Ktl-icon-tai-lieu

Kỹ thuật cẳt gan của Blumgart

Được đăng lên bởi les7eva
Số trang: 33 trang   |   Lượt xem: 1172 lần   |   Lượt tải: 0 lần
8
Techniques of Hepatic Resection
HOWARD M. KARPOFF, MD
WILLIAM R. JARNAGIN, MD
JOSÉ MELENDEZ, MD
YUMAN FONG, MD, FACS
LESLIE H. BLUMGART, MD, FACS, FRCS (ENG, EDIN, GLAS)

Hepatic resection is appropriate treatment for a variety of benign and primary or secondary malignant
hepatic lesions. In appropriate patients with malignant disease, resection generally offers the best
opportunity for long-term survival or cure. In
patients with benign tumors, resection is safe and
effective when carried out for symptoms directly
related to the tumor.
In patients with malignant tumors submitted to a
potentially curative operation, complete resection
requires a negative histologic margin. Previously, a
margin of 1 cm of normal parenchyma was considered essential, but recent studies have suggested that
this is not necessarily the case, and margins of less
than 1 cm are adequate.1,2 In many cases, tumor
proximity to major vascular structures will preclude
a resection margin of more than a few millimeters,
which is generally sufficient. Regardless, anatomically based partial hepatectomy is the best means of
achieving a negative margin. Wedge resections are
usually inadequate and potentially dangerous, especially for large tumors, and are often associated with
greater blood loss and a greater incidence of positive
histologic margins.3 Anatomic segmental resections
are much more controlled and are generally superior
to wedge resections.
Hepatic resection for benign hepatic tumors may
be indicated for relief of symptoms (such as pain or
early satiety), for uncertainty in diagnosis, or for
lesions with malignant potential. In contrast to the
situation with malignant tumors, however, most
benign tumors can be removed with maximal spar159

ing of normal parenchyma. Consequently, lesions
such as hemangiomas, adenomas, complex cysts, or
fibronodular hyperplasia are often excised by enucleation (Fig. 8–1) or anatomic resections with limited margins.
The fear of uncontrolled hemorrhage was a major
impediment to the evolution of hepatic resection as an
effective form of therapy. While bleeding remains a
concern, operative technique has improved greatly,
and experienced centers have realized significant
reductions in blood loss and transfusion requirements,
even after major resections. Portal-triad clamping
reduces hepatic arterial and portal venous bleeding
but does not address the hepatic veins, which are usually the major source of blood loss. Our approach to
hepatic resection, dev...
159
Hepatic resection is appropriate treatment for a vari-
ety of benign and primary or secondary malignant
hepatic lesions. In appropriate patients with malig-
nant disease, resection generally offers the best
opportunity for long-term survival or cure. In
patients with benign tumors, resection is safe and
effective when carried out for symptoms directly
related to the tumor.
In patients with malignant tumors submitted to a
potentially curative operation, complete resection
requires a negative histologic margin. Previously, a
margin of 1 cm of normal parenchyma was consid-
ered essential, but recent studies have suggested that
this is not necessarily the case, and margins of less
than 1 cm are adequate.
1,2
In many cases, tumor
proximity to major vascular structures will preclude
a resection margin of more than a few millimeters,
which is generally sufficient. Regardless, anatomi-
cally based partial hepatectomy is the best means of
achieving a negative margin. Wedge resections are
usually inadequate and potentially dangerous, espe-
cially for large tumors, and are often associated with
greater blood loss and a greater incidence of positive
histologic margins.
3
Anatomic segmental resections
are much more controlled and are generally superior
to wedge resections.
Hepatic resection for benign hepatic tumors may
be indicated for relief of symptoms (such as pain or
early satiety), for uncertainty in diagnosis, or for
lesions with malignant potential. In contrast to the
situation with malignant tumors, however, most
benign tumors can be removed with maximal spar-
8
Techniques of Hepatic Resection
HOWARD M. KARPOFF, MD
WILLIAM R. JARNAGIN, MD
JOSÉ MELENDEZ, MD
YUMAN FONG, MD, FACS
LESLIE H. BLUMGART, MD, FACS, FRCS (E
NG,EDIN,GLAS)
ing of normal parenchyma. Consequently, lesions
such as hemangiomas, adenomas, complex cysts, or
fibronodular hyperplasia are often excised by enu-
cleation (Fig. 8–1) or anatomic resections with lim-
ited margins.
The fear of uncontrolled hemorrhage was a major
impediment to the evolution of hepatic resection as an
effective form of therapy. While bleeding remains a
concern, operative technique has improved greatly,
and experienced centers have realized significant
reductions in blood loss and transfusion requirements,
even after major resections. Portal-triad clamping
reduces hepatic arterial and portal venous bleeding
but does not address the hepatic veins, which are usu-
ally the major source of blood loss. Our approach to
hepatic resection, developed by the senior author,
involves inflow and outflow vascular control before
parenchymal transection, low central venous pressure
anesthesia to minimize hepatic venous bleeding, and
anatomically based resections. Using this approach,
we have reduced the median blood loss to less than
1 L and the number of patients requiring transfusion
to less than half.
4
Some authors use the technique of
total vascular isolation routinely for all resections.
This is a fundamentally different approach that may
be useful in a handful of cases. Moreover, Belghiti
and colleagues, in a prospective study, found that total
vascular isolation offered little advantage to the
approach described above and was actually associated
with greater blood loss.
5
In our experience of approx-
imately 1,700 hepatic resections since 1992, we have
not found it necessary to use vascular isolation.
Kỹ thuật cẳt gan của Blumgart - Trang 2
Để xem tài liệu đầy đủ. Xin vui lòng
Kỹ thuật cẳt gan của Blumgart - Người đăng: les7eva
5 Tài liệu rất hay! Được đăng lên bởi - 1 giờ trước Đúng là cái mình đang tìm. Rất hay và bổ ích. Cảm ơn bạn!
33 Vietnamese
Kỹ thuật cẳt gan của Blumgart 9 10 67