腹腔镜解剖性肝切除术治疗肝细胞癌的现状与思考

摘要/Abstract

摘要： 肝细胞癌（hepatocellular carcinoma,HCC）的发病率和病死率很高,肝切除术是其最有效的治愈性治疗措施之一。由于HCC经门静脉转移的生物学行为特征,解剖性肝切除术（anatomical liver resection,AR）在切除肿瘤的同时,一并切除了荷瘤门静脉分支流域肝段,能有效减少HCC术后局部复发,改善远期生存。近年来,腹腔镜AR已实现技术和理念双重跨越,广泛应用于HCC的治疗,并已形成规范化的操作流程,从外科学和肿瘤学的角度,均被证实能给患者带来微创和生存双重获益。3D可视化、腹腔镜超声和吲哚氰绿（indocyanine green,ICG）融合荧光等导航技术的应用,更有利于腹腔镜AR的实施。针对HCC患者,在条件允许情况下,应首选腹腔镜AR。但对肝硬化严重、剩余肝脏体积不足、肿瘤过大、位于中央区或邻近重要血管的HCC患者,也不必强求实施AR。无论是腹腔镜AR还是非解剖性肝切除术（non-anatomical liver resection,NAR）,均应秉持以肿瘤为中心、以切缘为本的原则。精湛的外科技术是实施腹腔镜AR的前提,早期诊断和综合治疗依然是提高HCC总体疗效的重要手段。腹腔镜限量AR强调以肿瘤为中心,以荷瘤门静脉流域为参考平面,既最大限度切除荷瘤门静脉流域肝组织,又最大限度保留功能性肝组织的结构和体积,将成为HCC微创精准治疗的重要手段之一。由于肝脏解剖复杂,HCC生物肿瘤学行为特殊多变,有关腹腔镜AR治疗HCC,尚存一些争议和值得思索解决的问题。

关键词: 肝细胞癌, 腹腔镜, 解剖性肝切除术

Abstract: Hepatectomy is one of the most effective therapeutic measures for the hepatocellular carcinoma (HCC) with high morbidity and mortality. Due to the biological characteristics of HCC metastasis through portal vein, removing both the tumor and the hepatic segment of the tumor-bearing portal territory by anatomical liver resection (AR) can effectively reduce the postoperative local recurrence and improve the long-term survival of HCC patients. In recent years, laparoscopic AR, which is widely used in the treatment of HCC, has formed a standardized operation process and achieved a double improvement in technology and concept. From the perspective of surgery and oncology, it has been proved that laparoscopic AR can bring patients both minimally invasive and survival benefits. The application of navigation techniques such as 3D visualization, laparoscopic ultrasound and indocyanine green (ICG) fusion fluorescence is more conducive to the implementation of laparoscopic AR. For HCC patients, laparoscopic AR should be the first choice if conditions permit. However, AR is not necessary for HCC patients with conditions such as severe cirrhosis, insufficient residual liver volume, large tumor and tumor located in the central region or adjacent major vessels. Both laparoscopic AR and non-anatomical liver resection (NAR) should adhere to the principle of tumor centered and margin oriented. Skillful surgical technique is the prerequisite for laparoscopic AR, while early diagnosis and comprehensive treatment remain important to improve the overall survive of patients with HCC. Laparoscopic limited AR emphasizes taking the tumor as the center and the tumor-bearing portal territory as the reference plane. It will not only maximally remove the liver tissue in the tumor-bearing portal territory, but also maximally retain the structure and volume of functional liver tissue, and it will become one of the most important methods for minimally invasive and precise treatment of HCC. Owing to the complexity of liver anatomy and the special and changeable bio-oncology behaviors of HCC, there are still some controversies and problems worthy of consideration in the treatment of HCC by laparoscopic AR.

Key words: Hepatocellular carcinoma, Laparoscope, Anatomical liver resection

郑博文, 郑树国. 腹腔镜解剖性肝切除术治疗肝细胞癌的现状与思考[J]. 肝癌电子杂志, 2021, 8(4): 1-5.

Zheng Bowen, Zheng Shuguo. Current status and consideration of laparoscopic anatomical liver resection for hepatocellular carcinoma[J]. Electronic Journal of Liver Tumor, 2021, 8(4): 1-5.

参考文献

[1] TANG A, HALLOUCH O, CHERNYAK V, et al.Epidemiology of hepatocellular carcinoma: target population for surveillance and diagnosis[J]. Abdom Radiol (NY), 2018, 43(1): 13-25.
[2] ZENG H, CHEN W, ZHENG R, et al.Changing cancer survival in China during 2003-15: a pooled analysis of 17 population-based cancer registries[J]. Lancet Glob Health, 2018, 6(5): e555-e567.
[3] JIAO S, LI G, ZHANG D, et al.Anatomic versus non-anatomic resection for hepatocellular carcinoma, do we have an answer? A meta-analysis[J]. Int J Surg, 2020, 80: 243-255.
[4] HIBI T, CHERQUI D, GELLER D A, et al.Expanding indications and regional diversity in laparoscopic liver resection unveiled by the International Survey on Technical Aspects of Laparoscopic Liver Resection (INSTALL) study[J]. Surg Endosc, 2016, 30(7): 2975-2983.
[5] MAKUUCHI M. Surgical treatment for HCC--special reference to anatomical resection[J]. Int J Surg, 2013, 11 Suppl 1: S47-S49.
[6] MORIS D, TSILIMIGRAS D I, KOSTAKIS I D, et al.Anatomic versus non-anatomic resection for hepatocellular carcinoma: A systematic review and meta-analysis[J]. Eur J Surg Oncol, 2018, 44(7): 927-938.
[7] FENG X, SU Y, ZHENG S, et al.A double blinded prospective randomized trial comparing the effect of anatomic versus non-anatomic resection on hepatocellular carcinoma recurrence[J]. HPB (Oxford), 2017, 19(8): 667-674.
[8] HUANG X, LU S.A Meta-analysis comparing the effect of anatomical resection vs. non-anatomical resection on the long-term outcomes for patients undergoing hepatic resection for hepatocellular carcinoma[J]. HPB (Oxford), 2017, 19(10): 843-849.
[9] KANG K J, AHN K S.Anatomical resection of hepatocellular carcinoma: A critical review of the procedure and its benefits on survival[J]. World J Gastroenterol, 2017, 23(7): 1139-1146.
[10] HOKUTO D, NOMI T, YASUDA S, et al.Does anatomic resection improve the postoperative outcomes of solitary hepatocellular carcinomas located on the liver surface?[J]. Surgery, 2018, 163(2): 285-290.
[11] MATSUMOTO T, KUBOTA K, AOKI T, et al.Clinical Impact of Anatomical Liver Resection for Hepatocellular Carcinoma with Pathologically Proven Portal Vein Invasion[J]. World J Surg, 2016, 40(2): 402-411.
[12] HASEGAWA K, KOKUDO N, IMAMURA H, et al.Prognostic Impact of Anatomic Resection for Hepatocellular Carcinoma[J]. Ann Surg, 2005, 242(2): 252-259.
[13] KAIBORI M, KON M, KITAWAKI T, et al.Comparison of anatomic and non-anatomic hepatic resection for hepatocellular carcinoma[J]. J Hepatobiliary Pancreat Sci, 2017, 24(11): 616-626.
[14] 王晓耘, 马增辉, 史佩东. 解剖性肝段切除术关键技术和争议[J/OL]. 中华肝脏外科手术学电子杂志, 2020, 9(4): 317-320.
[15] KANG W, KIM K, JUNG D, et al.Long-term results of laparoscopic liver resection for the primary treatment of hepatocellular carcinoma: role of the surgeon in anatomical resection[J]. Surg Endosc, 2018, 32(11): 4481-4490.
[16] ISHIZAWA T, GUMBS A A, KOKUDO N, et al.Laparoscopic Segmentectomy of the Liver[J]. Ann Surg, 2012, 256(6): 959-964.
[17] XIANG L, XIAO L, LI J, et al.Safety and Feasibility of Laparoscopic Hepatectomy for Hepatocellular Carcinoma in the Posterosuperior Liver Segments[J]. World J Surg, 2015, 39(5): 1202-1209.
[18] XIAO L, XIANG L, LI J, et al.Laparoscopic versus open liver resection for hepatocellular carcinoma in posterosuperior segments[J]. Surg Endosc, 2015, 29(10): 2994-3001.
[19] SONG J, WANG Y, MA K, et al.Laparoscopic hepatectomy versus radiofrequency ablation for minimally invasive treatment of single, small hepatocellular carcinomas[J]. Surg Endosc, 2016, 30(10): 4249-4257.
[20] MORISE Z, WAKABAYASHI G.First quarter century of laparoscopic liver resection[J]. World J Gastroenterol, 2017, 23(20): 3581-3588.
[21] RYU T, HONDA G, KURATA M, et al.Perioperative and oncological outcomes of laparoscopic anatomical hepatectomy for hepatocellular carcinoma introduced gradually in a single center[J]. Surg Endosc, 2018, 32(2): 790-798.
[22] 郑树国. 腹腔镜肝切除术肝静脉系统出血处理策略[J]. 中国实用外科杂志, 2017, 37(5): 485-489.
[23] 乔婷, 王峻峰. 影像组学在肝癌中的研究应用[J]. 影像研究与医学应用, 2021, 5(11): 1-2.
[24] 罗湘, 李涛, 朱继业, 等. 三维重建在精准肝切除治疗复杂原发性肝癌术前评估中的应用[J]. 中华医学杂志, 2021, 101(28): 2210-2215.
[25] MAKUUCHI M, HASEGAWA H, YAMAZAKI S.Ultrasonically guided subsegmentectomy[J]. Surg Gynecol Obstet, 1985, 161(4): 346-350.
[26] XU Y, CHEN M, MENG X, et al.Laparoscopic anatomical liver resection guided by real-time indocyanine green fluorescence imaging: experience and lessons learned from the initial series in a single center[J]. Surg Endosc, 2020, 34(10): 4683-4691.
[27] CHIOW A, RHO S Y, WEE I, et al.Robotic ICG guided anatomical liver resection in a multi-centre cohort: an evolution from "positive staining" into "negative staining" method[J]. HPB (Oxford), 2021, 23(3): 475-482.
[28] KALIL J A, POIRIER J, BECKER B, et al.Laparoscopic Parenchymal-Sparing Hepatectomy: the New Maximally Minimal Invasive Surgery of the Liver-a Systematic Review and Meta-Analysis[J]. J Gastrointest Surg, 2019, 23(4): 860-869.
[29] BERARDI G, IGARASHI K, LI C J, et al.Parenchymal Sparing Anatomical Liver Resections With Full Laparoscopic Approach: Description of Technique and Short-term Results[J]. Ann Surg, 2021, 273(4): 785-791.
[30] CONRAD C, OGISO S, INOUE Y, et al.Laparoscopic parenchymal-sparing liver resection of lesions in the central segments: feasible, safe, and effective[J]. Surg Endosc, 2015, 29(8): 2410-2417.