171例巨大肝癌手术切除治疗体会

　　中华外科杂志2000年第38卷第1期

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　　 摘　要　目的：探讨肝切除治疗巨大肝癌的安全性和可行性。方法：回顾性总结切除巨大肝癌(直径大于10cm)17例的治疗结果，对肝切除治疗巨大肝癌应注意的一些问题进行了讨论。结果：肝切除治疗巨大肝癌171例中，术后1个月内死亡2例(1.2%)，术后1、2、3、5和10年生存率分别为66.1%、42.1%、32.7%、12.2%和2.3%，说明肝切除对延长巨大肝癌患者生存时间的效果是明显的。结论：肝切除治疗巨大肝癌是安全可行而且有效的。

　　 关键词：癌，肝细胞　肝切除术

　　According to the tumor size, primary liver cancer(PLC) has been classified into the following types: minute pLC,≤ 2 cm in diameter; small PLC,＞2 cm,≤5 cm; PLC, ＞5 cm ≤ 10 cm; huge PLC;＞10 cm.^［1］ In western countries, PLC is rarely associated with cirrhosis. In China, however, PLC is always associated with cirrhosis accounting for 85%.^［2］ Patients with cirrhosis are often at risk of liver failure after hepatectomy, and the prognosis is very poor if liver failure occurs. Hence quite a few surgeons assert that surgical resection is only limited to micro and small PLC.^［1，2］ We noted that some huge PLC patients with cirrhosis could survive for a period if they could have surpassed the critical phase of operation. In the early 70s, we carried out hepatectomy for individuals with huge PLC. With the development of photography and further acknowledgement of liver surgical anatomy, surgical techniques and perioperative care have been greatly improved in the 80s and hepatectomy for huge PLC has been part of our daily practice.

　　PATIENTS

　　From January 1955 to December 1997,2973 patients with PLC underwent surgical resection. 1895(63.7%) of them were subjected to hepatectomy. In the patients having hepatectomy from 1955 to 1971, no huge PLC was resected. From 1972 to 1997, 130(6.9%) underwent hepatectomy for huge PLC. A total of 171 patients with huge PLC received hepatectomy. Among them41 patients received the operation in other hospitals.

　　Of the 171 patients, 152 were men and 19 women, (mean 39±8.2 years, range7-61 years). Among them, 106 (61.4%) were HBsAg positive. α-fetoprotein (AFP) level was measured in all patients. It was less than 22μg/L in 33 patients(19.3%), 21-399μg/L in 65 (38%), and 400-33,000μg/L in 73(42.7%). Prothrombin time was 1.79±0.51 and Indocyanine Green (ICG) retention(% at 15 min) 12.5±3.1. child′s status: class A in 162 patients and class B in 9. In 7 patients, 3 showed that the tumor size reduced by 0.5-1 cm three weeks after chemoembolization. The tumor size of the other 4 patients was not markedly reduced.

　　SURGICAL PROCEDURE

　　Right trisegmentectomy was performed in 7 patients, right hepatic lobectomy in 15, extended left lobectomy in 12, left hepatic lobectomy in 31, IV, V and VI segmentectomy in 6, IV, V and VIII segmentectomy in 7,V,VI and VII segmentectomy in 29, II and III segmentectomy in18, and wedge resection in 46. In combination, the diaphragm was resected in 6 patients, right adrenal gland in 3, stomach in 2, colon in 2, and spleen in 7. concomitant thrombectomy was performed in 44 patients. The total operative time was 132±26 minutes, parenchymal transection time 9.8±1.6 minutes, and ischemic time 11.5±3.4 minutes. Blood loss was 780±375 ml, and blood transfusion 860±450ml. histopathologically, hepatocellular carcinoma(HCC) was noted in 152 patients(88.9%),hepatocellular-cholangiocellular carcinoma (combined HCC)in 9(5.3%), clear cell carcinoma in 7(4.1%), and primary malignant mesenchymal tumors in10(5.8%). The maximal size of major tumor was 13.7±2.2 cm and the wet weight of resected specimen was 855±67g. Satellite nodules were observed in 62 patients(36.3%) and tumor emboli in the main trunk or the first branch of the portal vein in 49 (28.7%). Fibrous capsules were seen in 135 patients (78.9%), of which116 (85.9%) had capsule infiltration. Surgical margin was 0.61±0.13 cm. coexisted liver cirrhosis was found in 143 patients (83.6%). Postoperative bleeding occurred in 3 patients (1.8%),GI tract bleeding in 2(1.2%),bile leakage in 4(2.3%), intraabdominal abscess in 2(1.2%),massive ascites in5(2.9%),draining tract infection in 6(3.5%), and pleural effusion in 59(34.5%). there were operative deaths within a month (1.2%). Table shows the possible prognostic factors for survival in the 171 patients with huge PLC who underwent liver resection.

Table　Possible prognostic factors for survival in 171 patients with huge PLC undgoing liver resection

　　 Postoperative data were obtained from clinical re-examination or provided by patients' relatives and their doctors. the 1-, 2-, 3-, 5- and 10-year survival rates were 66.1%, 42.1%, 32.7%, 12.2% and 2.3%, respectively.

　　DISCUSSION

　　Feasibility and effect of hepatectomy for huge PLC

　　Conventionally, more than 3-5 cm surgical margin free from the tumor is essential for the so-called radical hepatectomy. With this criterion, curative resection is not available for most patients with liver cancer except those with small liver cancer whose tumors were located marginally and discovered by general checkup. It is widely recognized that most of PLC patients in other Asia countries are complicated by cirrhosis and can not tolerate extensive liver resection.［3-8］ Currently, restrict hepatectomy is prefered to preserve a great amount of residual liver tissue. In fact, however, the residual liver tissue in tumor-bearing liver is scanty on account of tumor extrusion or direct damage, meanwhile the liver tissue escaping the influence of the tumor would be enlarged compensatedly. As a result, the smaller the tumor, the greater the resected normal liver tissue, and vice versa. In a word, the ratio of the resected normal liver tissue for the tumor (diameter＞10 cm) must be less than that of the tumor (diameter＜5 cm) when right hepatectomy is performed. In other words, the resected amount of parenchymal tissue and the destroy of reserved liver function of the two aforementioned conditions are different.

　　With respect to the effect of hepatectomy for huge PLC,the 1-, 2-, 3-, 5- and 10-year survival rates were 66.1%, 42.1%, 32.7%, 12.2% and 2.3%, respectively in our series. Two patients survived more than 20 years. 68 patients with huge PLC were subjected to chemoembolization via the hepatic artery. Their 1-, 2-, and 3-year survival rates were 30.9%, 19.1%, 7.4%, respectively. None survived more than 5 years (P＞0.05). The results indicate that hepatectomy for huge PLC can increase the survival rate markedly.

　　problems in hepatectomy for huge PLC

　　Apparently, not all huge PLC is available for hepatectomy. The first thing that must be considered is whether the tumor is removable and whether the patients could tolerate such an operation. We suggest the following indications for the operation: good general condition and no apparent damage of the heart, lung and kidney; normal liver function (SGPT, TP, bilirubin, etc) and no hepatocellular jaundice and acite (Child A class); Kaolin Partial Thromboplastin time (KPTT) exceeding up to 3 seconds in comparison with normal control; normal iCG; the tumor in one side of the liver or in segments next to each other; no extrahepatic metastasis revealed by photography; compensatory enlargement of the liver after removal of the tumor and sufficient preservation of the residue.

　　Most surgeons recommend that the surgical margin for PLC should exceed 1 cm. For the whole PLC, however, it is impossible to reserve 1 cm surgical margin around the tumor edge. In most of our patients, the resection was performed only outside the capsule of the tumor in order to preserve more functioning parenchymal tissue of the liver. Cuting the parenchymal tissue from the first, second or third hilum to preserve 1 cm surgical margin free from the tumor is possible to injury the main blood vessels, resulting in anemia or necrosis of the related liver. Our experience demonstrated that resecting the tumor only outside the tumor capsule to preserve sufficient liver parenchymal tissue is satisfactory.

　　Yoshida and his colleagues noted that preservation of 1 cm surgical margin free from the tumor failed to prevent early intrahepatic recurrence. The reason was that undetectable minute tumors were found in the resected liver parenchymal tissue more than l cm from the tumor edge in some cases. Considering the factors influencing the therapeutic effects, we pay more attention to the pathologic and histologic features, whether satellite nodules and portal thrombosis exist. In our series, 49 patients (28.7%) had PLC in association with tumor thrombus in the main portal vein or its branches. The natural survival time is only about 60 days for a PLC patient with tumor thrombus in the portal vein, and any nonsurgical treatment does not work. The only effective treatment is the removal of tumor thrombus. In our study, the 1-, 2- and 3-yest survival rates with the removal of tumor thrombus were 38.8%, 22.4% and 4.1%, respectively. This effect was incomparable with that of any other nonsurgical treatment.

　　blood loss and blood transfusion during the operation

　　It is reported that the PLC patients with intraoperative blood loss up to4000-5000ml can still return to a normal health condition, even some patients with 10,000ml of blood loss still get well. The patients can surpass the critical phase because of the improvement of anesthetic management and intra-, postoperative techniques. But the massive loss of blood will make coagulant mechanisms out of order in the patients with cirrhosis. The massive transfusion of stored blood, which is used to maintain the stability of blood volume when blood loss is copious, will ultimately accentuate the change of coagulant mechanisms and cause uncontrolable extensive bleeding and even precipitate death because of severe hypovolumic shock. In addition, a large amount of blood transfusion carries the risk of diffusion of cancer cells and spread of communicable diseases. Moreover, we must diminish the intraoperative blood loss and transfusion as soon as possible when hepatectomy is carried out.

　　The causes for major haemorrhage during hepatectomy for PLC are multifactorial. Many patients with PLC are complicated by cirrhosis and portal hypertension or tumor thrombus in the main portal vein. There is much collateral circulation. When the hilum is incised, profuse bleeding occurs because the collateral is susceptible to be injured.When the tumor is huge it is difficult to obtain an adequate exposure. Conventionlly we make the liver free. In this course, excessive traction and extrusion make the liver bleeding because of the rupture of the superficial capsule of the tumor. Bleeding may also occur because of the laceration of the adherent right adrenal gland or the short venous branches of the inferior vena cava. Also bleeding may be due to the laceration of hepatic vein, portal vein or inferior vena cava during mobilization of the liver parenchymal. Therefore we have adopted hepatic resection in situ since1987, that is, we first eradicate the liver parenchymal, then mobilize the tumor-bearing coronal and triangular ligaments, and ultimately eradicate the parenchymal and tumor. This modality meets with the resection principles of malignant tumor and diminishes the diffusion of cancer cells due to extrusion and traction. Sine it is unnecessary to have excessive traction for the exposure of the second hilum and liver naked zone, there are no risks of laceration from the hepatic vein, portal vein or inferior vena cava. But surgeons are required to be familiar with liver surgical anatomy and to perform the procedure skillfully. We can also directly tie off afferent and efferent hepatic vessels of the tumor-bearing liver for the patients who are suitable for right, left or left lateral hepatectomy. This method is called“anemia hepatectomy without blockage of hilum”. It only blocks the blood flow of tumor-bearing liver. The method, convenient and time-saving,not only fits with the management principles of tumor but also has little influence on hemodynamics.

　　作者单位：陈孝平　同济医科大学同济医院肝胆外科，武汉430030，中国

　　吴在德　同济医科大学同济医院肝胆外科，武汉430030，中国

　　裘法祖　同济医科大学同济医院肝胆外科，武汉430030，中国

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