肝内异位脾种植6例报告并文献复习_段克才.pdf

版权归中国普通外科杂志所有http:/2023 年 1 月中国普通外科杂志Vol.32 No.1第 32 卷 第 1 期China Journal of General SurgeryJan.2023肝内异位脾种植6例报告并文献复习段克才，杨诚，方鲲鹏，董志涛，隋承军，戴炳华，耿利，杨甲梅（上海东方肝胆外科医院 特需诊疗科，上海 200438）摘 要 背景与目的：肝内异位脾种植（ES）在临床上较为罕见，患者多在体检中偶然发现肝内病灶，极易误诊为肝脏的良性或恶性肿瘤而影响治疗。因此，本研究探讨肝内ES的临床特点及其诊治方法。方法：回顾性分析总结2015年1月2022年1月上海东方肝胆外科医院收治的肝内ES患者的临床资料，并行相关文献复习。结果：6例肝内ES患者中，男性4例，女性2例；年龄3978岁，中位年龄51岁。均有外伤致脾破裂出血行脾切除手术史，脾切除术后至初诊肝内 ES 时间为 2033 年，中位时间 27 年；4 例为单纯肝内 ES，2 例为肝脏合并膈肌多发 ES；伴有右上腹不适者 1 例，其余 5 例均在体检中发现；术前 MRI 或 CT 检查 5例拟诊为肝癌，1例拟诊为血管平滑肌脂肪瘤。6例患者均行肝切除手术。术后病理均证实为异位脾组织，肝内ES灶大小为1.55.9 cm，中位直径3.2 cm，其中1例肝内2个病灶病理结果分别为肝内ES和肝细胞癌。6例患者术后恢复顺利，随访半年均未发现新发ES病灶。文献复习结果显示，脾外伤或脾切除术后，90%的ES发生于腹腔内，以小肠浆膜、大网膜、壁层腹膜、肠系膜及盆腔多见，而发生于肝脏、膈肌或其他远隔器官较为罕见。结论：既往有脾外伤行脾切除手术史者，发现肝内病灶应考虑 ES 可能；肝内 ES 生长缓慢，多无临床症状，明确诊断后对不伴有临床症状者无需特殊处理。关键词 肝肿瘤/诊断；脾组织植入；脾破裂；脾切除术中图分类号：R735.7Report of six cases of intrahepatic ectopic splenosis and literature reviewDUAN Kecai,YANG Cheng,FANG Kunpeng,DONG Zhitao,SUI Chengjun,DAI Binghua,GENG Li,YANG Jiamei(Department of Special Medical Services,Shanghai Eastern Hepatobiliary Surgery Hospital,Shanghai 200438,China)Abstract Background and Aims:Intrahepatic ectopic splenosis(ES)is relatively rare in clinical practice.In most patients,the intrahepatic lesions are accidentally found during physical examination,often misdiagnosed as benign or malignant liver tumors,and may be given inappropriate treatment.Therefore,this study was conducted to investigate the clinical characteristics of intrahepatic ES and its diagnosis and treatment methods.临床研究 doi:10.7659/j.issn.1005-6947.2023.01.008China Journal of General Surgery,2023,32(1):94-100.http:/dx.doi.org/10.7659/j.issn.1005-6947.2023.01.008基金项目：上海市科学技术委员会科技计划基金资助项目（21ZR1478400）。收稿日期：2022-11-14；修订日期：2023-01-02。作者简介：段克才，上海东方肝胆外科医院住院医师，主要从事肝胆胰外科方面的研究。通信作者：杨甲梅，Email:94第 1 期段克才，等：肝内异位脾种植6例报告并文献复习 版权归中国普通外科杂志所有http:/Methods:The clinical data of 6 patients with intrahepatic ES treated in Shanghai Eastern Hepatobiliary Surgery Hospital from January 2015 to January 2022 were retrospectively analyzed and summarized,and the relevant literature review was performed.Results:Of the 6 patients with intrahepatic ES,4 cases were males,and 2 cases were females,aged 39-78 years,with a median age of 51 years;all cases had a history of splenectomy for traumatic splenic rupture and hemorrhage,and the time from splenectomy to initial diagnosis of intrahepatic ES was 20-33 years,with a median time of 27 years;4 cases were pure intrahepatic ES,and 2 cases were multiple ES of the liver and diaphragm;one case was accompanied by discomfort of the right upper abdomen,and all the other 5 cases were found in physical examination;5 cases were initially diagnosed as liver cancer,and 1 case was as initially diagnosed as angiomyolipoma by preoperative MRI or CT.All 6 patients underwent hepatectomy.Postoperative pathological examination confirmed that all the specimens were ectopic splenic tissue.The size of the intrahepatic splenic implant was 1.5-5.9 cm,with a median diameter of 3.2 cm.In one patient,the two lesions were ES and hepatocellular carcinoma,respectively,as determined by pathological examination.All 6 patients recovered uneventfully after the operation,and no new ES lesions were found during half a year follow-up period.The results of literature review showed that 90%of the ES occur in the abdominal cavity,which is frequently found in the serosa of the small intestine,the greater omentum,the parietal peritoneum,the mesentery,and the pelvic cavity,but rarely detected in the liver,the diaphragm,and other remote organs.Conclusion:In individuals with a previous history of splenectomy for splenic trauma,the possibility of heterotopic ES should be considered after detecting intrahepatic lesions;Intrahepatic ES grows slowly,and most of them have no clinical symptoms.No special treatment is needed for those without clinical symptoms after a definite diagnosis.Key words Liver Neoplasms/diag;Splenosis;Splenic Rupture;SplenectomyCLCCLC numbenumber r:R735.7异位脾种植（ectopic splenosis，ES）是指由于脾外伤或脾切除术后所引起的脾组织碎片自体种植1。Von Kuttner 最早于 1910 年通过尸检所见首次 提 出 了 脾 外 伤 后 ES 的 概 念，后 Buchbinder 于1939 年报道了 37 例外伤后 ES 的病例2。有关数据3-4表明，脾损伤或脾切除术后 ES 的发生率为16%67%，自脾破裂到 ES 确诊的平均时间间隔从5 个月至 32 年不等。90%的 ES 发生于腹腔内，而发生于肝内的 ES 约占 3%，临床上易误诊为肝脏的良性或恶性肿瘤5。本研究对我院收治的 6 例肝内ES 患者的临床资料进行分析，对其病史、影像学检查特点和治疗方法进行总结，加深临床医生对肝内 ES 的认识，避免误诊该类疾病。报告如下。1 资料与方法 1.1 临床资料收集 2015 年 1 月2022 年 1 月上海东方肝胆外科医院收治的 6 例肝内 ES 患者的临床资料。患者的基本资料见表 1。回顾性分析 6 例肝内 ES 患者的临床资料，对其病史、影像学检查特点和治疗方法进行总结，明确临床诊断要点和治疗原则。1.2 治疗过程及随访情况本组共 6 例肝内 ES 患者，其中男性 4 例；女性 2 例，年龄 3978 岁，中位年龄 51 岁；均有外伤致脾破裂出血行脾切除手术史，脾切除术后至初诊肝内 ES 时间为 2033 年，中位时间 27 年。6 例中4 例单纯肝内 ES，2 例肝脏合并膈肌多发 ES；肝内ES 伴有右上腹不适者 1 例，其余 5 例均在体检中发现；术前 MRI 或 CT 检查 5 例拟诊为肝癌，1 例拟诊为血管平滑肌脂肪瘤（图 1）。6 例患者均行肝切除手术，术后病理均证实为异位脾组织，肝内 ES 灶大小为 1.55.9 cm，中位直径 3.2 cm，其中 1 例肝内2 个病灶病理结果分别为肝内 ES 和肝细胞癌；所切除肝内 ES 灶都有相同的病理特征，肉眼下可见95中国普通外科杂志第 32 卷 版权归中国普通外科杂志所有http:/病灶包膜完整，切面呈暗红色或灰褐色，质软易碎（图 2A），镜下可见红髓和白髓，白髓内见淋巴结，红髓脾索不规则，内见血细胞及淋巴细胞，脾血窦连接成网，形态不规则（图 2B）。6 例患者术后恢复顺利，随访半年均未发现新发 ES 病灶。表16例肝内ES患者的基本资料Table 1Basic data