98例复杂性肝多房棘球蚴病外科治疗方案的比较分析

摘要/Abstract

摘要：

目的探讨复杂性肝多房棘球蚴病的临床治疗策略,总结治疗经验。方法回顾性分析2015年10月至2017年10月青海大学附属医院收治的复杂性多房棘球蚴病患者资料,根据病灶分布情况,将中晚期或晚期患者纳入本研究,排除肝细粒棘球蚴病患者、早期肝多房棘球蚴病患者、仅行阿苯达唑药物治疗的患者。按照治疗方式分为准根治性切除组、姑息性切除组、肝移植组,分析患者的手术时间、术中出血量、术后并发症及复发随访情况。应用SPSS 20.0统计学软件对数据进行统计分析。结果符合纳入标准的患者98例,其中男40例,女58例,男女性别比1 : 1.45;患者年龄5~72岁,平均年龄38岁。准根治性切除组术后并发症发生率为55.7%（34/61）,其中低蛋白血症伴胸腔积液18例、肺部感染9例、切口感染3例、胆漏4例;术后复发率14.8%（9/61）,随访期间死亡3例。姑息性切除组术后并发症发生率41.4%（12/29）,其中胆漏合并残腔感染5例、肺部感染伴胸腔积液3例、2例梗阻性黄疸、1例切口感染、1例胆管-支气管漏;术后复发率17.2%（9/29）,随访期间死亡3例。准根治性切除与姑息性切除组术后并发症和复发率相比较无统计学意义（P ﹥ 0.05）,但在手术时间及出血量方面的差异具有统计学意义（P < 0.05）。肝移植组8例患者中,有4例死亡,包括1例急性排斥反应后多器官功能衰竭、2例凝血功能障碍致消化道出血、1例肝肾综合症,余4例患者均获得长期生存。结论复杂性肝多房棘球蚴病应针对患者病情制定个体化治疗方案,结合多学科诊疗模式,遵循损伤控制外科原则,以使患者最大化获益。

关键词: 肝多房棘球蚴病, 肝切除术, 治疗

Abstract:

ObjectiveTo explore the clinical treatment strategies for complicated hepatic alveolar echinococcosis and summarize treatment experiences. Methods A retrospective analysis was made on patients with complicated hepatic alveolar echinococcosis admitted to the Affiliated Hospital of Qinghai University from October 2015 to October 2017. According to the distribution of lesions, patients with advanced or mid-stage echinococcosis.were included in the study. Patients with hepatic cystic echinococcosis, early hepatic alveolar echinococcosis, and those treated with albendazole alone were excluded. According to the treatment design, they were divided into the quasi-radical surgical resection group （61 cases）, the palliative surgical resection group（29 cases）, and the liver transplantation group（8 cases）. The operation duration, intraoperative blood loss, postoperative complications, and recurrence during follow-up were analyzed. Data were analyzed with SPSS 20.0. Results Ninety-eight patients were included in the study, including 40 males and 58 females （male to female ratio of 1 : 1.45）. The patients aged 5 to 72 years, with an average age of 38 years. The incidence of postoperative complications in the quasi-radical resection group was 55.7% （34/61）, including 18 cases of hypoproteinemia accompanied by pleural effusion, 9 with lung infection, 3 with incision infection, and 4 with bile leakage; the recurrence rate was 14.8% （9/61）, and 3 died during follow-up. The incidence of postoperative complications in the palliative surgical resection group was 41.4%（12/29）, including 5 with bile leakage complicated by residual cavity infection, 3 with pulmonary infection with pleural effusion, 2 with obstructive jaundice, 1 with incision infection, and 1 with bile duct-bronchial leak; the postoperative recurrence rate was 17.2% （9/29）, and 3 died during follow-up. There was no significant difference in the postoperative complication incidence or recurrence rate between the quasi-radical resection group and the palliative resection group （P > 0.05）, but a significant difference was found in the operation duration and blood loss （P < 0.05）. Among the 8 patients who received liver transplantation, 4 died with 1 due to multiple organ failure after acute rejection, 2 gastrointestinal bleeding due to coagulopathy, and 1 hepatorenal syndrome, and the remaining 4 patients had long-term survival. Conclusion The treatment protocol for complicated hepatic alveolar echinococcosis needs to be individualized, in combination with multidisciplinary and highlighting damage control during surgery, in order to maximize patients' benefits.

Key words: Hepatic alveolar echinococcosis, Hepatectomy, Treatment

中图分类号:

R532.32

许晓磊, 王志鑫, 王展, 叶海雯, 庞明泉, 周灜, 王海久, 樊海宁. 98例复杂性肝多房棘球蚴病外科治疗方案的比较分析[J]. 中国寄生虫学与寄生虫病杂志, 2018, 36(6): 552-559.

Xiao-lei XU, Zhi-xin WANG, Zhan WANG, Hai-wen YE, Ming-quan PANG, Ying ZHOU, Hai-jiu WANG, Hai-ning FAN. Treatment of complicated hepatic alveolar echinococcosis: our experience of 98 cases[J]. Chinese Journal of Parasitology and Parasitic Diseases, 2018, 36(6): 552-559.

图/表 5

图1

表1

表2

98例复杂性肝多房棘球蚴病患者外科治疗方式

手术方法 Surgical method	手术名称Surgery name	病例数 No. cases	百分率/%Rate/%
准根治性切除	前路右半肝切除 + 胆囊切除术 + Ia切除	2	2.0
Quasi-radical resection	Anterior right hepatectomy + cholecystectomy + Ia resection
	右半肝切除 + 胆囊切除术	13	13.3
	Right hepatectomy + cholecystectomy
	右半肝切除 + 胆囊切除术 + 右肾切除术	1	1.0
	Right hepatectomy + cholecystectomy + right nephrectomy
	扩大右半肝 + 胆囊切除术 + 肾切除术 + 膈肌修补术	2	2.0
	Expand right hepatic + cholecystectomy + nephrectomy + diaphragm repair
	肝右三叶切除 + 胆囊切除术 + 胆肠吻合术	9	9.2
	Right hepatic resection + cholecystectomy + cholangioenterostomy
	肝右三叶切除 + 胆囊切除术 + 门静脉重建 + T管引流术	3	3.1
	Right hepatic lobe resection + cholecystectomy + portal vein reconstruction + T tube drainage
	肝右三叶切除 + 胆囊切除术 + 尾状叶切除 +下腔静脉切除术	1	1.0
	Right hepatic resection + cholecystectomy + caudate lobe resection + inferior vena cava resection
	右半肝切除 + 胆囊切除术 + 腹部盆腔包虫切除术	1	1.0
	Right hepatectomy + cholecystectomy + abdominal pelvic hydatidectomy
	左半肝切除 + 胆囊切除术	7	7.1
	Left hepatectomy + cholecystectomy
	左肝切除 + 肝右前 + 右后肝管形成 + 肝肠吻合	2	2.0
	Left hepatectomy + right anterior right + right posterior hepatic duct formation + hepatic and intestinal anastomosis
	肝左外叶切除术 + 胆肠吻合术	6	6.1
	Left hepatectomy and cholangioenterostomy
	肝左外叶切除 + 脾切除术	1	1.0
	Left lateral hepatic lobectomy + splenectomy
	肝中叶 + 尾状叶切除术	3	3.1
	Middle lobe + caudate lobe resection
姑息性切除	肝段切除术	10	10.2
Palliative resection	Hepatic segmentectomy
	肝右叶部分切除术	10	10.2
	Artial resection of the right lobe of the liver
	肝脏坏死病灶减体术 + PTCD	3	3.1
	Liver necrosis lesion reduction + PTCD
	肝右后叶切除 + 囊肿穿刺引流	3	3.1
	Right hepatic posterior lobe resection + cyst puncture drainage
	肝右叶部分切除 + 开颅脑包虫切除	6	6.1
	Partial resection of the right lobe of the liver + removal of cranial cysts
	肝右叶部分切除 + 右肺病灶切除术	1	1.0
	Partial resection of right hepatic lobe + right lung resection
	肝左外叶切除术 + 肝脏S8段微波消融术	3	3.1
	Left hepatic lobe resection + liver S8 segment microwave ablation
	肝脏病灶减体术 + ERCP + PTCD	1	1.0
	Liver lesion reduction + ERCP + PTCD
	肝脏部分切除 + 门静脉置换 + 胆肠吻合术	1	1.0
	Partial hepatectomy + portal vein replacement + cholangioenterostomy
	肝左叶部分切除 + T管引流	1	1.0
	Partial resection of left hepatic lobe + T tube drainage
肝移植	自体肝移植 Autologous liver transplantation	6	6.1
Liver transplantation	同种异体肝移植 Allogeneic liver transplantation	2	2.0

表2

图2

表3

参考文献 27

[1]	Tamarozzi F, Covini I, Mariconti M, et al. Comparison of the diagnostic accuracy of three rapid tests for the serodiagnosis of hepatic cystic echinococcosis in humans[J]. PLoS Negl Trop Dis, 2016, 10(2): e0004444.
[2]	Brunetti E, Garcia HH, Junghanss T.Cystic echinococcosis: chronic, complex, and still neglected[J]. PLoS Negl Trop Dis, 2011, 5(7): e1146.
[3]	温浩, 吐尔干艾力·阿吉, 邵英梅, 等. 棘球蚴病防治成就及面临的挑战[J]. 中国寄生虫学与寄生虫病杂志, 2015, 33(6): 466-471.
[4]	Kern P, Wen H, Sato N, et al. WHO classification of alveolar echinococcosis: principles and application[J]. Parasitol Int, 2006, 55(55Suppl): S283-S287.
[5]	McManus DP, Zhang W, Li J, et al. Echinococcosis[J]. Lancet, 2003, 362(9392): 1295-1304.
[6]	Parsak CK, Demiryurek HH, Inal M, et al. Alveolar hydatid disease: imaging findings and surgical approach[J]. Acta Chir Belg, 2007, 107(5): 572-577.
[7]	Grosso G, Gruttadauria S, Biondi A, et al. Worldwide epidemiology of liver hydatidosis including the Mediterranean area[J]. World J Gastroenterol, 2012, 18(13): 1425-1437.
[8]	Hatipoglu S, Bulbuloglu B, Piskin T, et al. Living donor liver transplantation for alveolar echinococcosis is a difficult procedure.[J]. Transplant Proc, 2013, 45(3): 1028-1030.
[9]	Joliat GR, Melloul E, Petermann D, et al. Outcomes after liver resection for hepatic alveolar echinococcosis: a single-center cohort study[J]. World J Surg, 2015, 39(10): 2529-2534.
[10]	陈哲宇. 肝包虫病的治疗[J]. 中国普外基础与临床杂志, 2015(2): 129-130.
[11]	Koch S, Bresson-Hadni S, Miguet JP, et al. Experience of liver transplantation for incurable alveolar echinococcosis: a 45-case European collaborative report[J]. Transplantation, 2003, 75(6): 856-863.
[12]	中国医师协会外科医师分会包虫病外科专业委员会. 肝两型包虫病诊断与治疗专家共识(2015版)[J]. 中华消化外科杂志, 2015, 14(4): 253-264.
[13]	Landen S,Van de Sande J, Berger P, et al. Alveolar echinococcosis in a Belgian urban dweller[J]. Acta Gastroenterol Belg, 2013, 76(3): 317-321.
[14]	Buttenschoen K, Kern P, Reuter S, et al. Hepatic infestation of Echinococcus multilocularis with extension to regional lymph nodes[J]. Langenbecks Arch Surg, 2009, 394(4): 699-704.
[15]	Morakote N, Thamprasert K, Lojanapiwat B, et al. Cystic echinococcosis in Thailand with a special note on detection by serology in one family[J]. Southeast Asian J Trop Med Public Health, 2007, 38(5): 796-798.
[16]	Maoz D, Greif F, Chen J.Operative treatment of hepatic hydatid cysts: a single center experience in Israel, a nonendemic country[J]. ISRN Surg, 2015, 2013(2013): 276807.
[17]	Parray FQ, Ahmad SZ, Sherwani AY, et al. Primary paraspinal hydatid cyst: a rare presentation of echinococcosis[J]. Int J Surg, 2010, 8(5): 404-406.
[18]	McManus DP, Gray DJ, Zhang W, et al. Diagnosis, treatment, and management of echinococcosis[J]. BMJ, 2012, 344(11 1): e3866.
[19]	Chen JS, Huang JQ, Chen XL, et al. Risk factors associated with intraoperative major blood loss during resection of hepatocellular carcinoma[J]. Hepatogastroenterology, 2015, 62(140): 790-793.
[20]	Gillet M, Miguet JP, Mantion G, et al. Orthotopic liver transplantation in alveolar echinococcosis of the liver: analysis of a series of six patients.[J]. Transplant Proc, 1988, 20(1): 573-576.
[21]	温浩, 栾梅香, 王喜艳, 等. 国内首例肝移植治疗肝泡型包虫病报告[J]. 疾病预防控制通报, 2001, 16(3): 100.
[22]	Liance M, Bresson-Hadni S, Vuitton DA, et al. Effects of cyclosporin a on the course of murine alveolar echinococcosis and on specific cellular and humoral immune responses against Echinococcus multilocularis[J]. Int J Parasitol, 1992, 22(1): 23-28.
[23]	Bresson-Hadni S, Blagosklonov O, Knapp J, et al. Should possible recurrence of disease contraindicate liver transplantation in patients with end-stage alveolar echinococcosis? A 20-year follow-up study[J]. Liver Transpl, 2011, 17(7): 855-865.
[24]	Pichlmayr R, Bretschneider HJ, Kirchner E, et al. Ex situ operation of the liver—a new possibility in liver surgery[J]. Langenbecks Arch Chir, 1988, 373(2): 122-126.
[25]	温浩, 黄洁夫, 张金辉, 等. 体外肝肿瘤切除加自体肝移植术治疗肝内胆管细胞癌一例[J]. 中华外科杂志, 2006, 44(9): 642-644.
[26]	Wen H, Dong JH, Zhang JH, et al. Ex vivo liver resection followed by autotransplantation for end-stage hepatic alveolar echinococcosis[J]. Chin Med J, 2011, 124(18): 2813-2817.
[27]	Kilickesmez O, Bayramoglu S, Inci E, et al. Value of apparent diffusion coefficient measurement for discrimination of focal benign and malignant hepatic masses[J]. J Med Imaging Radiat Oncol, 2010, 53(1): 50-55.

特征Feature	准根治性切除（n = 61） Quasi-radical resectionresection （n = 61）	姑息性切除（n = 29） Palliative resection （n = 29）	肝移植（n = 8） Livertransplantation（n = 8）
年龄/岁 Age/years	38.11 ± 14.21	38.55 ± 14.15	35.87 ± 9.30
体重/kg Weight/kg	57.70 ± 11.97	55.76 ± 12.06	58.00 ± 6.35
性别Gender
男 Male	26	12	2
女 Female	35	17	6
Child-Pugh分级Child-Pugh classification
A	48	17	5
B	11	11	3
C	2	1	0
病变位置Lesion position
左叶 Left lobe	9	1	1
右叶 Right lobe	27	20	3
左叶 + 右叶 Left lobe + right lobe	22	7	2
左叶 + 尾状叶 Left lobe + caudate lobe	1	0	0
右叶 + 尾状叶 Right lobe + caudate lobe	1	0	1
左右叶 + 尾状叶	1	1	1
Left and right lobe + caudate lobe
病灶直径/cm Lesion diameter/cm	9.37 ± 2.82	9.49 ± 3.77	11.76 ± 3.10
浸润位置Infiltration position
第一肝门 First hepatic portal	5	3	1
第二肝门 Second hepatic portal	1	3	1
第一、二肝门	8	5	2
First and second hepatic portals
下腔静脉 Inferior vena	26	12	7
胆道 Biliary tract	20	7	2
门静脉左支 Left portal vein	13	7	2
门静脉右支 Right portal vein	29	21	4
膈肌 Diaphragm	11	10	1
侵犯器官 Organs with invasion
右肾或肾上腺	23	11	3
Right kidney or adrenal gland
胆囊 Gallbladder	20	0	0
胰腺 Pancreas	4	2	0
脾脏 Spleen	1	0	0
胃壁 Stomach wall	4	0	0
心包 Pericardium	1	0	1
肝外转移Extrahepatic metastasis
肺 Lung	35	12	5
脑 Brain	6	12	1
骨 Bone	1	3	0
后腹膜 Retroperitoneum	9	13	2
腹盆腔种植 Abdominal pelvic implant	3	0	0

手术资料	准根治性切除（n = 61）	姑息性切除 (n = 29)	X²/t/z	P
Surgical data	Quasi-radical resection （n = 61）	Palliative resection (n = 29)	X²/t/z	P
手术时间/h	4.66 ± 1.29	2.94 ± 0.71	-5.972	﹤0.05
Operation duration/h
术中出血量/ml	1 000（600~1 650）	700（200~950）	-4.212	﹤0.05
Intraoperative blood loss/ml
引流管时间/d	15.93 ± 9.48	15.55 ± 10.19	-0.099	﹥0.05
Drainage tube time/d
住院时间/d	29.02 ± 15.51	23.59 ± 11.57	1.673	﹥0.05
Hospital stay/d
白蛋白/g·L^-1 ALB/g·L^-1	30.55 ± 3.77	31.77 ± 4.40	-1.351	﹥0.05
谷丙转氨酶/U·L^-1 ALT/U·L^-1	33.97 ± 15.62	41.10 ± 16.20	-1.723	﹥0.05
微量胆红素/Umol·L^-1 TBIL/Umol·L^-1	19.8（10.3~46.8）	16.0（7.6~34.0）	-1.399	﹥0.05
术后并发症（是/否）
postoperative complication
Yes	34	12	1.622	﹥0.05
No	27	17
术后复发（是/否）
Postoperative recurance
Yes	9	9	0.079	﹥0.05
No	52	20