左半肝切除术中应用Pringle法联合左肝静脉阻断的临床体会
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摘要
目的:探讨Pringle法联合左肝静脉阻断法行左半肝切除术的有效性及安全性。方法:采用回顾性病例对照研究方法,收集2015年1月至2018年12月因肝细胞癌行左半肝切除术的139例患者的临床资料,71例患者采用Pringle法联合左肝静脉阻断,为观察组,68例患者采用单纯Pringle法阻断,为对照组。对比两组患者术前资料、手术相关资料、术后并发症及术后住院时间。将139例患者按手术方式分为开腹左半肝切除(n=62)与腹腔镜左半肝切除(n=77)两个亚组,分别对比术中、术后相关指标。结果:观察组与对照组患者的性别、年龄、乙肝病毒感染、BMI、术前血红蛋白、肝功能指标、手术史及Ishak评分等一般资料差异无统计学意义(P>0.05),两组手术时间、术中出血量、术中输血、肝门阻断时间、术后并发症发生率、术后住院时间差异亦无统计学意义。亚组分析显示,开腹手术中,观察组术中出血量[(169.9±91.0)mL vs.(233.6±118.9)mL,P=0.020]少于对照组;腹腔镜手术中,观察组手术开始至肝切除开始时间[(36.2±5.6)min vs.(32.9±6.5)min,P=0.018]、手术开始至关腹完成时间[(140.3±20.4)min vs.(128.3±15.7)min,P=0.005)]长于对照组;术中出血量差异无统计学意义。结论:Pringle法联合左肝静脉阻断应用于开腹左半肝切除术中效果确切,应用于腹腔镜左半肝切除术可能延长手术时间,且达不到减少出血的目的。
Objective:To evaluate the safety and efficacy of Pringle method in combination with left hepatic vein occlusion for left hepatectomy.Methods: The retrospective case-control study was adopted.Clinical data of 139 patients with hepatocellular carcinoma who underwent left hepatectomy from Jan.2015 to Dec.2018 were collected,including 71 patients who received Pringle method in combination with left hepatic vein occlusion( the test group) and 68 patients who received Pringle method alone( the control group).Preoperative data,surgery condition,postoperative complications and postoperative hospitalization time were compared between the two groups.Then the 139 patients receiving left hepatectomy were further divided into two subgroups based on the surgical methods: an open hepatectomy subgroup( n = 62) and laparoscopy subgroup( n = 77),and intraoperative and postoperative data were compared between different subgroups.Results: There were no statistically significant differences between the test group and control group in gender,age,HBV infection rate,body mass index,preoperative hemoglobin levels,liver function,prior surgical history,Ishak score,operation time,intraoperative bleeding volume,intraoperative blood transfusion,hepatic hilar block time,incidence of complications or postoperative hospital stay.When limited to patients receiving open hepatectomy,the test group showed significantly lower intraoperative bleeding volume than the control group [( 169.9±91.0) mL vs.( 233.6±118.9) mL,P = 0.020]; when limited to those receiving laparoscopic hepatectomy,the test group showed significantly longer time from the start of surgery to liver resection [( 36.2±5.6) min vs.( 32.9±6.5) min,P = 0.018]and longer time from the start of surgery to abdominal closure [( 140.3±20.4) min vs.( 128.3±15.7) min,P = 0.005) ],while intraoperative bleeding were not significant different.Conclusions: Pringle method combined with left hepatic vein occlusion is effective in open left hepatectomy but may prolong the operation time without reducing bleeding when used in laparoscopic left hepatectomy.
Objective:To evaluate the safety and efficacy of Pringle method in combination with left hepatic vein occlusion for left hepatectomy.Methods: The retrospective case-control study was adopted.Clinical data of 139 patients with hepatocellular carcinoma who underwent left hepatectomy from Jan.2015 to Dec.2018 were collected,including 71 patients who received Pringle method in combination with left hepatic vein occlusion( the test group) and 68 patients who received Pringle method alone( the control group).Preoperative data,surgery condition,postoperative complications and postoperative hospitalization time were compared between the two groups.Then the 139 patients receiving left hepatectomy were further divided into two subgroups based on the surgical methods: an open hepatectomy subgroup( n = 62) and laparoscopy subgroup( n = 77),and intraoperative and postoperative data were compared between different subgroups.Results: There were no statistically significant differences between the test group and control group in gender,age,HBV infection rate,body mass index,preoperative hemoglobin levels,liver function,prior surgical history,Ishak score,operation time,intraoperative bleeding volume,intraoperative blood transfusion,hepatic hilar block time,incidence of complications or postoperative hospital stay.When limited to patients receiving open hepatectomy,the test group showed significantly lower intraoperative bleeding volume than the control group [( 169.9±91.0) mL vs.( 233.6±118.9) mL,P = 0.020]; when limited to those receiving laparoscopic hepatectomy,the test group showed significantly longer time from the start of surgery to liver resection [( 36.2±5.6) min vs.( 32.9±6.5) min,P = 0.018]and longer time from the start of surgery to abdominal closure [( 140.3±20.4) min vs.( 128.3±15.7) min,P = 0.005) ],while intraoperative bleeding were not significant different.Conclusions: Pringle method combined with left hepatic vein occlusion is effective in open left hepatectomy but may prolong the operation time without reducing bleeding when used in laparoscopic left hepatectomy.
引文
[1] Martin AN,Kerwin MJ,Turrentine FE,et al.Blood transfusion is an independent predictor of morbidity and mortality after hepatectomy[J].J Surg Res,2016,206(1):106-112.
[2] 陈熙,胡朝辉,彭永海,等.控制性低中心静脉压在腹腔镜肝切除中的应用:前瞻性随机对照研究[J].中国微创外科杂志,2018,18(7):585-589.
[3] Man K,Fan ST,Ng IO,et al.Prospective evaluation of Pringle maneuver in hepatectomy for liver tumors by a randomized study[J].Ann Surg,1997,226(6):704-711.
[4] 张万广,柴松山.不同肝血流阻断方式在腹腔镜肝切除术中的应用评价[J].中国实用外科杂志,2017,37(5):469-473.
[5] Tranchart H,Gaillard M,Lainas P,et al.Selective Control of the Left Hepatic Vein During Laparoscopic Liver Resection:Arentius' Ligament Approach[J].J Am Coll Surg,2015,221(4):e75-79.
[6] Balzan S,Belghiti J,Farges O,et al.The "50-50 criteria" on postoperative day 5:an accurate predictor of liver failure and death after hepatectomy[J].Ann Surg,2005,242(6):824-828.
[7] Cauchy F,Fuks D,Nomi T,et al.Incidence,risk factors and consequences of bile leakage following laparoscopic major hepatectomy[J].Surg Endosc,2016,30(9):3709-3719.
[8] Chen X,Li B,He W,et al.Mesohepatectomy versus extended hemihepatectomy for centrally located hepatocellular carcinoma[J].Hepatobiliary Pancreat Dis Int,2014,13(3):264-270.
[9] 刘连新,梁英健.腹腔镜肝切除术肝实质离断技巧及器械选择[J].中国实用外科杂志,2017,37(5):473-476.
[10] 李未祥,侯辉,耿小平.腹腔镜肝切除血管阻断方式的应用[J].腹腔镜外科杂志,2016,21(9):648-652.
[11] Dua MM,Worhunsky DJ,Hwa K,et al.Extracorporeal Pringle for laparoscopic liver resection[J].Surg Endosc,2015,29(6):1348-1355.
[12] 徐邦浩,文张,宋经清,等.前入路肝切除联合选择性肝静脉阻断技术在 ALPPS 治疗肝右叶巨块型肝癌中的应用 (附 9 例报道)[J].中国普外基础与临床杂志,2017,24(12):1444-1449.
[13] 郑树国.腹腔镜肝切除术肝静脉系统出血处理策略[J].中国实用外科杂志,2017,37(5):485-489.
[14] D’Antini D,Rauseo M,Grasso S,et al.Physiological effects of the open lung approach during laparoscopic cholecystectomy:focus on driving pressure[J].Minerva Anestesiol,2018,84(2):159-167.
[15] Cheung TT,Dai WC,Tsang SH,et al.Pure Laparoscopic Hepatectomy Versus Open Hepatectomy for Hepatocellular Carcinoma in 110 Patients With Liver Cirrhosis:A Propensity Analysis at a Single Center[J].Ann Surg,2016,264(4):612-620.
[2] 陈熙,胡朝辉,彭永海,等.控制性低中心静脉压在腹腔镜肝切除中的应用:前瞻性随机对照研究[J].中国微创外科杂志,2018,18(7):585-589.
[3] Man K,Fan ST,Ng IO,et al.Prospective evaluation of Pringle maneuver in hepatectomy for liver tumors by a randomized study[J].Ann Surg,1997,226(6):704-711.
[4] 张万广,柴松山.不同肝血流阻断方式在腹腔镜肝切除术中的应用评价[J].中国实用外科杂志,2017,37(5):469-473.
[5] Tranchart H,Gaillard M,Lainas P,et al.Selective Control of the Left Hepatic Vein During Laparoscopic Liver Resection:Arentius' Ligament Approach[J].J Am Coll Surg,2015,221(4):e75-79.
[6] Balzan S,Belghiti J,Farges O,et al.The "50-50 criteria" on postoperative day 5:an accurate predictor of liver failure and death after hepatectomy[J].Ann Surg,2005,242(6):824-828.
[7] Cauchy F,Fuks D,Nomi T,et al.Incidence,risk factors and consequences of bile leakage following laparoscopic major hepatectomy[J].Surg Endosc,2016,30(9):3709-3719.
[8] Chen X,Li B,He W,et al.Mesohepatectomy versus extended hemihepatectomy for centrally located hepatocellular carcinoma[J].Hepatobiliary Pancreat Dis Int,2014,13(3):264-270.
[9] 刘连新,梁英健.腹腔镜肝切除术肝实质离断技巧及器械选择[J].中国实用外科杂志,2017,37(5):473-476.
[10] 李未祥,侯辉,耿小平.腹腔镜肝切除血管阻断方式的应用[J].腹腔镜外科杂志,2016,21(9):648-652.
[11] Dua MM,Worhunsky DJ,Hwa K,et al.Extracorporeal Pringle for laparoscopic liver resection[J].Surg Endosc,2015,29(6):1348-1355.
[12] 徐邦浩,文张,宋经清,等.前入路肝切除联合选择性肝静脉阻断技术在 ALPPS 治疗肝右叶巨块型肝癌中的应用 (附 9 例报道)[J].中国普外基础与临床杂志,2017,24(12):1444-1449.
[13] 郑树国.腹腔镜肝切除术肝静脉系统出血处理策略[J].中国实用外科杂志,2017,37(5):485-489.
[14] D’Antini D,Rauseo M,Grasso S,et al.Physiological effects of the open lung approach during laparoscopic cholecystectomy:focus on driving pressure[J].Minerva Anestesiol,2018,84(2):159-167.
[15] Cheung TT,Dai WC,Tsang SH,et al.Pure Laparoscopic Hepatectomy Versus Open Hepatectomy for Hepatocellular Carcinoma in 110 Patients With Liver Cirrhosis:A Propensity Analysis at a Single Center[J].Ann Surg,2016,264(4):612-620.
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