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目的探讨合并肝硬化或肝炎的肝癌患者安全手术能耐受的切缘大小。方法前瞻性研究连续76例肝癌标本的肿瘤体积及无瘤肝体积;根据CT测算前40例患者的无瘤肝体积。分析切肝量、无瘤肝切除率(HPRR)与术后肝功能、并发症和切缘的关系。结果76例患者切缘为(5±7)mm;标本肿瘤体积和无瘤肝体积分别为(107±203)cm3和(153±120)cm3。前40例患者CT测得的无瘤肝体积为(1079±179)cm3,HPRR为(14.0±9.3)%。HPRR≤20%、20%~30%的患者术后并发症发生率、并发症积分和术后1周内总胆红素最大值低于>30%的患者(P<0.05)。术后并发症积分为0分的HPRR低于3~6分者(P<0.05)。术前肝功能、HPRR、手术大小、肝门阻断时间和标本肝体积均是影响术后肝功能和并发症的重要因素(P<0.05)。结论对无肉眼癌栓或子灶的肝癌患者,如肿瘤直径小于10 cm,10 mm切缘能保证足够的剩余肝功能和完全清除癌周肝内的微转移,如肿瘤直径大于10 cm,6 mm切缘能基本保证足够的剩余肝功能和清除99%的癌周肝内的微转移;而对有肉眼癌栓或子灶的肝癌患者,如肿瘤直径小于6 cm,20 mm切缘能基本保证足够的剩余肝功能和清除99%的癌周肝内的微转移。
Objective To investigate the margin of surgical margin that can be tolerated in patients with liver cancer who have cirrhosis or hepatitis. Methods The prospective study of 76 consecutive specimens of liver cancer, tumor-free volume and tumor-free liver volume; CT-based calculation of the first 40 patients with tumor-free liver volume. To analyze the relationship between the amount of hepatectomy, tumor-free hepatic resection rate (HPRR) and postoperative liver function, complications and margins. Results The margins of 76 patients were (5 ± 7) mm. The tumor volume and tumor-free liver volume were (107 ± 203) cm3 and (153 ± 120) cm3, respectively. The tumor-free liver volume measured by CT in the first 40 patients was (1079 ± 179) cm3, and the HPRR was (14.0 ± 9.3)%. The incidence of postoperative complications, complication scores and patients with total bilirubin less than 30% within 1 week after HPRR≤20% and 20% ~ 30% (P <0.05). Postoperative complications score of 0 points of HPRR less than 3 to 6 points (P <0.05). Preoperative liver function, HPRR, operative size, hilar blocking time, and specimen liver volume were both important factors influencing postoperative liver function and complications (P <0.05). Conclusion For patients with non-cancerous or tumorous liver cancer, if the diameter of the tumor is less than 10 cm, a margin of 10 mm can ensure sufficient residual liver function and completely eliminate the intrahepatic micrometastasis of the tumor. For example, if the tumor diameter is larger than 10 cm, 6 mm margins can basically ensure adequate residual liver function and clearance of 99% of the peritumoral liver cancer micrometastases; and for patients with liver cancer with macroscopic tumor emboli or foci, such as tumor diameter less than 6 cm, 20 mm margin can basically Ensure adequate residual liver function and clearance of micrometastases in the liver by 99%.