦克，DE）间置移植物。在其他10例病例中，来自残肝的整个静脉流出被重建或重新植入下腔静脉（n = 8）或使用来自肝切除侧的门静脉段作为移植物（n = 2）。2例采用体外静脉-静脉转流术，1例采用原位冷灌注肝脏。结果围手术期死亡2例（12%）。1例患者在右三叶切除术后3周死于肝功能衰竭，并重建了左肝静脉，1例患者在切除术后3个月死于小肠穿孔形成疝的败血症，4例患者有术后肝功能衰竭的证据，经支持性治疗后消退，1例患者需要临时透析。末次随访时，所有血管重建均通畅。中位随访时间为23个月，3例患者在14、18和30个月时死于恶性肿瘤复发，另1例患者在22个月时死于进行性肝衰竭，1年和3年生存率分别为88%和50%。结论肝脏恶性肿瘤累及肝静脉并不一定妨碍切除。肝切除和肝静脉重建可以在选定的情况下进行。与手术相关的风险增加似乎被可能的益处所平衡，特别是当考虑到缺乏替代治疗方法时。
Summ. Background Data Involvement of the hepatic veins requiring reconstruction has traditionally been considered a contraindication to resection for advanced tumors of the liver because the surgical risks are high and the long-term prognosis poor. Recent advances in liver surgery gleaned from split and live donor liver transplantation that necessitate hepatic vein reconstruction can be applied to hepatic resection in some cases.Methods Sixteen patients who underwent hepatic resection requiring hepatic vein reconstruction from 1996-2001 were reviewed. The mean age was 43 years (range 2-61). Nine patients were resected for hepatocellular carcinoma (HCC), five patients for colorectal metastases, and one patient each for hepatoblastoma and cholangiocarcinoma. In six patients with HCC and cirrhosis, the right hepatic vein was reconstructed to provide venous outflow to liver segments not adequately drained by a remaining major hepatic vein. Four of these six patients required the use of Gore-Tex (W. L. Gore & Associates, Inc., Newark, DE) interposition grafts. In the 10 other cases the entire venous outflow from the remnant Fiver was reconstructed or reimplanted into the inferior vena cava primarily (n = 8) or using segments of the portal vein from the resected side of the liver as a graft (n = 2). Ex-vivo procedures with the use of veno-venous bypass were required in two cases and in-situ cold perfusion of the liver was used in one case.Results There were two perioperative deaths (12%). One patient died of liver failure 3 weeks after right trisegmentectomy with reconstruction of the left hepatic vein and one patient died at 3 months after resection due to sepsis from a segment of small bowel that perforated into a diaphragmatic hernia, Four patients had evidence of postoperative liver failure that resolved with supportive management and one patient required temporary dialysis. All vascular reconstructions were patent at last followup. With median followup of 23 months, 3 patients have died of recurrent malignancy at 14, 18 and 30 months, while an additional patient went on to die of progressive liver failure at 22 months, Actuarial 1 and 3 year survival was 88% and 50% respectively.Conclusion Hepatic vein involvement by hepatic malignancy does not necessarily preclude resection. Liver resection with reconstruction of the hepatic veins can be performed in selected cases. The increased risk associated with the procedure appears to be balanced by the possible benefits, particularly when the lack of alternative curative approaches is considered.