非酒精性脂肪性肝病患者肝癌筛查的必要性及可行性

原发性肝癌的发病率和死亡率与日俱增,严重影响公众健康。其中慢性肝病,尤其是肝硬化,是导致肝癌的主要病因和危险因素。随着对病毒性肝炎的有效防治,以及肥胖、糖尿病等代谢综合征的发病率迅速增长,非酒精性脂肪性肝病已成为最常见的慢性肝病原因,因此对非酒精性脂肪性肝病患者进行肝癌筛查刻不容缓。现综述概括总结了非酒精性脂肪性肝病及...     

非酒精性脂肪性肝炎的诊断和治疗进展

非酒精性脂肪肝疾病(nonalcoholic fatty liver disease,NAFLD)以肝细胞中脂肪过多积累为标志,包括非酒精性脂肪肝(nonalcoholic fatty liver,NAFL)和非酒精性脂肪性肝炎(nonalcohol-ic steatohepatitis,NASH),其中NASH可能会...     

Bariatric surgery is associated with reduction in non-alcoholic steatohepatitis and hepatocellular carcinoma: A propensity matched analysis

IntroductionObesity is a risk factor for non-alcoholic steatohepatitis (NASH) and hepatocellular carcinoma (HCC). Bariatric surgery can provide durable weight-loss, but little is known about the later development of NASH and HCC after surgery.MethodsBariatric surgery (n = 3,410) and obese controls (n = 46,873) from an institutional data repository were propensity score matched 1:1 by demographics, comorbidities, BMI, and socioeconomic factors. Comparisons were made through paired univariate analysis and conditional logistic regression.ResultsTotal of 4,112 patients were well matched with no significant baseline differences except initial BMI (49.0 vs 48.2, p = 0.04). Bariatric group demonstrated fewer new-onset NASH (6 0.0% vs 10.3%, p < 0.0001) and HCC (0.05% vs 0.34%, p = 0.03) over a median follow-up of 7.1 years. After risk-adjustment, bariatric surgery was independently associated with reduced development of NASH (OR 0.52, p < 0.0001).ConclusionsBariatric surgery is associated with reduced incidence of NASH and HCC in this large propensity matched cohort. This further supports the use of bariatric surgery for morbidly obese patients to ameliorate NASH cirrhosis and development of HCC.     

Hepatocellular Carcinoma Arising from Nonalcoholic Steatohepatitis: Report of Two Cases

Sporadic cases of hepatocellular carcinoma (HCC) originating from nonalcoholic steatohepatitis (NASH) have recently been reported. Thus, we investigated the prevalence of NASH in patients with HCC. A review of the clinical records of 481 patients who underwent liver resection for HCC in our department between January 1991 and December 2003 revealed only two (0.4%) patients with HCC associated with NASH. Both of these patients had noninsulin-dependent diabetes mellitus, and neither had a history of alcohol consumption or blood transfusion. All serologic markers for hepatitis B and C viruses were negative. Histological examination of the noncancerous hepatic tissue revealed NASH with moderate hepatic fibrosis in one patient and cirrhosis in the other. Thus, clinical follow-up and screening for HCC should be done for patients with hepatic fibrosis caused by NASH, even though this form of hepatitis is an uncommon cause of HCC.     

原发性肝癌自发性破裂一期手术切除

目的探讨、研究原发性肝癌自发性破裂的手术切除和围术期处理技术。方法回顾性总结了1993年1月～2003年8月施行肝癌切除术的32例自发性破裂肝病例,并以同期随机抽取32例非破裂肝癌病例作为对照,综合比较、分析两组病人的术前、中、后的临床资料。结果破裂与非破裂组术前肝功能Child鄄Pugh分级、肿瘤包膜及门静脉浸润,术中肝门阻断时间、术时及住院时间的差异无显著性。破裂组肝脏的肿瘤直径、术中失血量、输血量、术后并发症发生率及住院病死率均较非破裂组显著高。多元统计回归分析显示术中失血量是决定原发性肝癌自发性破裂病人术后并发症发生率之独立因素。进一步分析控制术中失血的方法选择,各组间差异无显著性,但Pringle手法居首位。结论原发性肝癌自发性破裂病人是否作一期手术切除在于术前准确评估及术中能否采用恰当方法有效地控制出血。     

Long-term results of elective hepatectomy for the treatment of ruptured hepatocellular carcinoma

Background/Purpose According to the General rules for the clinical and pathological study of primary liver cancer, compiled by the Liver Cancer Study Group of Japan, ruptured hepatocellular carcinoma (HCC) is classified as stage 4, even if the tumor is small and solitary. We examined the long-term results of elective hepatectomy for the treatment of ruptured HCC. Methods A first hepatectomy was performed without operative death in 193 patients with HCC. Ten patients had ruptured HCC (ruptured group) and 183 patients had nonruptured HCC (nonruptured group). The extension of HCC was macroscopically classified as stage 1 in 23 patients, stage 2 in 71, stage 3 in 53, and stage 4 in 46. Results Cumulative survival rates in the ruptured group at 1, 5, and 10 years were 90.0%, 67.5%, and 20.3%, respectively. The cumulative survival rate was lower in patients with stage 4 disease in the nonruptured group than that in patients in the ruptured group (P < 0.05). Cumulative survival rates did not differ significantly between patients in the ruptured group and those with stage 2 or stage 3 disease. Conclusions Survival rates after elective hepatectomy in patients with ruptured HCC are good, even if the disease is classified as stage 4.     

肝细胞性肝癌自发破裂出血的治疗策略

【摘要】 目的 探讨肝细胞性肝癌自发性破裂出血患者的治疗策略。方法〓对江门市人民医院两个不同历史阶段收治的肝癌破裂患者的临床资料进行回顾性对比研究,第一阶段(1992~2002年)肝癌破裂患者47例,采取手术或保守治疗;第二阶段(2003~2013年)肝癌破裂患者58例,采用手术、经肝动脉栓塞或保守治疗,对比两阶段患者的30天、1年生存率和累计生存率。结果〓第一阶段保守治疗22例,急诊肝切除25例,30天死亡22例;第二阶段12例保守治疗,急诊肝切除29例,经肝动脉栓塞17例,其中10例栓塞之后行肝切除手术,30天死亡例16例。两阶段中手术治疗患者较非手术治疗患者累积生存率高(P﹤0.05);第二阶段患者累积生存率较第一阶段高(P=0.036),两阶段中手术治疗患者的累积生存率比较无统计学差异(P=0.234)。结论 对于自发性肝癌破裂出血患者,保守治疗预后差,经肝动脉栓塞为有效的急诊止血措施,对合适的患者实施急诊或分期肝切除可延长患者生存时间。     

肝细胞癌自发破裂的预测和临床预后

目的 研究影响肝癌自发破裂的危险因素及预后因素,评估选择性一期肝切除的治疗效果.方法 从2002年4月至2006年11月在东方肝胆外科医院确诊为肝癌的4209例患者中,有200例肝癌自发破裂.回顾性分析200例自发破裂患者的临床特点和预后因素.评估不同治疗手段的预后,并与随机选取的202例同期未发生破裂的肝癌患者进行对比.结果 多因素回归分析显示肝硬化、高血压、血管癌栓、肝外侵犯及肿瘤大于5 cm是肝癌自发破裂的预测因素.在200例肝癌自发破裂患者中,105例行肝切除治疗、33例肝动脉插管化疗栓塞(TACE),62例保守治疗.所有肝癌破裂患者的中位生存时间为6个月(1 ～72个月),1、3、5年总体生存率分别为32.5％、10％和4％.肝切除组患者中位生存时间为12个月(1～72个月),TACE组为4个月(1～30个月),而保守组为1个月(1～19个月).行肝切除的肝癌破裂患者(105例)1、3、5年总体生存率分别为57.1％、19.0％和7.6％,而同期未破裂肝切除肝癌患者(98例)1、3、5年总体生存率分别为77.1％、59.8％和41.2％(P＜0.001).结论 对于伴有肝硬化、高血压、血管癌栓、肝外侵犯及肿瘤大于5 cm的肝癌患者,应警惕肝癌自发破裂的高风险.选择性一期肝切除治疗的肝癌破裂患者能够获得长期生存,尽管其总体预后较肝癌未发生破裂患者差.     

巨噬细胞吞噬功能受损对肝癌自发性破裂的影响

目的检测巨噬细胞吞噬功能，探讨肝癌自发性破裂的发病机制。方法收集肝癌破裂组和非破裂组患者标本各9例，采用流式细胞术和免疫组织化学的方法，检测两组患者肝脏标本内巨噬细胞吞噬功能。结果自发性破裂组巨噬细胞吞噬免疫复合物能力明显低于非破裂组[6．35‰（4．05、8．42‰）vs9．16‰（6．42、10．82‰），P〈0．05]；自发性破裂组内巨噬细胞表面受体CD11b、CD18和CD16的表达量百分率明显少于非破裂组[6．19％（4．70、7．02％）vs10．25％（8．83、11．95％），P〈0．05；4．46％（3．85、5．77％）、vs7．09％（5．55、12．60％），P〈0．05；2．64％（1．74、4．11％、vs6．43％（4．83、9．67％），P〈0．05]。结论患者肝脏内巨噬细胞吞噬功能下降导致血管壁免疫复合物沉积、血管受损及小动脉脆病弱性变，在稍受外力的情况下极易破裂出血，并可能与肝癌自发性破裂有关。     

Bilateral adrenal metastases from a primary hepatocellular carcinoma

Metastatic tumors to the adrenal gland are more common than primary adrenal carcinoma. However, bilateral adrenal metastases as the first manifestation of an occult or small hepatocellular carcinoma (HCC) are very rare. An elderly male presented with transient edema of lower limbs with findings of bilateral adrenal masses and a small liver lesion on CT scan. In spite of thorough biochemical and imaging investigative modalities the final diagnosis of metastatic carcinoma could be reached only after a needle core biopsy of the lesions.     

经导管肝动脉化疗栓塞联合手术切除治疗肝细胞癌破裂出血

目的 探讨经导管肝动脉化疗栓塞(transcatheter arterial chemoembolization,TACE)联合手术切除治疗肝癌破裂出血的临床价值.方法 回顾性分析我院2008年1月至2011年12月收治的26例肝癌破裂出血患者的临床资料.其中经TACE治疗19例、手术切除7例,有8例TACE后再手术切除.结果 26例肝癌破裂出血患者中19例经TACE治疗后休克及时纠正,生命体征很快稳定,复查CT肿瘤缩小;其中8例TACE治疗1个月后行Ⅱ期肿瘤切除,AFP均下降或正常,疗效优良.7例Ⅰ期手术者1例术后死亡,4例发生腹腔肿瘤种植转移.结论 TACE可有效治疗肝癌破裂出血、减少不可切除病例的剖腹探查止血手术、提高肿瘤切除率.TACE联合手术切除可显著降低肿瘤腹腔种植转移率.     

Liver transplantation for nonalcoholic steatohepatitis in young patients

Nonalcoholic steatohepatitis (NASH) is the hepatic manifestation of obesity and insulin resistance. The aim of this study was to determine the frequency of NASH as an indication for liver transplantation (LT) in children and young adults and to characterize patient and graft survival. The study included all children and young adult patients (up to the age of 40 years) who underwent LT in the United States for NASH cirrhosis from the 1987 to 2012 United Network for Organ Sharing (UNOS) database. Kaplan–Meier analysis was used to assess patient and graft survival. A total of 330 patients were included, 68% were Caucasian, and the mean BMI was 33.6 ± 6.3. Age at time of LT ranged between 4 and 40 years (mean 33.9 ± 6.6 years). Fourteen subjects were <18 years of age at time of LT and 20 were between the ages of 18 and 25 years. Median follow‐up after 1st LT was 45.8 months [10.7, 97.3]. During this time, 30% of subjects (n = 100) died and 11.5% (n = 38) were retransplanted including 13 for NASH recurrence. In conclusion, NASH can progress to end‐stage liver disease requiring LT in childhood and early adulthood. A significant number of young patients transplanted for NASH cirrhosis required retransplantation.     

Liver transplantation in hepatocellular carcinoma

The initial enthusiasm for orthotopic liver transplantation (OLT) in patients with hepatocellular carcinoma (HCC) soon vanished as early recurrences appeared [3, 5, 6]. OLT in HCC remains a controversial issue. We evaluated the efficacy of preoperative studies to select No-Mo patients and determined whether pT stage and histopathological grade (G) have a prognostic significance. A group of 25 patients, all previously thoroughly studied to rule out extrahepatic disease, underwent OLT for HCC. All patients were pNo after pathological study and none of the six patients who died in the postoperative period showed extrahepatic dissemination at necropsy (pMo). The recurrence rate was 43%. The 2 and 5 years actuarial survival was 62% and 43% respectively. The pT and G were not prognostic factors for long-term survival. We think that HCC is still a good indication for OLT because almost 50% of patients have good survival prospects.     

Synchronous right hepatectomy and cesarean section in a pregnant lady with hepatocellular carcinoma

INTRODUCTIONCancer in pregnancy is rare and hepatocellular carcinoma (HCC) during pregnancy is even rarer. Due to limited experience, management of these patients remains challenging.PRESENTATION OF CASEA 33-year old pregnant lady presented with HCC at 28 weeks of gestation. She underwent synchronous cesarean section and right hepatectomy at 32 weeks of gestation. The post-operative course was uneventful. She was discharged home on day 10 after surgery. Histolopathology confirmed HCC. The surgical resection margins were clear. At a follow-up of 3 months after surgery, the mother was disease free and the infant was well.DISCUSSIONHCC during pregnancy is extremely rare. The experience in its management and outcomes are lacking. In managing any patient diagnosed with a malignant neoplasm in pregnancy, both the mother and the fetus have to be considered.CONCLUSIONWith adequate preoperative assessment and a good management strategy, good results can be obtained for both the mother and the baby for a pregnant patient with HCC.     

Efficacy of a liver resection for hepatocellular carcinoma in patients with chronic renal failure

Purpose As there is still little information available on hepatic resection in patients with chronic renal failure (CRF) in the literature, it is believed that a liver resection for HCC in CRF patients with various related complications is always risky. Methods We retrospectively reviewed the clinical and pathological records of 17 patients with CRF who had undergone hepatectomy for HCC, and of 51 non-CRF patients subjected to hepatectomy for HCC during the same period. Results The operative and pathological findings were comparable between the two groups. Postoperative circulatory insufficiency occurred more frequently in the CRF group (P = 0.013). Although the disease-free survival rates were comparable between the two groups, the overall survival rates were significantly lower in the CRF group than in the non-CRF group (P = 0.031). Conclusions A hepatectomy for HCC should be considered even for CRF patients with various complications if careful perioperative management and suitable multidisciplinary treatment for recurrent disease are provided.     

原发性肝癌合并脾功能亢进外科治疗的Meta分析

目的 比较肝脾联合切除术与单纯肝癌切除术在治疗原发性肝癌合并脾功能亢进的围手术期并发症发生率和死亡率、术后生存率方面有无明显差异.方法 计算机检索PubMed、Embase、Cochrane Library、中国期刊全文数据库、中国生物医学文献数据库、数字化期刊全文数据库以及中文科技期刊全文数据库,同时根据以上检索所得文献的参考文献进行扩大检索.使用改良Sackett's分级法进行质量评价,采用Cochrane协作网提供的RevMan5.2.7统计软件进行Meta分析.结果 共纳入8项研究,共计772例患者.结果显示,肝脾联合切除组(HS)与单纯肝癌切除组(H)相比,在围手术期并发症发生率(OR合并=0.90,95％ CI-0.63～1.29,P-0.56)、围手术期死亡率(OR合并=1.04,95％CI=0.3～3.58,P=0.96)、以及5年生存率(OR合并=1.53,95％ CI =0.99～2.36,P=0.05)上差异并无统计学意义.然而,HS组在术后白细胞计数(MD =5.47,95％CI=5.13～5.82,P＜0.01)及血小板计数(MD=174.89,95％CI=116.61～233.18,P＜0.01)方面,较H组有显著上升,差异具有统计学意义.结论 相对于单纯肝切除而言,肝脾联合切除治疗肝癌合并脾功能亢进在围手术期并发症发生率、死亡率,以及术后5年生存率方面差异无统计学意义.然而HS组在术后白细胞及血小板得到显著回升,这可能有利于患者术后免疫功能的恢复和后续的化疗.     

96序列相似的家庭成员B在肝癌的表达及其临床意义

目的:观察96序列相似的家庭成员B(FAM96B)在肝癌组织及癌旁组织中的表达,并探讨其临床意义。方法:收集2012年1月至2013年12月期间在中国人民解放军中部战区总医院接受手术治疗的肝癌患者的组织标本及临床病例资料。采用免疫组织化学技术(IHC)、蛋白质印迹法(Western blot)检测FAM96B在96例肝...