Background. R0 minor parenchyma-sparing hepatectomy (PSH) is feasible for colorectal liver metastases (CRLM) in contact with hepatic veins (HV) at hepatocaval confluence since HV can be reconstructed, but in the case of contact with the first-order glissonean pedicle (GP), major hepatectomy is mandatory. To pursue an R0 parenchyma-sparing policy, we proposed vessel-guided mesohepatectomy for liver partition (MLP) and eventually combination with liver augmentation techniques for staged major PSH.Methods. We analyzed 15 consecutive vessel-guided MLPs for CRLM at the hepatocaval confluence. Patients had a median of 11 (range: 0–67) lesions with a median diameter of 3.5 cm (range: 0.0–8.0), bilateral in 73% of cases.Results. Grade IIIb or more complications occurred in 13%, median hospital stay was 14 (range: 6–62) days, 90-day mortality was 0%. After a median follow-up of 17.5 months, 1-year OS and RFS were 92% and 62%. In nine (64%) patients, MLP was combined with portal vein embolization (PVE) or ALPPS to perform staged R0 major PSH. Future liver remnant (FLR) volume increased from a median of 15% (range: 7–20%) up to 41% (range: 37–69%). Super-selective PVE was performed in three (33%) patients and enhanced ALPPS (e-ALPPS) in six (66%). In two e-ALPPS an intermediate stage of deportalized liver PSH was necessary to achieve adequate FLR volume.Conclusions. Vessel-guided MLP may transform the liver in a paired organ. In selected cases of multiple bilobar CRLM, to guarantee oncological radicality (R0), major PSH is feasible combining advanced surgical parenchyma sparing with liver augmentation techniques when FLR volume is insufficient.
背景：对于紧贴肝静脉汇合处（HV）的结直肠癌肝转移（CRLM），由于肝静脉可重建，R0级微创肝实质保留切除术（PSH）是可行的；但若肿瘤侵犯一级格利森蒂带（GP），则必须进行大范围肝切除术。为贯彻R0级肝实质保留原则，我们提出采用血管引导的肝中部分切除术（MLP）进行肝脏分割，并最终联合肝脏增容技术实施分阶段大范围PSH。 方法：我们连续分析了15例因CRLM在肝静脉汇合处接受血管引导MLP的病例。患者中位病灶数为11个（范围：0-67），中位直径3.5厘米（范围：0.0-8.0），73%为双侧病灶。 结果：IIIb级及以上并发症发生率为13%，中位住院时间14天（范围：6-62），90天死亡率为0%。中位随访17.5个月后，1年总生存率（OS）和无复发生存率（RFS）分别为92%和62%。其中9例（64%）患者将MLP与门静脉栓塞术（PVE）或联合肝脏分割和门静脉结扎的分阶段肝切除术（ALPPS）相结合，实施了分阶段R0大范围PSH。未来剩余肝体积（FLR）从中位15%（范围：7-20%）增至41%（范围：37-69%）。3例（33%）患者接受超选择性PVE，6例（66%）接受增强型ALPPS（e-ALPPS）。在2例e-ALPPS中，需通过门静脉离断的中间阶段PSH以获得足够的FLR体积。 结论：血管引导的MLP可将肝脏转化为成对器官。对于经选择的多发性双叶CRLM病例，为保证肿瘤根治性（R0），当FLR体积不足时，结合先进的外科肝实质保留技术与肝脏增容技术，实施大范围PSH是可行的。
肿瘤(癌症)患者之家