Hepatic artery ligation and therapeutic embolization

Hepatic arterial therapy includes simple hepatic artery ligation, total hepatic artery devascularization, temporary hepatic artery occlusion, and hepatic artery embolization. Simple hepatic artery ligation refers to ligation of the proper hepatic artery in the hepatoduodenal ligament, or ligation of the left or right hepatic artery. Total hepatic artery decompression refers to the ligation of all the hepatic ligaments, including the sacral ligament, the triangular ligament, the coronary ligament, and the liver and stomach ligament. The common bile duct and portal vein are preserved only in the hepatoduodenal ligament. . Temporary hepatic artery occlusion refers to the cutting of the perihepatic ligament and the accessory hepatic artery, but does not cut off the hepatic artery, only blocks the hepatic artery for a period of time and then reopens to delay the establishment of the collateral circulation of the liver. drug. Intraoperative hepatic artery embolization refers to the injection of chemotherapeutic drugs and embolic agents through the hepatic artery intubation on the basis of hepatic artery ligation. The main purpose of hepatic arterial therapy is to block tumor blood supply and cause tumor necrosis. According to different blocking time, permanent and temporary arterial blockage can be divided, and extravascular and intravascular blockade can be divided according to the blocking mode. Treating diseases: liver cancer Indication Hepatic artery ligation and therapeutic embolization apply to: According to the purpose of surgery, the indications for hepatic artery ligation can be divided into the prevention of hepatic hemorrhage, the preparation of hepatic lobe resection, the palliative treatment of liver cancer and the preparation of second-stage resection of liver cancer. 1, the common causes of liver hemorrhage are liver trauma, spontaneous rupture of liver tumors and biliary bleeding. (1) Liver trauma: Hepatic wound hemorrhage is the main cause of early death of liver trauma. Therefore, hepatic artery ligation can be used in complicated liver rupture such as liver penetrating injury, central rupture of the liver, or treatment of uncontrollable hepatic rupture with tamponade and patient conditions that do not allow for more complicated surgery. (2) Liver tumor spontaneous rupture and hemorrhage: more common in liver cancer, hepatic hemangioma and other rupture bleeding, when the lesion can not be removed and can not suture hemostasis, the affected side of the hepatic artery branch can be ligated to achieve hemostasis. (3) Biliary hemorrhage: Hepatic artery ligation is a simple and effective method for the treatment of biliary bleeding. Hepatic artery ligation for the treatment of biliary bleeding is: 1 hepatobiliary infection to form ulcer bleeding, bleeding site is difficult to determine; 2 multiple or bilateral bleeding, bleeding site is difficult to determine; 3 intrahepatic biliary bleeding, liver without limitations Lesions, hepatic artery tremor, blockade of hepatic artery tremor disappeared; 4 critically ill patients can not withstand more complicated surgery; 5 technically do not have patients with hepatectomy. 2, the preparation of hepatectomy for large hepatic cavernous hemangioma difficult to separate surgery, you can first ligature the affected side of the hepatic artery, so that the tumor shrinks, and then separate, can achieve less bleeding, easy to operate. 3, palliative treatment of liver cancer liver cancer is suitable for hepatic artery ligation and embolization indications: 1 primary liver cancer involving left and right hepatic or hepatic hilar can not be removed; 2 liver cancer rupture hemorrhage can not be removed; 3 secondary liver cancer The primary tumor has been controlled or has been resected; 4 recurrent hepatocellular carcinoma that cannot be resected; 5 liver cancer can not be embolized or poorly treated by other methods, especially hepatic artery cannulation; 6 cirrhosis is not very serious, no jaundice, ascites and coagulation Prolonged zymogen time; 7 portal veins without cancerous plugs. 4, the second-stage resection of liver cancer preparation for the first-stage resection of large liver cancer, hepatic artery ligation and intraoperative chemotherapy embolization, after the tumor is reduced and then the second phase of resection, can get a good therapeutic effect. 5, other liver diseases can not be resected hepatic cavernous hemangioma, hepatic aneurysm and hepatic artery portal vein fistula can not be resected or transplanted, feasible hepatic artery ligation treatment. Contraindications 1. Shock or insufficient blood volume and extracellular fluid. 2, hypoxemia, hepatic artery ligation will further lead to liver hypoxia. 3, moderately cirrhosis or liver function has obvious damage. 4, liver cancer or thrombosis and other causes of portal vein embolism. 5, have more than moderate esophageal varices. 6, severe metabolic disorders such as hypoglycemia, hyponatremia when the portal vein blood flow and blood oxygen saturation capacity decreased. 7, serious heart, lung, kidney and other important organ lesions can not tolerate surgery. Preoperative preparation 1, quickly restore blood volume and extracellular fluid, correct shock: blood loss should be supplemented with whole blood, severe dehydration should be supplemented with plasma, plasma and balance fluid, etc., to maintain normal blood pressure, correct water, electrolytes and acid-base disorders. When the combined cardiac function is reduced, the cardiotonic agent can be applied to increase the cardiac output. It is also conceivable to use glucagon and low molecular weight dextran to increase portal blood flow. 2, continuous oxygen aspiration to correct shock while giving oxygen, oxygen flow rate of 3 ~ 4L / min, can correct hypoxia, improve portal oxygen content. 3, active liver protection treatment 1 preoperative high glucose, high protein and high vitamin diet, oral vitamins C, B and K, increase liver function reserve; 2 patients with hypoproteinemia intravenous infusion of albumin, improve albumin Content; 3 patients with poor general condition, intravenous infusion of hypertonic glucose, branched-chain amino acids, energy mixture, etc., increase liver glycogen reserves, reduce protein consumption. 4, the necessary preoperative examination, especially to understand the liver function, renal function, prothrombin time or not. Upper gastrointestinal endoscopy or barium meal examination to see if there is esophageal varices. B-ultrasound to understand the location, extent, size of the liver lesions, embolism of the portal vein, presence or absence of ascites. Check the ECG, chest, etc. to understand the heart and lung conditions. 5, preoperative blood preparation, intramuscular injection of vitamin K11, preoperative night with soapy water enema, morning stomach, etc., in order to reduce the contents of the gastrointestinal tract, so that the intestinal tract can rest, reduce oxygen consumption, maintain portal oxygen The content is at a higher level. Surgical procedure 1. Hepatic artery ligation (1) Do a right rectus abdominis incision or a right inferior rib incision into the abdomen. Check the liver to confirm that the tumor can not be resected but suitable for ligation of the hepatic artery. The surgeon puts the left hand finger into the small omentum hole, the thumb is placed on the surface of the hepatoduodenal ligament, and the hepatic artery is pulsating and temporarily pinched. Hepatic artery blood flow for a few minutes to observe the effect after blocking, such as liver trauma or tumor rupture bleeding, whether the liver discoloration range is consistent with the lesion. (2) Carefully cut the anterior layer of the hepatoduodenal ligament according to the position of the hepatic artery, separate the ligation of small blood vessels and lymphatic vessels, expose the proper hepatic artery, cut the arterial sheath, and continue to separate the left and right hepatic artery along the proper hepatic artery. . (3) The hepatic artery is freed by about 0.5 cm, and double-ligated with a medium-sized silk thread, and the artery does not have to be cut. According to different ligation sites, it can be divided into hepatic artery ligation, left hepatic or right hepatic artery ligation. After the ligation of one side of the hepatic artery, the color of the liver becomes darker, which indicates that the ligation effect is good. 2, hepatic artery embolization (1) After separating the hepatic artery and the left and right hepatic artery, the ligation was not performed, and the hepatic artery of the affected side was further separated by about 1 cm, and the proximal end of the proximal end was double-ligated. (2) The distal end of the artery is suspended as a traction, and an oblique cut is made between the ligature and the traction with an ophthalmic scissors, and a plastic tube having a diameter of about 2 mm is inserted, and the traction line is ligated and fixed. (3) Injecting methylene blue into the catheter and observing the liver staining to adjust the depth of the catheter tip. Generally, it can be inserted into 2cm, and if it is too deep, it is easy to enter the branch. (4) Transcatheter injection of chemotherapeutic drugs and embolic agents include iodized oil and gelatin sponge. The amount of embolization agent administered is determined by the size of the tumor and the degree of cirrhosis of the liver. Generally, the iodized oil does not exceed 15ml, and the gelatin sponge does not exceed one. (5) After the injection is completed, the catheter is pulled out, and the wire is double-ligated to the distal end of the artery. Check the abdomen after no bleeding. complication 1, liver abscess Jochimsen reported 6 cases of hepatic abscess caused by hepatic artery ligation and hepatic arterial catheterization, which occurred between 0.5 and 5 months after surgery. There was a case of right hepatic artery ligation and embolization in our hospital. The patient continued to have high fever for more than 2 months. Three months after discharge, he died of liver abscess entering the right chest. Therefore, a broad-spectrum antibiotic should be infused after surgery. The patient continued to have high fever and the white blood cells increased significantly. B-ultrasound found that there was a liquid dark area in the liver or the original tumor was liquefied. B-ultrasound guided liver puncture should be performed. The liquid should be drained and the antibiotic solution should be used. rinse. Remove the drainage tube after the liquid dark area disappears. 2, necrotizing cholecystitis The reason is that the gallbladder artery is embolized and caused by ischemic necrosis of the gallbladder. It is characterized by persistent pain in the right upper quadrant, fever, and white blood cells. In severe cases, there are signs of right upper quadrant tenderness, rebound tenderness and muscle tension. After perforation of the gallbladder, signs of diffuse peritonitis are caused. B-ultrasound showed a significant increase in gallbladder, thickened edema in the gallbladder wall, and flocculation in the gallbladder cavity. Necrotic cholecystitis should be actively anti-inflammatory treatment, while gastrointestinal decompression, fasting. If conservative treatment is ineffective, body temperature continues to rise, white blood cell count exceeds 20 × 109 / L, or gallbladder perforation, emergency cholecystectomy or ostomy should be considered. The key to prevent necrotizing cholecystitis is to prevent the embolization agent, especially gelatin sponge, from injecting into the gallbladder artery to cause embolization of the distal end of the gallbladder artery. Therefore, the end of the catheter should exceed the beginning of the gallbladder artery, or the cholecystectomy should be performed at the same time. 3, liver failure Hepatic artery ligation has a lesser effect on liver function. It is difficult to establish collateral circulation in the short term after hepatic artery embolization, liver tissue damage is serious, liver function abnormality can last for more than 1 to 2 months, and severe liver cirrhosis can lead to liver Functional failure, manifested as progressive progressive jaundice, progressive increase in ascites, albumin reduction, prolonged prothrombin time, and elevated transaminase. At this time, even if active liver protection is given, liver function is difficult to recover. The key to preventing liver failure is to strictly control the surgical indications. 4, liver infarction It is common in embolization of hepatic artery, especially gelatin sponge. Due to the failure of collateral circulation after hepatic artery extremity embolization, focal hepatic infarction is caused. The main treatment is to protect the liver and fight infection, and to prevent the formation of abscess.