自1888年Langenbuch为肝脏肿瘤患者施行首例肝切除术后，肝脏外科至今已有一百多年历史。我国的肝脏外科经历了20世纪50年代的大肝癌的规则性切除，60年代的肝移植，70年代的小肝癌的局部切除，80年代的复发肝癌的再切除和肝癌的二期切除，90年代确立的肝癌综合治疗以及21世纪的肝癌转移、复发的防治研究阶段。肿瘤的早期发现和以手术切除为主的综合治疗大大提高了肝癌患者的生存率，手术切除仍是获得长期生存的最重要手段。随着肝脏解剖学的发展、影像学技术的进步、术中超声的应用、肝储备功能评估方法的改进、围手术期处理的完善、手术技术的进步以及手术器械的发展，使肝切除手术的死亡率和术后并发症发生率大大降低。近年来，微创观念和微创外科技术的兴起以及肝移植特别是活体肝移植(LDLT)的蓬勃开展，对传统的肝切除术造成巨大冲击，也因此促使了肝切除术的不断发展、丰富和完善。如何安全、彻底地切除肝脏病灶，同时保留充足的功能性肝组织，成为外科医师面临的新挑战。................
ObjectiveTo study the relationship between cholecystectomy and Helicobacter pylori （Hp） infection. MethodsOne hundred and eleven patients with cholecystolithiasis were chosen as the investigation group, while 577 patients with upper digestive tract symptoms without cholecystolithiasis as the control group. All the patients took the 13C breath test to determine whether they were infected by Hp. All the patients with Hp infection continued eradical therapy for Hp infection for one course after cholecystectomy and were followed up on outpatient basis. ResultsThe infection rate in the investigation group was 45.9%, while 27.4% in the control group. During the 3 to 6 months of followup for the patients undergoing eradical therapy for Hp infection, we found no patient complaining of epigastric pain, malaise, belching and nausea. ConclusionThe infection rate of Hp in patients with cholecystolithiasis is high, Hp may be one of the factors causing “postcholecystectomy syndrome”. Eradical therapy for Hp after cholecystectomy will help improve the effects of operation.
Objective To evaluate the effectiveness and prognosis of patients in advanced hepatocellular carcinoma (HCC) with portal vein (PV) tumor thrombus received external-beam radiation therapy (EBRT). Methods The clinical data of 126 HCC patients with PV tumor thrombus who were referred for EBRT at our institution from January 2000 to November 2009 were analyzed retrospectively. EBRT was designed to focus on the tumor thrombus with or without primary intrahepatic tumors， to deliver a median total conventional dose of 50 Gy (range of 30-60 Gy). Predictors of survival were identified using univariate and multivariate analysis. Results Unfavorable pretreatment predictors were associated by multivariate analysis with lower albumin and higher α-fetoprotein levels, poorer Child-Pugh liver function classification, poorer intrahepatic tumor control， lymph node metastases， and the two-dimensional EBRT technique. The dose of EBRT showed no significant in both univariate and multivariate survival analysis. Conclusions In patients with HCC， EBRT is effectively prevents progression in cases of PV tumor thrombus， but palliative dose of EBRT is not related to survival.EBRT is not related to survival.
Objective To report the authors’ own experience and results of recent studies of anatomical liver resection for patients with hepatocellular carcinoma (HCC). Methods From January 2004 to June 2005, anatomical liver resection procedure were completed in 93 patients with HCC. Surgical techniques were designed to reduce intraoperative blood loss, blood transfusion and postoperative complications by parenchymal crushing with kelly forceps, inflow and outflow selective clamping. In 13 patients with large liver tumors, liver hanging maneuver performed in the course of hemihepatectomy. Liver transection with intermittent closure of the blood influx to the liver, using a Pringle manoeuvre. Results Of 93 patients undergoing hepatectomy for HCC, underlying cirrhosis was present in 82 (88%) patients. The median blood loss was 300 ml (100－6 000 ml) and 71%（66/93） of the patients did not require blood transfusion.The postoperative complication rate was 34%（32/93）, complications were primarily subphrenic collection (8 cases). Within 30 postoperative days, no death was recorded. Conclusion The anatomical liver resection of HCC may be improve the surgical outcome.
ObjectiveTo evaluate the safety and technical feasibility of salvage liver transplantation (SLT) after liver resection, and its influence on prognosis. MethodsThe clinical data of 289 patients who underwent liver transplantation by cadaveric grafts treating for hepatocellular carcinoma met the UCSF criteria from June 2001 to December 2008 were analyzed retrospectively. Among them, 242 patients underwent primary liver transplantation (PLT, PLT group), and 47 patients underwent SLT for recurrence (SLT group). Perioperative factors and survival were compared between two groups. ResultsThere were no significant differences of age, gender, and pathology of tumor between two groups (Pgt;0.05). The operation time in the SLT group was significantly longer than that in the PLT group 〔(7.1±1.8) h versus (6.4±1.4) h， P=0.004〕. The differences of intraoperative blood loss 〔(2 560.5±2 683.6) ml versus (2 042.9±2 006.2) ml， P=0.173〕 and blood transfusion 〔(13.8±12.9) U versus (9.9±12.6) U， P=0.087〕 were not significant between two groups. The mean interval time from resection to transplantation was (32.8±32.4) months. The median followup was 38.7 months, 3year overall and diseasefree survivals were not significantly different (82.3% versus 75.5%, P=0.312; 78.8% versus 70.1%, P=0.755, respectively) between the SLT group and PLT group. According to intentiontotreat analysis, the 3year overall survival in the SLT group was significantly longer than that in the PLT group (88.4% versus 76.2%, P=0.047). ConclusionsIn selected patients, liver resection prior to transplantation neither increases operative morbidity nor impairs prognosis following liver transplantation. SLT after liver resection, can be an alterative treatment for HCC.
Objective To study the effect of HBeAg on recurrence and survival after radical resection of small (≤3 cm) hepatocellular carcinoma (HCC). Methods Two hundreds and twenty-three HCC patients undergone radical resection from 1999 to 2000 were divided into two groups according to serum HBeAg status， HBeAg positive group (n=73) and HBeAg negative group (n=150). The patients’ factors, operative factors and tumorous facors were studied retrospectively between the two groups. And risk factors of overall survival (OS) and disease-free survival (DFS) were analyzed. Results There were no significant differences in operative and tumorous factors between the two groups, but the HBeAg positive group were younger with more severe cirrhosis (P=0.004, P=0.008). The OS and DFS were significantly different between the HBeAg positive group and HBeAg negative group. The 1-, 3- and 5-year OS were 91.5%, 76.8%, 60.1% and 95.2%, 85.3%, 73.2%, respectively (P=0.053)； and the 1-, 3- and 5-year DFS were 73.3%, 53.7%, 40.3% and 86.6%, 65.5%, 54.5%, respectively (P=0.002). Multivariate analysis revealed that age ＞50 years, HBeAg positive and macronodular cirrhosis were significantly related to OS, and HBeAg positive, multiple tumor nodulars were significantly related to DFS. Positive serum HBeAg status was an independent risk factor for both OS and DFS. Conclusion Positive serum HBeAg is closely related to early recurrence and survival after radical resection of patients with small HCC.