目的:评价全肝血管隔绝术(THVE)技术改良用于下腔静脉(IVC)肝切除术的疗效。
方法:在前5年期间接受肝切除术的301例患者中,8例(2.7%)需要THVE或改良的IVC交叉夹钳方法,以切除IVC大量受累的肝肿瘤。其中7例诊断为结直肠癌肝转移,1例诊断为肝细胞癌。所有肿瘤都涉及IVC,在所有8例患者中,THVE对于合并切除IVC是不可避免的。对THVE进行了技术修改,以最大程度地减少血管闭塞的程度和持续时间。从而降低损坏的风险。
结果:广泛解剖IVC后面的空间,再将肝脏从腔后空间抬起,可有效控制THVE之前和期间IVC周围的出血。该程序有助于修改颅骨IVC交叉夹的定位。将颅IVC交叉钳从上至肝后IVC或肝静脉汇合的转换减少了THVE的持续时间,同时通过IVC恢复了肝血流或全身循环。倾斜的颅IVC交叉钳夹避免了残余半肝的缺血。通过这些技术修改,THVE的平均持续时间为13.4±8.4分钟,这比以前文献中报道的要短得多。所有8例患者的肝功能恢复顺利。没有死亡病例,重新操作,或严重并发症(即,Clavien-Dindo等级为III或以上)。
结论:腔后肝脏提升操作和颅骨交叉钳夹的修改对于最小化THVE的持续时间是有用的。
OBJECTIVE: To evaluate the efficacy of technical modifications of total hepatic vascular exclusion (THVE) for hepatectomy involving inferior vena cava (IVC).
METHODS: Of 301 patients who underwent hepatectomy during the immediate previous 5-year period, 8 (2.7%) required THVE or modified methods of IVC cross-clamping for resection of liver tumors with massive involvement of the IVC. Seven of the patients had diagnosis of colorectal liver metastases and 1 had diagnosis of hepatocellular carcinoma. All tumors involved the IVC, and THVE was unavoidable for combined resection of the IVC in all 8 of the patients. Technical modifications of THVE were applied to minimize the extent and duration of vascular occlusion, thereby reducing the risk of damage.
RESULTS: Broad dissection of the space behind the IVC coupled with lifting up of the liver from the retrocaval space was effective for controlling bleeding around the IVC before and during THVE. The procedures facilitate modification of the positioning of the cranial IVC cross-clamp. Switching the cranial IVC cross-clamp from supra- to retrohepatic IVC or to the confluence of hepatic vein decreased duration of the THVE while restoring hepatic blood flow or systemic circulation via the IVC. Oblique cranial IVC cross-clamping avoided ischemia of the remnant hemi-liver. With these technical modifications, the mean duration of THVE was 13.4 ± 8.4 min, which was extremely shorter than that previously reported in the literature. Recovery of liver function was smooth and uneventful for all 8 patients. There was no case of mortality, re-operation, or severe complication (i.e., Clavien-Dindo grade of III or more).
CONCLUSIONS: The retrocaval liver lifting maneuver and modifications of cranial cross-clamping were useful for minimizing duration of THVE.