中国实用外科杂志

中国实用外科杂志 ›› 2023, Vol. 43 ›› Issue (10): 1171-1175.DOI: 10.19538/j.cjps.issn1005-2208.2023.10.21

• 论著 • 上一篇    下一篇

剩余肝体积不足肝细胞癌病人以术中吲哚菁绿排泄试验决定手术策略的安全性及有效性分析

石维一，纪    任，刘春红，洪晓明，邱思远，范卫填，陈智仁，黄楚琳，张丹图   

  1. 香港大学深圳医院肝胆胰外科，广东深圳 518053
  • 出版日期:2023-10-01 发布日期:2023-10-24

  • Online:2023-10-01 Published:2023-10-24

摘要： 目的    探讨对剩余肝体积不足［剩余肝体积/标准肝体积（FLR/SLV）<40%］的肝细胞癌（HCC）病人以术中吲哚菁绿15 min滞留率（ICG R15）决定手术策略的安全性及有效性。方法    回顾性分析2015年6月至2021年6月香港大学深圳医院肝胆胰外科收治的FLR/SLV<40%的31例HCC病人的临床资料，均计划行右半肝或扩大右半肝切除术，术中暂时性阻断门静脉右支和肝右动脉后进行ICG R15检测，ICG R15<20%则行同期右半肝或扩大右半肝切除（同期组，18例），ICG R15≥20%则行联合肝脏分隔和门静脉结扎的二步肝切除术（分期组，13例），比较两组手术时间、出血量、术后并发症、病死率及住院时间等指标。结果    31例HCC病人均成功完成手术。分期组与同期组术前ICG R15值中位数差异无统计学意义（P＞0.05），而术中ICG R15值差异有统计学意义［28.7%（23.6%~57.3%） vs. 14.8%（8.8%~10.8%），Z=-4.686，P＜0.05］。两组术中出血量、术后输血以及术后并发症发生率差异无统计学意义（P＞0.05），术后均无死亡病例。术后病理学检查结果示，两组病人均有不同程度的肝纤维化（S1~S3）和肝硬化（S4），发生率差异无统计学意义［肝纤维化：76.9%（9/13） vs. 83.3%（15/18），P=0.856；肝硬化：15.4%（2/13） vs. 16.7%（3/18），P=0.9237］。两组病人1、2、3年累积生存率和无瘤生存率差异无统计学意义（P＞0.05）。结论    对于剩余肝体积不足的HCC病人，以术中ICG R15决定手术是否分步实施方法安全、有效，既可扩大根治性手术指征，又可避免部分病人的非必要分期手术。

关键词: 吲哚菁绿, 联合肝脏分隔和门静脉结扎的二步肝切除术, 肝切除术, 剩余肝体积, 肝细胞癌

Abstract: Experience analysis of intraoperative ICG R15 guiding the step-by-step operation of HCC patients with insufficient future liver remnant        SHI Wei-yi, JI Ren, LIU Chun-hong, et al. Department of Hepatobiliary and Pancreatic Surgery, the University of Hong Kong-Shenzhen Hospital, Shenzhen 518053, China 
Corresponding author: JI Ren, E-mail:jir@hku-szh.org
Abstract    Objective    To investigate the safety and efficacy of intraoperative indocyanine green retention percentage at 15 min(ICG R15) to determine surgical staging in HCC patients with future liver remnant(FLR/SLV)<40%. Methods  The data of 31 cases of HCC with future liver remnant（FLR/SLV）<40% in the University of Hong Kong Shenzhen Hospital from June 2015 to June 2021 were retrospectively analyzed. The ICG R15 was measured after temporary occlusion of the right portal vein and right hepatic artery. If less than 20%, simultaneous right hepatectomy/extended right hepatectomy(n=18) was performed, and if greater than 20%, staged hepatectomy(ALPPS) was performed(n=13), the operation time, blood loss, postoperative complications, mortality and hospitalization time were compared between the two groups. Results    All 31 HCC patients successfully completed the surgery. There was no statistically significant difference in the median preoperative ICG R15 value between the two groups (P>0.05), while there was a statistically significant difference in the median intraoperative ICG R15 value (28.7%(23.6%~57.3%) vs. 14.8%(8.8%~10.8%), Z=-4.686, P<0.05). The blood loss, transfusion, and postoperative complications were similar in the two groups (P>0.05), and there was no postoperative death. The postoperative pathological examination results showed that both groups of patients had varying degrees of liver fibrosis (S1-S3) and cirrhosis (S4, with no statistically significant difference in incidence (P>0.05). Survival analysis showed that there was no statistically significant difference in cumulative survival rate and tumor-free survival rate between the two groups (P>0.05). Conclusion    For HCC patients with insufficient future liver remnants, intraoperative ICG R15 is used to determine whether the step-by-step operation is safe and reliable, which can not only expand the indications for radical surgery, but also avoid unnecessary staged surgery for some patients.

Key words: indocyanine green, associating liver partition and portal vein ligation for staged hepatectomy, hepatectomy, future liver remnant, hepatocellular carcinoma