黄家龙,韦秋吉,黄云清,吴红德,区军杰

肝癌，尤其是肝细胞癌（HCC），是全球范围内发病率和死亡率极高的恶性肿瘤。手术切除是实现根治和长期生存的最主要手段。然而，肝癌患者常合并肝硬化，肝脏储备功能有限，限制了可切除的肝体积。术后肝功能衰竭（Post-hepatectomy Liver Failure，PHLF）是肝脏外科最凶险的并发症，而剩余肝脏体积（future liver remnant，FLR）不足是限制肝癌切除的核心瓶颈。对于肿瘤负荷大或合并肝硬化的患者，FLR不足常使手术切除陷入“切除不彻底则复发风险高，切除范围过大则肝衰风险高”的两难境地。因此，如何安全、有效地增加FLR已成为扩大肝癌手术适应症、提高手术安全性的核心热点议题。随着肝脏外科理论创新与技术突破，以肝脏强大再生能力为基础的FLR增容技术不断发展，本综述旨在系统阐述近年来在临床应用中，通过门静脉栓塞（PVE）、联合肝脏分割和门静脉结扎的二步肝切除术（ALPPS）、肝静脉系统重建、联合辅助治疗等多技术融合的个体化治疗体系，比较其优劣，并展望未来发展方向。

肝癌手术；剩余肝脏体积；术后肝功能衰竭。

[1] 中华人民共和国国家卫生健康委员会医政司.原发性肝癌诊疗指南(2024年版)[J].中国实用外科杂志,2024,44(4):361-386. [2] Kishi Y,Vauthey JN.Issues to be considered to address the fu-ture liver remnant prior to major hepatectomy[J].Surg Today,2021,51(4):472-484. [3] Okabe H,Beppu T,Ishiko T,et al.Preoperative portal vein em-bolization(PVE)for patients with hepatocellular carcinoma canimprove resectability and may improve disease-free survival[J].J Surg Oncol,2011,104(6):641-646. [4] Huang Y,Ge W,Kong Y,et al.Preoperative portal vein emboli-zation for liver resection:An updated meta-analysis[J].J Cancer,2021, 12(6):1770-1778. [5] Dhurandhar V,Waugh R,Ahmed S,et al.An observational study to determine volume changes in the functional liver remnant fol-lowing portal vein embolization[J].JGH Open,2021,5(8):941-946. [6] Loveday BPT,Jaberi A,Moulton CA,et al.Effect of portal vein embolization on treatment plan prior to major hepatectomy for hepatocellular carcinoma[J].HPB(Oxford),2019,21(8):1072-1078. [7] Chansangrat J,Keeratibharat N.Portal vein embolization:ratio-nale,techniques,outcomes and novel strategies[J].Hepat On-col,2021,8(4):42. [8] 彭淑牖,黄从云,王许安,等.末梢门静脉栓塞技术在余肝体积不足肝细胞癌中的应用价值[J].中华外科杂志,2021,59(10):829-835. [9] 刘文瑛,阙园,欧阳再兴,等.末梢门静脉栓塞联合多模态影像技术在巨大肝癌外科治疗中的应用[J].实用医学杂志,2023, 39(12):1546-1550. [10] 焦娇,郭意男,章国君,等.乙肝肝硬化进展原发性肝癌的危险因素研究[J].预防医学,2019,31(4):363-370. [11] Piardi T,Memeo R,Renard Y,et al.Management of large hepa-tocellular carcinoma by sequential transarterial chemoemboli-zation and portal vein embolization:A systematic review of the literature[J].Minerva Chir,2016,71(3):192-200.PMID:26883849. [12] Schlitt HJ,Hackl C,Lang SA.'In-situ split'liver resection/ALPPS-historical development and current practice[J].Visc Med,2017, 33(6):408-412. [13] Aloia TA,Vauthey JN.Associating liver partition and portal vein ligation for staged hepatectomy(ALPPS):What is gained and what is lost?[J].Ann Surg,2012,256(3):e16-e19. [14] Figueras J,Belghiti J.The ALPPS approach:Should we sacrifice basic therapeutic rules in the name of innovation?[J].World J Surg,2014,38(6):1520-1521. [15] Dokmak S,Belghiti J.Which limits to the"ALPPS"approach?[J].Ann Surg,2012,256(3):e16-e17. [16] Schadde E,Ardiles V,Robles-Campos R,et al.Early survival and safety of ALPPS:first report of the International ALPPS registry[J]. Ann Surg,2014,260(5):829-838. [17] Truant S,El Amrani M,Baillet C,et al.Laparoscopic partial ALPPS:Much better than ALPPS![J].Ann Hepatol,2019,18(1):269-273. [18] Machado MAC,Surjan RC,Makdissi F.Robotic ALPPS[J].Ann Surg Oncol,2020,7(4):1174-1179. [19] Guiu B,Chevallier P,Denys A,et al.Simultaneous trans-hepatic portal and hepatic vein embolization before major hepatectomy:the liver venous deprivation technique[J].Eur Radiol,2016,26(12):4259-4267. [20] Guiu B,Quenet F,Escal L,et al.Extended liver venous depriva-tion before major hepatectomy induces marked and very rapid increase in future liver remnant function[J].Eur Radiol,2017,27(8):3343-3352. [21] Kobayashi K,Yamaguchi T,Denys A,et al.Liver venous depri-vation compared to portal vein embolization to induce hypertro-phy of the future liver remnant before major hepatectomy:A single center experience[J].Surgery,2020,167(6):917-923. [22] Le Roy B,Gallon A,Cauchy F,et al.Combined biembolization in-duces higher hypertrophy than portal vein embolization before major liver resection[J].HPB(Oxford),2020,22(2):298-305. [23] Chebaro A,Buc E,Durin T,et al.Liver venous deprivation or as-sociating liver partition and portal vein ligation for staged hepa- tectomy?:A retrospective multicentric study[J].Ann Surg,2021,274(5):874-880. [24] Böning G,Fehrenbach U,Auer TA,et al.Liver venous depriva-tion(LVD)versus portal vein embolization(PVE)alone prior to extended hepatectomy:A matched pair analysis[J].Cardiovasc Intervent Radiol,2022,45(7):950-957. [25] 侯昌龙,王继洲,宋瑞鹏,等.术前肝静脉剥夺术同期联合精准肝动脉化疗栓塞在原发性大肝癌二期切除中应用价值研究[J].中国实用外科杂志,2022,42(6):667-671. [26] Gaba RC,Lewandowski RJ,Kulik LM,et al.Radiation lobec-tomy:Preliminary findings of hepatic volumetric response to lo-bar yttrium-90 radioembolization[J].Ann Surg Oncol,2009,16(6):1587-1596. [27] Hamad A,Aziz H,Kamel IR,et al.Yttrium-90 radioemboliza-tion:Current indications and outcomes[J].Gastrointest Surg,2023,27(3):604-614. [28] Malhotra A,Liu DM,Talenfeld AD.Radiation segmentectomyand radiation lobectomy:A practical review of techniques[J].Tech Vasc Interv Radiol,2019,22(2):49-57. [29] 邵明华,谭斌彬,付颖,等.钇-90树脂微球经动脉放射栓塞治疗初始不可切除肝脏恶性肿瘤的安全性和短期疗效[J].中华消化外科杂志,2024,23(7):969-975. [30] 肖治宇,陈亚进.不可切除中晚期肝癌的转化治疗后肝切除术[J].中国实用外科杂志,2021,41(3):275-280. [31] 陈亚进.肝癌转化治疗现状与思考[J].中国实用外科杂志,2021,41(3):253-256+261.

点击下载PDF