摘要
世界不同国家和地区肝癌和肝癌破裂发生率差异很大。同肝癌一样,肝癌破裂病死率很高。肝癌破裂的原因,推论很多而且十分具有争议性。肝癌破裂的诊断主要通过临床和影像学检查,确诊率很高。肝癌破裂的治疗主要分为3个处理阶段:(1)急症阶段。主要通过复苏治疗,稳定病人和停止肝癌破裂出血。停止肝癌破裂出血的方法包括改善病人凝血功能障碍,介入治疗(肝动脉栓塞)和手术治疗(围肝脏纱布填塞、肝动脉结扎、使用能量器械或化学制剂直接止血和急症期肝部分切除术)。(2)评估阶段。病人肝癌破裂停止出血后进行评估,包括病人整体情况、肝功能、肿瘤分期、肝癌(包括肿瘤位置)能否切除、剩余肝脏体积情况、是否伴有肝硬化或门静脉高压症。(3)决定性治疗阶段。该阶段主要分为治愈性和非治愈性。由于肝癌破裂是肝移植的禁忌证,肝部分切除术是唯一治愈性手段。术中使用蒸馏水或5-氟尿嘧啶灌洗腹腔,可有效降低术后肝癌腹膜转移率。肝部分切除术可在急症期(出血期间),延迟早期(肝癌破裂时间≤8 d)或延迟晚期(肝癌破裂时间>8 d)施行。在急症期或延迟早期施行肝部分切除术,术后肝癌腹膜转移率比延迟晚期低。肝癌破裂停止出血后,对于无法施行肝部分切除术的病人,其治疗方法与没有肝癌破裂的病人无较大差别。在可施行肝部分切除术的病人中,手术是最好的治疗手段。肝部分切除术病人的远期生存率高于其他任何非手术治疗(包括经肝动脉栓塞或化疗栓塞)。
The incidences of hepatocellular carcinoma(HCC)and ruptured HCC differ significantly in different countries and regions of the world.Ruptured HCC has a very high mortality rate,although the underlying mechanisms why it occurs remain controversial.The diagnosis of ruptured HCC is made based on clinical and imaging examinations.Management of ruptured HCC can be divided into 3 phases.Phase 1:the emergency phase.The treatment aims are to stabilize the patient and stop bleeding by resuscitation.Methodswhich can be used to stop bleeding include correction of coagulopathies,interventional therapy(transarterial embolization)and surgery(including perihepatic packing,hepatic artery ligation,application of energy source or direct injection of ethanol,or even emergency partial hepatectomy).Phase 2:the assessment phase.After the bleeding has been stopped,the next phase is assessment,which includes assessing the general condition of patients,liver function,tumor staging,resectability of tumor,volume of future liver remnant,comorbidity and association with cirrhosis and/or portal hypertension.Phase 3:definitive treatment phase.The definitive treatment can be divided into curative and non-curative treatments.As ruptured HCC is a contraindication to liver transplantation,the only available curative treatment is partial hepatectomy.There is evidence to show that peritoneal irrigation with water or 5-FU during partial hepatectomy for ruptured HCC can reduce the rate of tumor implantation.The timing of partial hepatectomy can be emergency(during the rupture time),early delayed(within 8 days of HCC rupture)or late delayed(>8 days of HCC rupture).Evidence is emerging that partial hepatectomy carried out in the emergency or early delayed period has a lower incidence of peritoneal tumor implantation and metastasis compared with the late delayed period to carry out partial hepatectomy.After the bleeding stopped in patients with ruptured HCC,the treatment of patients with unresectable HCC would be similar to those with non-ruptured HCC.In
作者
刘允怡
LAU Wan Yee(Faculty of Medicine,the Chinese University of Hong Kong,Hong Kong,China)
出处
《中华消化外科杂志》
CAS
CSCD
北大核心
2020年第2期113-118,共6页
Chinese Journal of Digestive Surgery
关键词
肝肿瘤
肝癌破裂
破裂机制
治疗
预后
Hepatic neoplasms
Ruptured hepatocellular carcinoma
Mechanisms of rupture
Treatment
Prognosis
