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目的探讨经皮微波或射频消融肝实质分隔联合门静脉栓塞计划性肝切除术(percutaneous microwave/radiofrequency ablation liver partition and portal vein embolization for planned hepatectomy,PAPEP)替代联合肝脏分隔和门静脉结扎的二步肝切除术(associating liver partition and portal vein ligation for staged hepatectomy,ALPPS)治疗剩余肝体积(future liver remnant,FLR)不足肝癌和胆管癌的可行性和安全性。方法回顾性分析2015年7-9月浙江省人民医院肝胆胰外科应用PAPEP治疗FLR不足的2例原发性肝癌和1例肝门部胆管癌的临床资料。先超声引导下经皮微波消融分隔预留侧和切除侧肝实质(percutaneous microwave ablation liver partition,PMA),PMA后1~3 d行门静脉栓塞术(portal vein embolization,PVE),PVE后10~13 d测量FLR,术前系统评估后限期肝切除术:2例肝癌分别行肝右三叶和右尾叶切除术、扩大右半肝切除术,1例肝门部胆管癌行肝右三叶和尾叶切除、肝肠内引流术。结果 PMA前3例标准全肝体积(standard liver volume,SLV)分别为1231.2m L、1202.9m L、1217.1m L,FLR分别为355.6 m L、383.4 m L、385.0 m L,FLR/SLV分别为28.9%、31.9%、31.6%。PMA时间118~132 min,PVE时间158~180 min,PMA或PVE术后病人低热经对症处理好转,肝功能无明显变化。PMA+PVE后10~13 d FLR分别为502.1 m L、527.4 m L、476.3 m L,较术前分别增大41.2%、37.6%、23.7%。肝切除术时间230~440 min,术中出血120~1800 m L。肝门部胆管癌术后并发膈下脓肿,经穿刺后治愈;1例肝癌术后并发腹水、黄疸,经内科治疗后治愈,术后住院时间15~40 d。结论 PAPEP有望代替ALPPS治疗剩余肝体积不足的肝癌或肝门部胆管癌。
Objective To investigate the feasibility of percutaneous microwave / radiofrequency ablation of liver partition and portal vein embolization for planned hepatectomy (PAPEP) in combination with two-stage liver resection combined with hepatic compartmentalization and portal vein ligation (associating liver partition and portal vein ligation for staged hepatectomy, ALPPS) for the treatment of future liver remnant (FLR) insufficiency and safety of hepatocellular carcinoma and cholangiocarcinoma. Methods The clinical data of 2 patients with primary hepatocellular carcinoma and 1 hilar cholangiocarcinoma with inadequate FLR were retrospectively analyzed from July to September 2015 in Zhejiang Provincial People’s Hospital for hepatobiliary and pancreatic surgery. Percutaneous microwave ablation of the liver parenchyma (PMA) was performed under ultrasound-guided percutaneous microwave ablation. Portal vein embolization (PVE) was performed 1-3 days after PMA. After PVE 10-13 d measurement of FLR, preoperative systematic assessment of the period of liver resection: 2 cases of liver cancer were right hepatic and right caudate lobe resection, to expand the right hepatectomy, 1 case of hilar cholangiocarcinoma of the right hepatic lobe and Caudal lobectomy, intrahepatic drainage. Results The standard liver volumes (SLVs) of the first three cases of PMA were 1231.2 m L, 1202.9 m L and 1217.1 m L, respectively. The FLR were 355.6 m L, 383.4 m L and 385.0 m L, respectively. The FLR / SLV were 28.9%, 31.9%, 31.6%. PMA time 118 ~ 132 min, PVE time 158 ~ 180 min, PMA or PVE postoperative patients with low fever by the symptomatic treatment improved, no significant change in liver function. The FLR of PMA + PVE from 10 to 13 days were 502.1 m L, 527.4 m L and 476.3 m L, respectively, which increased by 41.2%, 37.6% and 23.7% respectively compared with that before operation. Hepatectomy time 230 ~ 440 min, intraoperative bleeding 120 ~ 1800 m L. Hepatitis B cholangiocarcinoma was complicated with subphrenic abscess and was cured after puncture. One case of hepatocellular carcinoma complicated with ascites and jaundice was cured after medical treatment. The postoperative hospital stay was 15-40 days. Conclusions PAPEP is expected to replace ALPPS in the treatment of liver cancer or hilar cholangiocarcinoma with insufficient remaining liver volume.