经皮经肝钢圈选择性门静脉栓塞术在肝门部胆管癌术前的应用

摘要

Objective To evaluate percutaneous transhepatic selective portal vein embolization (PVE) with steel coils performed before major liver resection in treating hilar cholangiocarcinoma. Methods From April 2007 to January 2009, 28 patients with hilar cholangiocarcinoma were treated in our department.Of the 28 patients, 12 were not suitable for surgery because the remnant liver volume was too small, and PVE had to be carried out in them (PVE group). Among these 12 patients, 10 were finally received major liver resection (PVE plus resection group). Pure major liver resection was employed in the remaining 16 patients who had sufficient remnant liver volume (resection group). All patients receiving PVE, including 8 males and 4 females with an average age of (51.6 ± 8.2) years (in the range of 40 - 64 years) . had Bismuth type Ⅳ hilar cholangiocarcinoma in association with obstructive jaundice. Bef'ore PVE. 11 of 12 patients underwent selective biliary drainage of reserve remnant liver, total serum bilirubin level was at (97.99 ±60.78) μmol/L with a range of (12.4 － 167.9) μmol/L. Ipsilateral or contralateral percutaneous transhepatic PVE with multiple steel coils was performed after super-selective catheterization of portal branch was successfully completed. Hepatic hemodynamic, liver volume and liver functions were determined both before and after the procedure. FLR (future liver remnant)hypertrophy was assessed by comparing CT scans obtained before PVE and that obtained two weeks after PVE. Evaluation of therapeutic effectiveness was based on the changes of absolute FLR size and total liver volume. Postoperative mortality and occurrence of complications were compared between PVE plus resection group and resection group. The safety of PVE was analyzed.Results Successful PVE was achieved in all 12 cases. of whom subsequent major hepatectomy was smoothly completed in 10.Surgery was unable to be carried out due to distant metastasis in one case and due to insufficient proliferation of reserve remnant liver in another case. Two weeks after PVE. the reserve remnant liver volume was mcreased, the difference in remnant liver volume after the treatment was statistically significant (P ＜ 0.05) when compared with that determined before PVE. Nor severe portal hypertension neither serious complications, such as hepatic dysf'unction. occurred. Conclusion Preoperative percutaneous transhepatic selective portal vein embolization with steel coils is feasible for the treatment of hilar cholangiocarcinoma. The technique is safe and effective.It can actively induce the regeneration and hypertrophy of' un-embolized hepatic lobe, effectively improve the resection rate of the tumor, reduce the perioperative risks of major hepatic resection and enhance the safety of surgery. (J Intervent Radiol. 2011,20: 534-539)%目的 探讨肝门部胆管癌扩大肝切除术前使用经皮经肝钢圈选择性门静脉栓塞术(PVE)的应用和疗效.方法 2007年4月至2009年1月收治肝门部胆管癌28例,分为两组,将预保留肝占全肝体积<50%、接受PVE者设为PVE组12例,其中10例最终接受联合扩大肝切除者设为PVE肝切除组;同期未行PVE而接受扩大肝切除术者为非PVE切除术组(16例).PVE均为伴有梗阻性黄疸的Ⅵ型肝门部胆管癌,11例PVE前行预保留肝选择性胆管引流,PVE前血清胆红素(TB)为(98.0±60.8)(12.4～167.9)μmol/L.PVE采用经皮经肝、同侧或对侧门静脉穿刺,放置多枚弹簧圈栓塞门静脉分支.记录PVE前后肝脏血流动力学、体积、功能等方面的变化,比较PVE肝切除组与非PVE肝切除组的术后病死率和并发症发生率.结果 12例PVE均获得成功,10例PVE后顺利施行扩大肝切除术,1例(1/12)因发现远处转移未行手术,另1例(1/12)因PVE后预保留肝叶增生不全未行手术.栓塞术后2周预保留肝叶体积增大差别有统计学意义(P<0.05),未出现严重门静脉高压、肝功能损害等严重并发症.结论 PVE在肝门部胆管癌扩大肝切除术前的临床应用可行、有效和安全,能有效的诱导未栓塞肝叶的增生肥大.提高肿瘤的切除率,增加手术切除的安全性.