湖南省人民医院/湖南师范大学附属第一医院 肝脏外二科，湖南 长沙 410002
The Second Department of Hepatology, Hunan Provincial People's Hospital /the First Affiliated Hospital of Hunan Normal University, Changsha 410002, China
背景与目的 巨大肝恶性肿瘤一般分化程度低，常合并血管侵犯。近年来，随着局部治疗与综合治疗的进步，巨大肝恶性肿瘤的治疗效果得到了改善。手术切除是重要的治疗方法之一。然而手术往往难度较大，术中可能出现如瘤体破裂，癌栓播散，转移灶遗漏等原因，导致治疗效果不确切。本文通过探讨术中超声（IOUS）及术中超声造影（CEIOUS）在巨大肝恶性肿瘤手术治疗中的应用及意义，以期优化手术流程，获得更好的肿瘤学效果。方法 回顾性分析湖南省人民医院2019年1月—2021年8月28例运用IOUS及CEIOUS指导手术治疗的巨大肝恶性肿瘤患者资料。所有病例均实施开腹手术，统计分析研究对象的病理结果，手术方式，肿瘤大小，癌栓及肝内转移灶的情况，手术时间，术中出血及输血量，术后住院时间及术后并发症等数据。结果 所有患者均实施开腹手术。切口采用反“L”形切口（6例），“鱼钩”形切口（9例）及胸腹联合切口（13例）；全组患者的肝切除范围涉及全部肝段，部分患者联合其他脏器切除；术中肉眼可见血管癌栓者（11例），行癌栓合并瘤体整体切除（5例）或血管切开取栓（6例）；术前影像学与IOUS及CEIOUS发现的肝内转移灶（11例），行切除或微波消融。手术时间190~560 min，平均（365.18±110.45）min；出血量100~1 800 mL，平均（598.21±414.43）mL；7例术中输浓缩红细胞，输注量400~1300 mL，平均（714.29±328.78）mL；6例术中输新鲜冷冻血浆，输注量150~400 mL，平均输注量（325.00±117.26）mL；肝门阻断次数1~12次，平均（4.82±2.36）次。术后病理示，肝细胞癌24例，胆管细胞癌2例，肝细胞癌合并胆管分化1例，肝母细胞瘤1例；肿瘤最大径10~22 cm，平均最大径（13.07±3.57）cm；24例患者合并微血管癌栓（包括11例肉眼可见癌栓）。平均住院时间（14.71±4.84）d。术后并发症Clavien分级分别为I级23例，II级1例，IIIa级4例。结论 巨大肝恶性肿瘤切除手术中运用IOUS及CEIOUS，可帮助优化手术策略及方案，帮助术中明确肿块与血管的关系，帮助术中定位癌栓及子灶，对于保障术中安全，术后恢复及远期治疗效果有重要意义。
Background and Aims Giant hepatic malignant tumor are generally poorly differentiated and often associated with vascular invasion. In recent years, the therapeutic efficacy for giant hepatic malignant tumor has been improved with the progress of both regional and comprehensive treatment. Surgical excision is one of the main treatment modalities. However, the operation is often difficult due to the intraoperative complexity such as tumor rupture, tumor thrombus spread, and omission of metastasis, which may cause the uncertainty of the treatment results. This study was performed to investigate the application and significance of intraoperative ultrasound (IOUS) and intraoperative contrast-enhanced ultrasound (CEIOUS) in the surgical treatment of giant hepatic malignant tumor, so as to help optimize the surgical procedure and obtain better oncological results.Methods The clinical data of 28 patients with giant hepatic malignant tumor undergoing surgical treatment under guidance of IOUS and CEIOUS at Hunan Provincial People's Hospital from January 2019 to August 2021 were retrospectively analyzed. All patients underwent laparotomy, and the pathological results, surgical methods, tumor size, tumor thrombus and intrahepatic metastasis, operative time, intraoperative bleeding and blood transfusion volume, postoperative hospital stay and postoperative complications were statistically analyzed.Results All patients underwent open surgery. The incisions included the inverse L-shaped incision (6 cases), fishhook-shaped incision (9 cases) and thoracicoabdominal incision (13 cases); all hepatic segments were involved in terms of the liver resection scope for the entire group, and some patients underwent combined resection of other organs; patients (11 cases) with visible vascular tumor thrombus underwent en-block resection of the primary tumor with the tumor thrombus (5 cases) or thrombectomy by venous incision (6 cases); the intrahepatic metastases (11 cases) identified by preoperative imaging examination and IOUS or CEIOUS were treated by excision or microwave ablation. The mean operation time was (365.18±110.45) min (range 190-560 min), the average blood loss was (598.21±414.43) mL (range 100-1 800 mL), 7 patients transfused with packed red cells during operation with an average infusion volume of (714.29±328.78) mL (range 400-1 300 mL), and 6 patients received fresh frozen plasma during operation with an average infusion volume of (325.00±117.26) mL (range 150-400 mL); the average number of hepatic inflow occlusion times was 4.82±2.36 (1-12 times). The postoperative pathological results showed that there were 24 cases of hepatocellular carcinoma, 2 cases of cholangiocarcinoma, 1 case of hepatocellular carcinoma with bile duct differentiation and 1 case of hepatoblastoma; the mean maximum diameter of the tumor was (13.07±3.57) cm (range 10-22 cm); there were 24 patients with microvascular tumor thrombus (including the 11 cases with visible vascular tumor thrombus). The mean hospital stay was (14.71±4.84) d (range 8-28 d). Clavien classification of surgical complications was grade I in 23 cases, grade II in 1 case and grade IIIa in 4 cases, respectively.Conclusion The application of IOUS and CEIOUS in the resection of giant hepatic malignant tumor can help optimize the surgical strategy and operation plan, identify the relationship between the tumor and blood vessels, and locate the tumor thrombus and metastatic lesions, which is of great significance to ensure the intraoperative safety, satisfactory postoperative recovery and long-term oncological outcomes.