膈面肝肿瘤腹腔镜超声引导消融治疗体会

doi:10.3969/j.issn.1674-8115.2023.03.017

摘要/Abstract

摘要：

目的·探讨膈面肝肿瘤腹腔镜超声引导下微波消融治疗的安全性、有效性，以及具体的使用体会。方法·回顾性分析2019年11月—2021年4月于浙江中医药大学附属温州中医院接受腹腔镜超声引导下微波消融治疗的13例膈面肝肿瘤病例。腹腔镜下观察腹腔内有无转移，根据需要离断镰状韧带、冠状韧带、三角韧带，在肝脏膈顶裸区或脏面填塞纱布垫。腹腔镜超声扫查肝脏，确定肿瘤位置及有无新发肿瘤，同时活检后使用超声造影剂对肿瘤多点多角度消融，在退针过程中腹腔镜直视观察有无出血，并行针道消融。消融后再次超声造影，必要予时追加消融。观察围手术期并发症，比较术前、术后的血生化指标、白细胞水平以及术后磁共振成像（magnetic resonance imaging，MRI）表现。结果·13例患者均成功施行腹腔镜超声引导下微波消融治疗，所有患者围手术期均未出现膈肌损伤、心率失常、肺炎、气胸、大出血、胆瘘、肠管损伤等严重并发症；术前白细胞［（4.9±1.0）×10⁹个/L］和术后第2日白细胞［（8.7±2.5）×10⁹个/L］的差异具有统计学意义（P=0.000）。术前谷丙转氨酶［15.0（22.0，77.5）U/L］和术后第2日谷丙转氨酶［69.0（135.0，371.0）U/L］的差异具有统计学意义（P=0.013）；术后1月复查MRI增强证实，病灶完全坏死率达100%。结论·腹腔镜超声引导下肝肿瘤消融，首先是在腹腔镜下进行的手术，通过建立气腹、离断韧带、纱布隔离等方法使肝脏周围形成一个安全的隔离带；然后在腹腔镜超声探头的直视下对膈面肝肿瘤进行消融，以提供一种更加安全、有效的治疗方法。

关键词: 肝癌, 腹腔镜, 腹腔镜超声, 消融, 微波消融

Abstract:

Objective ·To investigate the safety and effectiveness of laparoscopic ultrasound-guided microwave ablation for phrenic surface liver tumors, as well as the specific experience of its use. Methods ·A retrospective analysis was performed on 13 cases of diaphragmatic liver tumor who received laparoscopic ultrasound-guided microwave ablation in Zhejiang University of Traditional Chinese Medicine Affiliated Wenzhou Hospital from November 2019 to April 2021. The falciform ligament, coronal ligament and deltoid ligament were severed according to the need, and gauze pads were filled on the diaphragmatic surface or visceral of the liver. Laparoscopic ultrasound scan of the liver was performed to determine the location of the tumor and whether there were new tumors. Meanwhile, ultrasound contrast agent was used to perform multi-point and multi-angle ablation of the tumor after biopsy. During the process of needle withdrawal, laparoscopic direct observation was performed to observe whether there was bleeding, and needle path ablation was performed. After ablation, contrast-enhanced ultrasound was repeated and additional ablation was performed if necessary. Perioperative complications were observed and preoperative and postoperative blood biochemical indexes, white blood cells level and postoperative MRI manifestations were compared. Results ·All the 13 patients were successfully treated with laparoscopic ultrasound-guided microwave ablation. There were no serious complications such as diaphragm injury, arrhythmia, pneumonia, pneumothorax, massive bleeding, biliary fistula and intestinal injury. The white blood cells before surgery [(4.9±1.0)×10⁹/L] and day 2 after surgery [(8.7±2.5)×10⁹/L] were significantly different (P=0.000). The glutamic-pyruvic transaminase [15.0 (22.0, 77.5) U/L] before surgery and day 2 after surgery [69.0 (135.0, 371.0) U/L] were significantly different (P=0.013). One month after the operation, MRI enhancement confirmed that the total necrosis rate of the lesion was 100%. Conclusion ·Laparoscopic ultrasound-guided hepatic tumor ablation, which is first performed under laparoscopy, forms a safe isolation zone around the liver through the establishment of pneumoperitoneum, severed ligament, gauze isolation and other methods. Then, under the direct vision of laparoscopic ultrasound probe, the diaphragmatic liver tumors are ablated to achieve a safer and more effective method.

Key words: liver cancer, laparoscope, laparoscopic ultrasound, ablation, microwave ablation

中图分类号:

R735.7

张寅, 吴贤, 谢炳銮, 王奕. 膈面肝肿瘤腹腔镜超声引导消融治疗体会[J]. 上海交通大学学报（医学版）, 2023, 43(3): 391-396.

ZHANG Yin, WU Xian, XIE Bingluan, WANG Yi. Experience of laparoscopic ultrasound-guided ablation of diaphragmatic liver tumors[J]. Journal of Shanghai Jiao Tong University (Medical Science), 2023, 43(3): 391-396.

图/表 5

图1 腹腔镜下肿瘤消融的隔离带Note： A. Diaphragmatic surface of right liver and abdominal wall after pneumoperitoneum establishment. B. Diaphragmatic surface of left liver and abdominal wall after pneumoperitoneum establishment. C. Gauze was packed in the bare area of the diaphragmatic roof after the left coronary ligament was severed.

Fig 1 Isolation zone of tumor ablation from laparoscopic perspective

图2 腹腔镜超声下左肝外叶肿瘤Note： A. Image before gauze packing. B. Image after gauze stuffing.

Fig 2 Tumor in the left lateral lobe of liver under LUS

表1 手术前后血生化指标和白细胞水平的变化（n=13）

Tab 1 Changes of blood biochemical indexes and white blood cells level before and after operation （n=13）

Item	Preoperative	Postoperative	t/Z value	P value
White blood cell/(×10⁹·L^-1)	4.9±1.0	8.7±2.5	6.437	0.000
Direct bilirubin/(μmol·L^-1)	7.8 (11.9, 19.5)	5.4 (8.8, 23.5)	1.153	0.249
Alkaline phosphatase/(U·L^-1)	63.5 (78.0, 94.5)	60.5 (84.0, 103.0)	0.490	0.624
Alanine transaminase/(U·L^-1)	15.0 (22.0, 77.5)	69.0 (135.0, 371.0)	2.481	0.013
Creatinine/(μmol·L^-1)	51.0 (56.0, 69.0)	50.5 (57.0, 68.5)	0.981	0.327

图3 部分病例的术前及术后1月MRI对比Note： Red arrow indicates the location of the tumor.

Fig 3 Preoperative and 1-month postoperative MRI comparisons of some cases

图4 部分病例肝肿瘤的消融前、中、后LUS下图像

Fig 4 LUS images of some cases before, during and after ablation

参考文献 17

1	LLOVET J M. Updated treatment approach to hepatocellular carcinoma[J]. J Gastroenterol, 2005, 40(3): 225-235.
2	邱宝安, 赵文超, 夏念信, 等. 手术部分肝切除与射频消融治疗多发肝细胞癌预后比较[J]. 解放军医学院学报, 2015, 36(3): 226-229.
	QIU B A, ZHAO W C, XIA N X, et al. Effect of hepatic resection vs. radiofrequency ablation on multiple hepatocellular carcinoma[J]. Academic Journal of Chinese PLA Medical School, 2015, 36(3): 226-229.
3	吕明德, 匡铭, 梁力建, 等. 手术切除和经皮热消融治疗早期肝癌的随机对照临床研究 [J]. 中华医学杂志, 2006, 86(12): 801-805.
	LÜ M D, KUANG M, LIANG L J, et al. Surgical resection versus percutaneous thermal ablation for early-stage hepatocellular carcinoma: a randomized clinical trial[J]. Zhonghua Yi Xue Za Zhi, 2006, 86(12): 801-805.
4	中国肝胆外科术中超声学院. 腹腔镜超声在肝脏外科的应用专家共识(2017)[J]. 临床肝胆病杂志, 2018, 34(3): 486-493.
	Chinese College of Intraoperative Ultrasound for hepatobiliary Surgery. Expert consensus on laparoscopic ultrasound guided laparoscopic liver surgery (2017)[J]. Journal of Clinical Hepatol, 2018, (3): 486-493.
5	BIRSEN O, ALIYEV S, AKSOY E, et al. A critical analysis of postoperative morbidity and mortality after laparoscopic radiofrequency ablation of liver tumors[J]. Ann Surg Oncol, 2014, 21(6): 1834-1840.
6	张雯雯, 王宏光, 史宪杰. 腹腔镜超声引导下肝肿瘤射频消融治疗的研究进展[J].解放军医学院学报, 2016, 37(5): 514-517, 521.
	ZHANG W W, WANG H G, SHI X J. Advances in laparoscopic ultrasound guided radiofrequency ablation for treatment of liver tumor[J]. Academic Journal of Chinese PLA Medical School, 2016, 37(5): 514-517, 521.
7	SANTAMBROGIO R, OPOCHER E, ZUIN M, et al. Surgical resection versus laparoscopic radiofrequency ablation in patients with hepatocellular carcinoma and child-pugh class A liver cirrhosis[J]. Ann Surg Oncol, 2009, 16(12): 3289-3298.
8	SALAMA I A, KORAYEM E, ELABD O, et al. Laparoscopic ultrasound with radiofrequency ablation of hepatic tumors in cirrhotic patients[J]. J Laparoendosc Adv Surg Tech A, 2010, 20(1): 39-46.
9	LAI E C, TANG C N, HA J P, et al. The evolving influence of laparoscopy and laparoscopic ultrasonography on patients with hepatocellular carcinoma[J]. Am J Surg, 2008, 196(5): 736-740.
10	SOLIMAN H O, GAD Z S, MAHMOUD A M, et al. Laparoscopy with laparoscopic ultrasound for pretreatment staging of hepatic focal lesions: a prospective study[J]. J Egypt Natl Canc Inst, 2011, 23(4): 141-145.
11	王智, 池嘉昌, 翟博. 超声引导下经皮微波消融治疗膈顶部肝癌的疗效观察[J].介入放射学杂志, 2020, 29(3): 305-309.
	WANG Z, CHI J C, ZHAI B. Ultrasound-guided percutaneous microwave ablation for the treatment of hepatocellular carcinoma adjacent to diaphragmatic dome[J]. Journal of Interventional Radiology, 2020, 29(3): 305-309.
12	刘丽莉, 方勇, 王凯峰, 等. CT引导射频消融治疗膈顶部肝癌的临床研究[J]. 肿瘤, 2014, 34(1): 60-66.
	LIU L L, FANG Y, WANG K F, et al. Clinical investigation of CT-guided radiofrequency ablation for liver cancer in hepatic dome area[J]. Tumor, 2014, 34(1): 60-66.
13	朱传东, 丁怀银, 王礼学, 等. CT引导下经皮微波消融治疗膈顶部复发性小肝癌15例疗效观察[J]. 现代肿瘤医学, 2018, 26(5): 733-736.
	ZHU C D, DING H Y, WANG L X, et al. Clinical observation of CT-guided microwave ablation in 15 cases of recurrent small hepatocellular carcinoma against the diaphragmatic dome [J]. Journal of Modern Oncology, 2018, 26(5): 733-736.
14	唐田, 古善智, 李国文, 等. 超声引导联合人工胸水微波消融膈顶部肝肿瘤[J]. 中南大学学报(医学版), 2017, 42(2):184-187.
	TANG T, GU S Z, LI G W, et al. Ultrasound-guided microwave ablation with artificial pleural effusion for liver tumor adjacent to diaphragmatic dome[J]. Journal of Central South University (Medical Science), 2017, 42(2): 184-188.
15	韩玥, 张景, 闫东, 等. 人工气胸在CT引导下肝脏膈顶肿瘤微波消融中的应用[J]. 中国医学前沿杂志(电子版), 2017, 9(5): 119-122.
	HAN Y, ZHANG J, YAN D, et al. CT-guided percutaneous microwave ablation with artificial pneumothorax for liver malignancies in the hepatic dome[J]. Chinese Journal of the Frontiers of Medical Science (Electronic Version), 2017, 9(5): 119-122.
16	张寅, 赵玲玲, 吴贤, 等. 腹腔镜超声引导下肝肿瘤消融术的模型及进针设计[J]. 腹腔镜外科杂志, 2022, 27(6): 428-433.
	ZHANG Y, ZHAO L L, WU X, et al. Needle insertion and model design of liver tumor ablation guided by laparoscopic ultrasound [J]. Journal of Laparoscopic Surgery, 2022, 27(6): 428-433.
17	双剑博, 吴楠, 严琦敏, 等. 超声引导结合腹腔镜对高危部位肝癌的微波消融治疗[J]. 中华普通外科杂志, 2019, 34(5): 449-450.
	SHUANG J B, WU N, YAN Q M, et al. Ultrasound-guided combined with laparoscopy for the treatment of high risk liver cancer by microwave ablation [J]. Chinese Journal of General Surgery, 2019, 34(5): 449-450.

[1]	孙惠华, 田秋菊, 吴蓓雯. 不同气腹模式下腹腔镜手术患者下肢深静脉血流速度的比较[J]. 上海交通大学学报（医学版）, 2022, 42(9): 1329-1335.
[2]	卢雨, 王昊, 巴乾. 肠道菌群在肝癌发生发展及治疗中的作用研究进展[J]. 上海交通大学学报（医学版）, 2022, 42(7): 939-944.
[3]	刘桃桃, 邬静莹, 刘晓黎, 张梅, 曹立. EIF2B基因新突变致白质消融性白质脑病2例及文献复习[J]. 上海交通大学学报（医学版）, 2022, 42(7): 964-970.
[4]	胡哲轩, 张欣, 沃璐璐, 李静池, 王娇, 周佽想, 赵倩. TRMT61A在肝癌细胞中的功能及其机制研究[J]. 上海交通大学学报（医学版）, 2022, 42(6): 742-750.
[5]	赵宝红, 任红霞, 吴晓霞, 靳园园, 刘文跃, 赵亮, 张晖, 郭鑫, 孙雪. 腹腔镜诊治新生儿高位空肠闭锁/狭窄的效果观察[J]. 上海交通大学学报(医学版), 2021, 41(9): 1162-1168.
[6]	柴红, 黄琴, 陈泽泉, 杨佳欢, 余永利. 消融前刺激性甲状腺球蛋白对分化型甲状腺癌合并结节性甲状腺肿复发或转移的诊断价值[J]. 上海交通大学学报(医学版), 2021, 41(5): 617-621.
[7]	张冬蕾, 魏华兵, 周力璜, 钱晓哲. 快速康复外科联合胸腹腔镜下食管癌根治术对老年患者的疗效分析[J]. 上海交通大学学报(医学版), 2021, 41(1): 74-77.
[8]	蒋天宇，刘海山，马君俊，臧潞，陆爱国，董峰，冯波，宗雅萍，孙晶，何子锐，洪希周，郑民华. 腹腔镜直肠双吻合术吻合口不同加固方式对吻合口漏的影响[J]. 上海交通大学学报(医学版), 2020, 40(7): 950-956.
[9]	李晓溪1，谢华1，黄轶晨1，吕逸清1，梁龑1，陈方1, 2, 3. 连续型脾性腺融合1例报道及文献复习[J]. 上海交通大学学报(医学版), 2020, 40(7): 1001-1004.
[10]	贺明，魏倩，张颖婷. 铁死亡相关机制与其在肝脏相关疾病中作用的研究进展[J]. 上海交通大学学报(医学版), 2020, 40(11): 1519-1523.
[11]	付学良1，张军峰1，郑彦2，王宇2，包映辉2，崔华2，花荣1. 二孔法腹腔镜辅助脑室腹腔分流术治疗脑积水的临床研究[J]. 上海交通大学学报（医学版）, 2019, 39(11): 1306-.
[12]	董凤伟，马佳莉，张莹. 合并慢性病的老年心房颤动患者消融术后复发危险因素研究[J]. 上海交通大学学报（医学版）, 2018, 38(9): 1092-.
[13]	董琦，孙为增，王玉芸，张京. 腹腔镜下行Soave根治术治疗先天性巨结肠患儿的疗效评估[J]. 上海交通大学学报（医学版）, 2018, 38(7): 841-.
[14]	韩可琪，阮昕，贺明. SIRT2在肝癌发生发展中的作用[J]. 上海交通大学学报（医学版）, 2018, 38(10): 1247-.
[15]	王岳萍，蔡蕾，朱岚，沈立翡. 合并卵巢畸胎瘤的抗N-甲基-D-天门冬氨酸受体脑炎的治疗[J]. 上海交通大学学报（医学版）, 2017, 37(2): 270-.