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摘要: 肝细胞癌合并门静脉癌栓为临床常见情况，但人们对其认识仍然存在不足。本文从门静脉癌栓的形成机制、门静脉癌栓的可见度分型以及肝内播散转移的原因和机制等方面提出了一些新的认识；在这些认识的基础上，又提出“门静脉优先”理念，即术中先要分离、结扎或阻断肿瘤所在区域的门静脉，然后游离肝脏、切除肿瘤；同时提出“门静脉探查”理念，即离断肝脏时要探查断面管道有无癌栓，然后才能结扎；最后提出“门静脉原位切开直视下取栓术”，即对于程氏Ⅱ型及部分Ⅲ型癌栓，先要游离、阻断门静脉主干及对侧分支，然后切开癌栓所在部位的门静脉，直视下取出癌栓。
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关键词:
- 门静脉癌栓 /
- 门静脉优先 /
- 门静脉探查 /
- 门静脉原位切开直视下取栓术
Abstract: Hepatocellular carcinoma complicated with portal vein tumor thrombus (PVTT) is a common clinical predicament, and its understanding remains insufficient. Here, some new ideas on the formation mechanism of PVTT, visibility classification of PVTT, and causes and mechanism of intrahepatic dissemination and metastasis are presented. Based on these ideas, the authors put forward the concept of "portal vein priority", that is, the portal vein in the area where the tumor is located should be dissected, ligated or blocked before mobilizing the liver and removing the tumor, the concept of "portal vein exploration", that is, during parenchymal dissection, the ducts on liver section should be explored for tumor thrombus before ligation, and "thrombectomy under direct vision with portal vein in situ incision", that is, for Chen's type Ⅱ and some type Ⅲ tumor thrombi, the main portal vein and the contralateral branch should be dissected and blocked first, then the portal vein is incised at the location of tumor thrombus and the tumor thrombus is extracted under direct vision. -
图 7 肝内“逆流转移”的机制
红色箭头：门静脉血流冲击癌栓正面；绿色箭头：湍流；紫色箭头：各种原因的挤压所致返流；黑色箭头：肝动脉-门静脉瘘所致返流；蓝色箭头：门静脉双向血流
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