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目的研究肝门胆管癌术前门静脉栓塞促进预保留肝增生的安全性和有效性。方法2007年4月至2008年5月收治肝门胆管癌50例,将预保留肝占全肝体积比<50%、且接受门静脉栓塞(PVE)者设为PVE组(8例),最终接受联合大部肝切除者为PVE肝切除组(6例),同期未行PVE接受大部肝切除者为非PVE肝切除组(17例)。PVE组男6例、女2例,年龄(51±7.8)(41～61)岁,均为BismuthⅣ型,2例合并乙肝后肝硬化。7例PVE前接受预保留肝的选择性胆道引流,PVE前血清总胆红素(TB)为(89.7±40.0)(12.4～140.5)μmol/L。PVE采用经皮经肝、同侧或对侧路径,放置多枚钢圈,栓塞门静脉左支1例、右支4例、左支+右前支3例。PVE前后CT测定肝体积。统计PVE后不良事件发生情况,并与PVE前后肝功能、肝体积指标,PVE肝切除组和非PVE肝切除组的术后死亡率和并发症发生率比较。结果8例PVE均成功。发生PVE并发症的为:胆漏1例(1/8),腹腔引流后不影响肝切除术。有轻微不良反应者为1例少量栓塞物漂移(1/8),无需特殊处理。PVE后3d肝功能指标与PVE前无统计差异,PVE后2周非栓塞肝体积与PVE前[(824±211)cm3vs(770±205)cm3,P<0.01]、非栓塞肝占全肝体积比与PVE前[(46.2±9.1)%vs(43.1±8.6)%,P<0.05]有统计学差异。1例合并肝硬化,肝增生不全,未术。另1例肿瘤进展,姑息手术。6例于PVE后(17±4)(13～24)d接受肝切除术,术前为TB(47.6±26.6)(11.5～84.8)μmol/L(与PVE前比,P<0.05)。肝切除范围:扩大左半肝1例、左三叶2例、右半肝1例、扩大右半肝2例。PVE肝切除组和非PVE组的手术死亡率(0vs5.9%,P>0.05)、并发症发生率(50.0%vs52.9%,P>0.05)无统计学差异。非PVE组术后1例死于急性肝衰竭,另1例肝功能不全最终康复。PVE组1例(合并肝硬化)并发肝脓肿,术后4.2月死于肝衰竭。结论在施行右半肝或超半肝切除的肝门部胆管癌术前,本研究所用的钢圈门静脉栓塞方法是安全的,并且能够有效诱导预保留肝叶增生;在接受更大范围的肝切除术后,手术死亡率和并发症发生率并未增加。
Objective To study the safety and efficacy of preoperative portal vein embolization for hepatic hilar cholangiocarcinoma to promote pre-retained liver hyperplasia. Methods From April 2007 to May 2008, 50 patients with hilar cholangiocarcinoma were treated. Pre-preserved liver accounted for less than 50% of the total liver volume, and patients receiving portal vein embolism (PVE) were enrolled as PVE group (n = 8) The majority of hepatectomy patients were treated with PVE hepatectomy (n = 6), while the other patients without PVE received hepatectomy were non-PVE hepatectomy (n = 17). PVE group 6 males and 2 females, age (51 ± 7.8) (41 to 61) years old, were Bismuth type Ⅳ, 2 cases with hepatitis B cirrhosis. Selective biliary drainage of pre-preserved liver was performed in 7 patients before PVE. Pre-PVE serum total bilirubin (TB) was (89.7 ± 40.0) (12.4-140.5) μmol / L. PVE percutaneous transhepatic, ipsilateral or contralateral path, placing multiple rims, embolization of the left portal vein in 1 case, 4 cases of right branch, left branch + right anterior branch in 3 cases. Liver volume was measured by CT before and after PVE. The incidence of adverse events after PVE was calculated and compared with postoperative PVE, liver volume, postoperative mortality and complication rates in PVE liver resection group and non-PVE liver resection group. Results 8 cases of PVE were successful. The occurrence of PVE complications: 1 case (1/8) of bile leakage, abdominal drainage does not affect the hepatectomy. Minor adverse events were minor excretion (1/8) of embolism without special treatment. There was no significant difference of liver function index and PVE before PVE, PVE 2 weeks before and after PVE [(824 ± 211) cm3 vs (770 ± 205) cm3, P <0.01] (46.2 ± 9.1)% vs (43.1 ± 8.6)%, P <0.05] before PVE. 1 case of cirrhosis, liver dysplasia, not surgery. Another case of tumor progression, palliative surgery. Six patients underwent hepatectomy at (17 ± 4) (13-24) days after PVE. The mean preoperative TB was 47.6 ± 26.6 (11.5-84.8) μmol / L (P <0.05 vs PVE). Liver resection range: 1 case of left hepatic enlargement, 2 cases of left clover, 1 case of right hepatic and 2 cases of right hepatic enlargement. There was no significant difference between the PVE group and the non-PVE group in operative mortality (0 vs 5.9%, P> 0.05) and the incidence of complications (50.0% vs 52.9%, P> 0.05). One patient died of acute liver failure in the non-PVE group and the other one was finally recovered after liver dysfunction. One patient (with cirrhosis) complicated with liver abscess in PVE group died of liver failure 4.2 months after operation. Conclusion The method of steel ring portal vein embolization used in this study is safe and can effectively induce pre-retained hepatic lobe hyperplasia before surgery for hilar cholangiocarcinoma with right or semi-hepatic resection. In patients receiving a wider range of hepatic After resection, the incidence of surgical mortality and complications did not increase.