对肝癌肝切除术指证的新近认识.pptx

对肝癌肝切除术指证的新近认识
第二军医大学东方肝胆外科医院
沈锋
有很多因素影响肝癌肝切除术的选择--
[Vauthey JN, HPB 2010]
在作肝切除选择时,主要考虑全身情况,肝功能,肝体积和肿瘤病理
Child-Pugh评分
[Ishizawa T, Gastroenterology 2008;
Bruix J, Hepatology 2010;
Vathey JN, HPB 2010]
肝切除术适合于Child–Pugh A 和 well B
Child–Pugh评分在预后评估上有局限性
Child–Pugh A 的病人可能已有肝功能的
明显损害:总胆红素升高,门脉高压,用利
尿剂控制的腹水
Liver function
终末期肝病模型(model for end stage liver disease, MELD)
MELD 评分能比较准确预测肝硬化病人手术后肝功能衰竭和其他
并发症的发生,是比较理想的肝储备功能评估方法
[hetti A, Liver Transpl 2006]
Retrospective evaluation of
145 cirrhotic patients
that underwent surgical resection
Risk of . liver failure (%)
AUC , 95% CI -
Risk of . complications (%)
AUC , 95% CI -
MELD评分=×ln(肌酐mg/dl)+×ln(胆红素mg/dl)+×ln(凝血酶原时间国际标准化比值)+×病因(胆汁淤滞性和酒精性肝硬化为0,病毒等其他原因肝硬化为1),结果取整数
9分以下,安全
11分以上,危险
9—11分?
Definition: “A tricarbocyanine dye that is used diagnostically in liver function tests and to determine blood volume and cardiac output”[Caesar, Clin Sci 1961]
Mechanism of Action: Its active transfer into the liver parenchymal cells leads to a rapid disappearance from the plasma, and it appears to be solely removed by the liver [Wheeler, Proc Soc Exp Biol Med 1958]
吲哚菁绿(indocyaninegreen,ICG)排泄试验
东京大学肝脏切除安全限量的评估标准
[Imamura H,JHP 2005]
Fibroscan
LSM using FibroScan reflects
the degree of hepatic fibrosis
[Ziol, Hepatology 2005]
LSM is a predictor of
Hepatocellular Carcinoma
[Masuzaki, Hepatology 2009]
LSM before surgery?
[Kim, Hepatol Int, 2008]
Fibroscan
LSM as a predictor of the development of postoperative hepatic insufficiency
LSM 72 pts before surgery
依靠肝功能的治疗选择
A
B
Limited resections
NO
YES
<10%
10-20%
20-40%
>40%
Major surgery ±
PVE
Major hepatectomy
No surgery
Limited resections (<3 segments)
CHILD-PUGH
PORTAL HYPERTENSION
ICGR15
[Yamanaka, World J Surg 2007]
肝体积计算
Future Liver Remnant (%) = Remnant Volume*100
Total Liver Volume
FLR
[Clavien PA, NEJM 2007]
结合多种因素的术前评估
Child-Pugh
Portal Hypertension
FLR
ICG