Diagnosis and treatment of hepatic alveolar echinococcosis with intraperitoneal implantable metastasis
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摘要:
肝泡型包虫病是由多房棘球绦虫感染所致的一种人畜共患性寄生虫病,其病灶生长方式类似肝脏恶性肿瘤,呈浸润性生长。肝泡型包虫病灶不仅可直接侵犯邻近组织,还可经淋巴管和血管转移。肝泡型包虫病发生腹腔种植性转移极其罕见。笔者介绍1例肝泡型包虫病腹腔种植性转移的诊断与治疗经验。
Abstract:Hepatic alveolar echinococcosis is a zoonotic parasitic disease caused by echinococcus multilocularis infection. The growth pattern of the lesions of hepatic alveolar echinococcosis is similar to that of liver malignant tumor showing invasive growth. Hepatic alveolar echinococcosis can not only directly invade the adjacent tissue structure, but also metastasize through the lymphatic tracts and blood vessels. Hepatic alveolar echinococcosis with intraperitoneal implantable metastasis is extremely rare. The authors introduce the diagnosis and treatment of 1 patient who had hepatic alveolar echinococcosis with intraperitoneal implantable metastasis.
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Keywords:
- Echinococcosis, hepatic /
- Metastasis /
- Peritoneum /
- Diagnosis /
- Treatment
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一、病例资料
病人女,57岁。以“左季肋区包块伴疼痛2年”为主诉于2020年9月收治入青海大学附属医院。病人入院时精神正常,无其他合并症及基础疾病。体格检查:全身皮肤、黏膜及巩膜未见明显黄染,左季肋区肋缘下可触及长径约5 cm包块,质地柔软、边界欠清晰、活动度差、压痛弱阳性;腹部平坦,未见胃肠型及蠕动波,未见腹部静脉曲张。实验室检查结果显示:ALT 31 U/L、TBil 5.8 μmol/L、Alb 38.6 g/L、ALP 97 U/L、PT 11.3 s、活化部分凝血活酶时间25.1 s、包虫IgG抗体阳性。腹部动态增强CT检查结果示肝左叶病灶,考虑为P2型泡型包虫病(图1A、1B)。肝包虫动态MRI检查结果:肝左叶病灶,考虑为泡型包虫病(P2N0M0期),门静脉左支受侵犯(图1C)。胸部及头颅CT检查结果未见明显异常。
图 1 肝泡型包虫病人术前影像学检查结果 1A:腹部动态增强CT检查结果示肝左叶病灶(➝),考虑为P2型泡型包虫病;1B:腹部动态增强CT检查结果示腹壁下未见任何组织或结构(➝);1C:肝包虫动态磁共振成像检查结果示肝左叶病灶(➝),考虑为泡型包虫病(P2N0M0期),门静脉左支受侵犯Figure 1. Preoperative imaging examination results of hepatic alveolar echinococcosis 1A: Result of dynamic enhanced CT examination showed lesion in the left lobe of liver (➝) which is considered as vesicular echinococcosis(P2); 1B: Result of dynamic enhanced CT examination showed no tissue or structure was found under the abdominal wall (➝); 1C: Result of dynamic MRI examination of hepatic hydatid showed lesion in the left lobe of liver (➝) which is considered as vesicular hydatid disease (P2N0M0) and left portal vein was invaded二、术前讨论
于文昊主治医师:病人2年前发现左季肋区包块伴疼痛,并有长期牧区居住史,肝泡型包虫病诊断明确,手术切除为最佳治疗方案。术前需明确剩余肝脏体积、病灶体积。因病灶与周围组织关系密切,术中需通过精细操作以最大程度保留健康肝脏。术前影像学检查结果示部分病灶与膈肌及大血管分界不清晰,术中存在无法完全切除病灶可能,拟行手术方式为扩大肝左叶切除术或包虫减瘤术。
王志鑫副主任医师:目前病人诊断为肝泡型包虫病,部分病灶与膈肌、下腔静脉、门静脉等分界不清晰,考虑受侵犯。病人一般状况较好,肝功能、血常规、凝血功能、心电图等检查结果基本正常。病人诊断明确,具备手术指征,排除相关手术禁忌证后拟行肝左叶切除术。
王海久主任医师:病人已完成基本检查,P2N0M0期肝泡型包虫病诊断明确。腹部动态增强CT检查及肝包虫动态MRI检查结果:病灶与周围血管关系紧密,肝左动脉、门静脉左支局部未见显示,考虑受病灶侵犯;病灶相邻胆管轻度扩张,病灶与膈肌分界不清晰。病人具备手术指征,无明显手术禁忌证,拟行肝左叶切除术。围手术期需关注病人肝功能变化,术中操作需仔细分离周围组织,避免损伤周围器官,保留健康肝脏。术前需积极准备,及时与病人及家属沟通,明确病情及手术风险。
三、治疗过程
病人及家属均签署知情同意书,手术方式拟行肝左叶切除术。术中探查可见肝左叶病灶性质、大小、位置与术前影像学检查结果吻合。术中游离肝右叶过程中,发现肝右叶膈面与右侧腹壁粘连紧密,分离过程中见1个质地坚轫、亮白色纤维囊壁(图2A)。囊壁边缘存在约5 cm宽度不规则裂口,予以切除(图2B)。此外,术中探查腹腔过程中发现大网膜、空肠肠壁及肠系膜间广泛附着珍珠样病灶(图2C)。经术中快速冷冻切片组织病理学检查确诊为肝泡型包虫病灶。针对上述情况,对病人行肝左叶切除+大网膜、部分肠管及腹腔病灶切除+肠肠吻合术。术后给予心电监护、吸氧、保肝治疗、营养支持、补充血容量、维持水电解质及酸碱平衡等措施后,病人恢复顺利,于术后第13天出院。出院时嘱病人口服阿苯达唑继续治疗1年,阿苯达唑300 mg/次,2次/d,定期复查肝、肾功能[1]。病人定期随访,饮食、睡眠、排便均正常。
图 2 肝泡型包虫病人术中情况 2A:分离肝右叶膈面与右侧腹壁粘连见1个质地坚轫、亮白色纤维囊壁(➝);2B:切除囊壁后标本;2C:大网膜、空肠肠壁及肠系膜间广泛附着珍珠样病灶Figure 2. Intraoperative photographs of patient with hepatic alveolar echinococcosis 2A: The right diaphragmatic surface of the liver was separated and the right abdominal wall was adhered to a solid bremsstrahlung and bright white fibrous cystic wall were observed (arrow); 2B: Photograph of the specimen after cyst wall resection; 2C: There were extensive pearly lesions in the greater omentum, jejunum, and mesentery四、术后讨论
泡型包虫病,又称泡型棘球蚴病或虫癌,为人畜共患性寄生虫病,由多房棘球绦虫感染所致,可分为结节型、巨块型及液化空洞型,病灶多位于肝脏[2‑8]。肝泡型包虫病人早期多无症状,病灶侵犯第一肝门或邻近组织器官并出现相应症状时,多已达到病程晚期[9‑12]。肝泡型包虫病灶生长方式类似肝脏恶性肿瘤,呈浸润性生长[13‑14]。目前的研究结果显示:肝泡型包虫病以出芽或浸润方式增殖,不断产生新囊泡,侵犯邻近组织或发生远处转移[15‑22]。肝泡型包虫病囊泡发生腹腔种植性转移极罕见。
笔者认为:该病人诊断为肝泡型包虫病腹腔种植性转移的主要依据为其肝左叶泡型包虫病灶完整,肝右叶组织结构正常,肝右叶边缘见一塌陷囊壁,部分肠管及腹壁内可见珍珠样散在病灶,经术后组织病理学检查确诊为泡型包虫病灶(图3);病灶可见3层结构,包括坏死结构,病灶浸润带(内见大量嗜酸性粒细胞、附近见大小不等泡状蚴小囊泡、底部可见部分嗜红色泡型包虫虫体集聚)及正常肝组织[23‑24]。
图 3 大网膜及肠壁组织术后组织病理学检查结果 3A:大网膜组织术后组织病理学检查结果示坏死结构(黑色箭头)及病灶浸润带(绿色箭头) HE染色 低倍放大;3B:肠壁组织术后组织病理学检查结果示正常肝组织(黑色箭头),病灶浸润带(黄色箭头)及坏死结构(绿色箭头) HE染色 低倍放大Figure 3. Histopathological examination of the greater omentum and intestinal wall after operation 3A: Post⁃operative hihiopathological examination of the greater omentum tissue revealed necrotic structures and infiltrated bands (black arrow shows necrotic tissue, green arrow shows infiltrated bands) Hematoxylin eosin staining Low magnification; 3B: Postoperative histomathological examination of intestinal wall tissue showed necrotic structure, lesion invasion zone, and normal liver tissue (black arrow shows normal liver tissue, yellow arrow shows invasion zone, green arrow shows necrotic tissue) Hematoxylin eosin staining Low magnification青海大学附属医院曾报道1例肝泡型包虫病行自体肝移植术后3个月,于切口附近发生包虫病灶种植性转移,提示肝泡型包虫病发生种植性转移可能[25]。此外,临床实践中发现:液化空洞型肝泡型包虫病灶,因其囊壁质地坚韧、菲薄、相对光滑,与囊型包虫病囊壁极其相似[26‑27]。该病人肝右叶膈面与腹壁间分离发现的囊壁不能排除为薄壁液化空洞型肝泡型包虫病的塌陷囊壁。
综上,该病人为肝泡型包虫病腹腔内种植性转移,转移灶来源于肝左叶下泡型包虫病灶破裂所致。因术中未见囊型包虫病灶,可排除囊型包虫病合并泡型包虫病或囊型包虫病囊包破裂致病灶转移[28]。
所有作者均声明不存在利益冲突严积灿, 陈志宇, 于文昊, 等. 肝泡型包虫病腹腔种植性转移的诊断与治疗[J]. 中华消化外科杂志, 2021, 20(9): 1007-1010. DOI: 10.3760/cma.j.cn115610-20210817-00398.http://journal.yiigle.com/LinkIn.do?linkin_type=cma&DOI=10.3760/cma.j.cn115610-20210817-00398
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图 1 肝泡型包虫病人术前影像学检查结果 1A:腹部动态增强CT检查结果示肝左叶病灶(➝),考虑为P2型泡型包虫病;1B:腹部动态增强CT检查结果示腹壁下未见任何组织或结构(➝);1C:肝包虫动态磁共振成像检查结果示肝左叶病灶(➝),考虑为泡型包虫病(P2N0M0期),门静脉左支受侵犯
Figure 1. Preoperative imaging examination results of hepatic alveolar echinococcosis 1A: Result of dynamic enhanced CT examination showed lesion in the left lobe of liver (➝) which is considered as vesicular echinococcosis(P2); 1B: Result of dynamic enhanced CT examination showed no tissue or structure was found under the abdominal wall (➝); 1C: Result of dynamic MRI examination of hepatic hydatid showed lesion in the left lobe of liver (➝) which is considered as vesicular hydatid disease (P2N0M0) and left portal vein was invaded
图 2 肝泡型包虫病人术中情况 2A:分离肝右叶膈面与右侧腹壁粘连见1个质地坚轫、亮白色纤维囊壁(➝);2B:切除囊壁后标本;2C:大网膜、空肠肠壁及肠系膜间广泛附着珍珠样病灶
Figure 2. Intraoperative photographs of patient with hepatic alveolar echinococcosis 2A: The right diaphragmatic surface of the liver was separated and the right abdominal wall was adhered to a solid bremsstrahlung and bright white fibrous cystic wall were observed (arrow); 2B: Photograph of the specimen after cyst wall resection; 2C: There were extensive pearly lesions in the greater omentum, jejunum, and mesentery
图 3 大网膜及肠壁组织术后组织病理学检查结果 3A:大网膜组织术后组织病理学检查结果示坏死结构(黑色箭头)及病灶浸润带(绿色箭头) HE染色 低倍放大;3B:肠壁组织术后组织病理学检查结果示正常肝组织(黑色箭头),病灶浸润带(黄色箭头)及坏死结构(绿色箭头) HE染色 低倍放大
Figure 3. Histopathological examination of the greater omentum and intestinal wall after operation 3A: Post⁃operative hihiopathological examination of the greater omentum tissue revealed necrotic structures and infiltrated bands (black arrow shows necrotic tissue, green arrow shows infiltrated bands) Hematoxylin eosin staining Low magnification; 3B: Postoperative histomathological examination of intestinal wall tissue showed necrotic structure, lesion invasion zone, and normal liver tissue (black arrow shows normal liver tissue, yellow arrow shows invasion zone, green arrow shows necrotic tissue) Hematoxylin eosin staining Low magnification
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