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肝実質温存手術の意義と有用性

小林, 光助 東京大学 DOI:10.15083/0002005117

2022.06.22

概要

背景:近年、術後肝不全の予防や再肝切除率の向上という観点から残肝容積をできるだけ温存する肝切除術(Parenchyma-sparing liver resection)を行う機会が増えている。外側区域切除術(Left lateral sectionectomy: LLS)は、外側区域に位置する肝細胞癌(hepato cellular carcinoma; HCC)の外科的治療にしばしば選択されている術式である。近年、腹腔鏡下肝切除の普及により外側区域に位置するHCCに対してparenchyma-sparing liver resection(すなわちCouinaudsegment2またはCouinaudsegment3の解剖学的切除[anatomic resection: AR]、以下[S2AR]および[S3AR]とする)ではなく、技術的に単純なことを理由にLLSが選択されている可能性が懸念される。背景肝の機能低下がみられることの多いHCCに対する肝切除では、可能な限り多くの肝実質を温存しながら、切除断端の癌陰性を確保することが必要である。そのため外側区域に位置するHCCに対してはparenchyma-sparing liver resectionに基づく戦略で治療する際にはS2ARまたはS3ARが検討される術式と考えられる。外側区域に位置する腫瘍に対し、2つの異なるアプローチ(つまりparenchyma-sparing liver resection strategyvs. LLS)で肝切除を行った際の肝再生の程度や長期予後の差異に関して報告はみられない。

今回、parenchyma-sparing liver resectionを施行した際の肝再生率と長期予後を明らかにするため、(1)肝外側区域に位置するHCCに対してparenchyma-sparing liver resection(S2ARまたはS3AR)を受けた患者とLLSを受けた患者の術後肝容積と短期・長期術後成績を比較した。(2)新たなParenchyma-sparing liver resectionの術式として、左肝静脈(left hepatic vein; LHV)の合併切除が必要なS2の肝腫瘍に対してumbilical fissure vein(UFV)を温存することで、S3のうっ血を回避することが可能であった拡大S2亜区域切除術を報告する。

(1)外側区域におけるParenchyma-sparing liver resectionの意義
方法:1994年から2014年まで、東京大学肝胆膵外科、人工臓器・移植外科でLLSまたはS2/S3ARを施行された89人のHCC患者を対象とした。これら89人の患者のうち、49人がLLSを施行され(LLS群)、40人がS2AR(n=11)またはS3AR(n=29)を施行された(S2/S3AR群)。

結果:術中出血量は、S2/S3AR群でLLS群よりも有意に高かった(453vs.260mL、p=0.024)。腫瘍径および手術断端距離は、S2/S3AR群でLLS群よりも有意に小さかった(腫瘍径:22.0vs.35.0mm、p<0.001)(手術断端距離:4.5vs.9.0mm、p=0.010)。手術時間、病理学的結果、術後合併症に2群間で有意な差は認めなかった。S2/S3AR群では、術後肝容積は術前肝容積と同等であったが(p=0.114)、LLS群の術後肝容積は術前肝容積よりも有意に小さかった(p=0.019)。2群間で全生存率と無再発生存率に有意な差は認めなかった(OS:p=0.056、RFS:p=0.102)。

(2)Parenchyma-sparing liver resectionの一例:拡大S2亜区域切除術
方法:2014年から2015年までの間にLHVに浸潤する肝腫瘍に対して、LHV合併切除を伴うS2亜区域切除を施行した3症例の短期成績とS3の肝再生率を検討した。

結果:サージカルマージンは全て陰性であり、全症例で術後合併症は認めなかった。S3の平均術後肥大率は111.6%(108.6%-138.2%)であり、CT上S3の不均一な造影パターンは認めず、うっ血のない正常な静脈還流が示唆され、UFVはすべての患者において開存が確認された。

結論:本研究にて以下のことを明らかにした。(1)外側区域に位置するHCCのS2/S3ARは、LLSと比較して全生存期間および無再発生存期間に差がなく、術後に再生した肝容積はLLS群より大きかった。(2)LHVへ浸潤しているS2の肝腫瘍に対してUFVを温存することによりS3の鬱血を回避する拡大S2亜区域切除術は、初回手術における腫瘍学的な根治度を下げることなく、再発時の治療の選択肢を広げる可能性がある術式である。

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