发布时间 : 星期日 文章肝胆手术大胆创新二步肝切除术 - 图文更新完毕开始阅读09bcb1a910661ed9ac51f337
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\
Ann 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, Rümmele P,Scherer MN, Padberg W, K?nigsrainer A, Lang H, Obed A, Schlitt HJ. Source
Department of Surgery, University Hospital Regensburg, Regensburg, Germany.
Abstract
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.
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 \approach. [Ann Surg. 2012]
Playing Play-Doh to prevent postoperative liver failure: the \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. 2012]
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, 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。