肝胆手术大胆创新二步肝切除术.doc

相关疾病： 肿瘤 肝硬化本文是刚发表在中华消化外科杂志的一篇文章，介绍了一种很新的肝脏手术方式，复旦中山周检团队报道了亚洲第一例。附件为文章全文及刘院士的述评。希望对手术感兴趣的战友一阅！因有战友指出，华西也报道了一例。故更改了标题。对“联合肝脏离断和门静脉结扎的二步肝切除术”的述评刘允怡 刘晓欣 【摘要】 联合肝脏离断和门静脉结扎的二步肝切除术(ALPPS)是 一 个 非 常 新 的 外 科 手 术 。 该 手 术 主 要 针 对 因 未来剩余肝脏体积较小而不能接受大范围肝切除术的 T分期较晚的肝癌患者而设计的。ALPPS第 1步手术后,患者剩余肝脏对手术的反应非常强烈,使得肝脏体积急剧增生。因而可在第 1步手术后 1周左右施行第 2步手术以切除所有肝内肿瘤(R0 切除)。本文追溯 ALPPS的发展历史,描述该手术的传统步骤和手术的偏离等情况,分析该手术的短期疗效。尽管 ALPPS后零死亡已有报道,但初步的研究结果表明:ALPPS的手术死亡率和并发症发生率仍然较高。ALPPS后尚没有明确的长远治疗肿瘤效果的报道。该手术在肝硬化肝癌患者中能否安全施行尚有疑问。但是还是认为选择门脉介入栓塞这一微创的方法更好，且风险更小。支持，外科的进步有些就是来源于一些意外发现及治疗过程中无法解释的现象。减肥手术被发现能够治疗糖尿病也是这种情况。这种方法为无法切除的肝脏肿瘤提供了一个治疗的途径，值得学习。期待着能有中长期患者生存率的报道。相关疾病： 肝癌 肿瘤相关疾病：肝癌肿瘤修改来源：中国新闻网7月18日，四川省人民医院器官移植中心成功实施了一种全新的肝癌切除手术，目前患者病情稳定。这标志着我国晚期肝肿瘤的根治性手术取得新的进展。据了解，这种手术于2012年在德国首创，正式名称为联合肝脏分割和门静脉结扎的分阶段肝切除术，简称ALPPS，是晚期肝肿瘤的根治性手术。据院方介绍，49岁的男性患者刘应奎是全国第一个接受此术式的患者，他近日因右上腹胀痛，进行CT检查后发现肝脏有巨大肿瘤，肿瘤原发于右肝，并在左肝发现了转移迹象。经过四川省人民医院医生的全面评估后，7月5日该患者实施了一期手术。“在第一阶段手术中，外科医生先将患者肝脏的左右叶彻底劈开”，四川省人民医院器官移植中心主任杨洪吉表示，肝脏劈开后通过结扎右侧门静脉，切断右侧的血液供应，然后再切除左侧肝脏肿瘤部分，保留正常肝组织。患者的右侧肝脏因为没有血液供给而萎缩，同时，左侧肝脏由于过量的血液供给而成倍增大。等到左侧肝脏增长到一定程度后，外科医生对病人进行第二阶段手术，切除右肝肿瘤。“这样所有的肝脏肿瘤全部就切除了”，杨洪吉说，不能一次性切除肝脏面积在65%以上，而是通过肝脏分离切除，保障患者的功能和生命安全。同时，为了保证肿瘤不蔓延到肝脏其他部位，手术的两阶段需要十天左右。一期手术后一周复查，患者的左肝已经代偿性增生了50%，并保持完好的肝功能，因此7月18日成功实施了二期手术。据杨洪吉介绍，这次新型手术的原理就在于肝脏有很强的再生功能。过去医学界一直认为一小瓣肝脏在体内长大50%需要半年或者更长的时间。现在研究表明，一小瓣肝脏在7至10天就可以长大50%。由于，患者必须短期内接受两次手术，这家要求患者的身体状态足够好才能承受这种手术。术前需要对患者进行一次全面的医疗评估，包括心脏功能和病史，肺功能以及麻醉师的评估。associating liver partition and portal vein ligation for staged hepatectomy (ALPPS)英意译中:肝脏分隔加门静脉结扎后二步肝切除术下面的这篇或是国际上该领域的第一篇处女作,尔后人们称之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.Schnitzbauer 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 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.Ann Surg.2012 Sep;256(3):e5; author reply e16-9. doi: 10.1097/SLA.0b013e318265fbbe.Long-term results with 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, Clavien 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 splitting 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.” 现在研究表明，一小瓣肝脏在7至10天就可以长大50%“。我想知道谁做的什么研究表明 “一小瓣肝脏在7至10天就可以长大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),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, 且不管其用何种方式测量的，也不管准确性如何，确实是增大了。2，从病理的角度讲这种增大的基础是什么？细胞数量增多了？还是每个细胞增大了？还是由于肝右门脉结扎后肝左叶血流量增多充血引起？最好有病理解释。3，另外，肝脏增大的同时有没有肝功检查支持其功能改善？和门静脉栓塞比如何？曲 度: 对肝脏分隔加门静脉结扎后二步肝切除术之利弊初步分析associating liver partition and portal vein ligation for staged hepatectomy (ALPPS)肝脏分隔加门静脉结扎后二步肝切除术优点:1.因在二步切肝术中可直视下测量欲保留肝大小,故残肝组织急速再生事实应不是问题.这是一种突破!2.该术或许能部分解决巨大肝癌或位置不佳肝癌,施行一步肝切除术后急性肝衰等问题.3.或许在二步肝十指肠切除术胆道重建时,考虑到残肝已急速再生其重建位置更趋正常.缺点:1.二步切肝术围术期併发症问题仍是大问题.Sixteen patients/25 (68%) experienced perioperative complications.2.二步切肝术后与一步切肝术相比,其生存率难以乐观;因肝脏肿瘤切除术后生存长短主要与病人肝肿瘤细胞恶性程度高低相关.3.在肝肿瘤伴随广泛肝硬化的病人中恐同样难于施行.4.或许尚未等到二步切肝术时,因肝脏分隔加门静脉结扎一步术中人为挤压与牵拉肝组织之故,肝肿瘤细胞已经广泛转移.个人初步看法:基本上可以这么判断这是该术另两大优点.但尚须前瞻性分组对照研究结果去证实之.同时祝贺上海中山医院周检团队与四川省人民医院杨洪吉团队在国内率先引进这种针对晚期肝癌的国际新术式!1. 关于这点本人对其毫不置疑;一是有CT对比,二是在二步术中可直接测量;2.一步术中门脉右支结扎后,整个门脉系统向肝营养血流均流向待保留左肝,故其快速肝再生;3.未看全文,不知细节.但推理判断,如做自身一步术与二步术对照,肝功能应该改善.-关键问题:该术如何预防术中术后肝癌细胞血道等途转移?该术能否提高这类晚期肝癌的远期生存率?在web of science，pubmed上检索，一年之内已经有32次引用阿根廷的10例手术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 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 report 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 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 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 right 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 hypertrophy 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美国的合并肝纤维化，门脉高压的Using ALPPS to 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 - 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.SourceGeneral 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 liver 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 stage, 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 completion 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 (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, with 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.德国的九例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 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 reduce 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 specific 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 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 patients 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 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) - faster 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 patient 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 hepatectomy 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 very 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 pneumoperitoneum.Machado MA,Makdissi FF,Surjan RC.SourceDepartment of Surgery, Sirio Libanes Hospital, Sao Paulo, Brazil. .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. 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 with 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 additional 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 trisectionectomy 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. 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.法国的4例Updates Surg.2013 Jun;65(2):141-8. doi: 10.1007/s13304-013-0214-3. 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 portal vein