肝脏血流分级阻断在肝切除术中的应用
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摘要
目的探讨肝脏血流分级阻断在肝切除术中的应用价值。方法回顾性分析2011年1月至2017年12月在江西省肿瘤医院行肝切除术的618例患者临床资料。其中男531例,女87例;年龄13～78岁,中位年龄45岁。患者均签署知情同意书,符合医学伦理学规定。术中采用肝血流分级阻断方法,第一肝门阻断为一级,联合肝下下腔静脉阻断为二级,全肝血流阻断为三级。观察患者止血效果、心脏血流动力学变化和并发症发生情况等。结果 618例患者共行650次肝切除术,其中623次采用肝脏血流分级阻断,74%(461/623)的手术获得良好的肝断面术野,13%(81/623)的手术获得较好的肝断面术野。284次手术采用一级阻断,其中221次获得良好的肝断面术野,28次获得较好的肝断面术野。266次采用二级阻断,其中225次获得良好的肝断面术野,33次获得较好的肝断面术野。73次采用三级阻断,其中15次获得良好的肝断面术野,20次获得较好的肝断面术野。二、三级阻断后血压有不同程度下降,心率有不同程度增加,松开肝下下腔静脉阻断带之后逐渐恢复。术后死于暴发性肝炎2例。术后发生肝功能不全2例,腹腔出血6例,消化道出血1例,肺水肿4例,肺部感染5例,右侧大量胸腔积液7例,麻醉后认知功能障碍3例,均经保守治疗治愈。结论肝脏血流分级阻断可使大多数肝切除患者手术视野清晰。第一肝门阻断简单、安全、有效,肝下下腔静脉阻断为分级阻断的技术关键,全肝血流阻断可控制肝静脉损伤所致的大出血。
Objective To investigate the application values of graded hepatic vascular occlusion in hepatectomy. Methods Clinical data of 618 patients who underwent hepatectomy in Jiangxi Cancer Hospital from January 2011 to December 2017 were retrospectively analyzed. Among them, 531 patients were male and 87 were female with a median age of 45 years. The informed consents of all patients were obtained and the local ethical committee approval was received. Graded hepatic vascular occlusion were applied during the operation. The porta hepatis occlusion was grade Ⅰ, occlusion of porta hepatis and the infrahepatic vena cava was grade Ⅱ, and total hepatic vascular occlusion was grade Ⅲ. The hemostatic effect, cardiac hemodynamic changes and complications of patients were observed. Results A total of 650 hepatectomy were performed in618 patients, graded hepatic vascular occlusion were applied in 623 hepatectomy. Satisfactory surgical fields of liver section were observed in 74%(461/623) of hepatectomy, and comparative good surgical fields in13%(81/623). GradeⅠocclusion was adopted in 284 hepatectomy, including satisfactory surgical fields of liver section in 221 hepatectomy and comparatively good surgical fields in 28 hepatectomy. GradeⅡocclusion was performed in 266 hepatectomy, including satisfactory surgical fields of liver section in 225 hepatectomy and comparatively good surgical fields in 33 hepatectomy. GradeⅢ occlusion was adopted in 73 hepatectomy,including satisfactory surgical fields of liver section in 15 hepatectomy and comparatively good surgical fields in 20 hepatectomy. After the grade Ⅱ and Ⅲ occlusion, the blood pressure of patients was decreased to different degrees and the heart rate was increased to varying degrees, which gradually recovered after loosening the infrahepatic vena cava occluding band. 2 cases died of fulminant hepatitis after surgery. Postoperatively, liver dysfunction was observed in 2 cases, abdominal hemorrhage in 6, gastrointestinal hemorrhage in 1, pulmonary edema in 4, pulmonary infection in 5, massive effusion within the right pleural cavity in 7 and cognitive dysfunction after anesthesia in 3. All the patients were cured by conservative treatments. Conclusions Graded hepatic vascular occlusion can yield clear surgical field in most patients in hepatectomy. The porta hepatis occlusion is simple, safe and effective. Occlusion of infrahepatic vena cava is the key of graded occlusion. Total hepatic vascular occlusion can effectively control the massive hemorrhage caused by hepatic vein injury.
Objective To investigate the application values of graded hepatic vascular occlusion in hepatectomy. Methods Clinical data of 618 patients who underwent hepatectomy in Jiangxi Cancer Hospital from January 2011 to December 2017 were retrospectively analyzed. Among them, 531 patients were male and 87 were female with a median age of 45 years. The informed consents of all patients were obtained and the local ethical committee approval was received. Graded hepatic vascular occlusion were applied during the operation. The porta hepatis occlusion was grade Ⅰ, occlusion of porta hepatis and the infrahepatic vena cava was grade Ⅱ, and total hepatic vascular occlusion was grade Ⅲ. The hemostatic effect, cardiac hemodynamic changes and complications of patients were observed. Results A total of 650 hepatectomy were performed in618 patients, graded hepatic vascular occlusion were applied in 623 hepatectomy. Satisfactory surgical fields of liver section were observed in 74%(461/623) of hepatectomy, and comparative good surgical fields in13%(81/623). GradeⅠocclusion was adopted in 284 hepatectomy, including satisfactory surgical fields of liver section in 221 hepatectomy and comparatively good surgical fields in 28 hepatectomy. GradeⅡocclusion was performed in 266 hepatectomy, including satisfactory surgical fields of liver section in 225 hepatectomy and comparatively good surgical fields in 33 hepatectomy. GradeⅢ occlusion was adopted in 73 hepatectomy,including satisfactory surgical fields of liver section in 15 hepatectomy and comparatively good surgical fields in 20 hepatectomy. After the grade Ⅱ and Ⅲ occlusion, the blood pressure of patients was decreased to different degrees and the heart rate was increased to varying degrees, which gradually recovered after loosening the infrahepatic vena cava occluding band. 2 cases died of fulminant hepatitis after surgery. Postoperatively, liver dysfunction was observed in 2 cases, abdominal hemorrhage in 6, gastrointestinal hemorrhage in 1, pulmonary edema in 4, pulmonary infection in 5, massive effusion within the right pleural cavity in 7 and cognitive dysfunction after anesthesia in 3. All the patients were cured by conservative treatments. Conclusions Graded hepatic vascular occlusion can yield clear surgical field in most patients in hepatectomy. The porta hepatis occlusion is simple, safe and effective. Occlusion of infrahepatic vena cava is the key of graded occlusion. Total hepatic vascular occlusion can effectively control the massive hemorrhage caused by hepatic vein injury.
引文
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[8]陈孝平,张志伟,张必翔,等.大范围肝切除术中合理应用控制出血技术的路线图[J].中华外科杂志,2013,51(1):87.
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[11]曲度,胡葆枫,张弦,等.无血肝切除术临床原理及肝血流阻断各种术式安全时限--附关于“肝血流阻断下肝切除术各式”统一命名建议方案[J].中国医师进修杂志,2008,31(29):73-76.
[12]Torzilli G,Procopio F,Donadon M,et al.Safety of intermittent Pringle maneuver cumulative time exceeding 120 minutes in liver resection:a further step in favor of the"radical but conservative"policy[J].Ann Surg,2012,255(2):270-280.
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[14]吴路鹏,冯柳兴,刘育键,等.前入路联合肝下下腔静脉阻断切除右肝巨大肝细胞癌[J].肝胆外科杂志,2017,25(4):292-294.
[15]吴超,陈孝平,喻晶晶,等.肝下下腔静脉阻断与选择性肝静脉阻断在肝切除术中的应用比较[J/CD].中华肝脏外科手术学电子杂志,2016,5(4):244-248.
[16]隋承军,沈伟峰,陆炯炯,等.肝下下腔静脉阻断联合入肝血流阻断在复杂肝切除术中应用[J].中国实用外科杂志,2012,32(9):771-774.
[17]Ueno M,Kawai M,Hayami S,et al.Partial clamping of the infrahepatic inferior vena cava for blood loss reduction during anatomic liver resection:a prospective,randomized,controlled trial[J].Surgery,2017,161(6):1502-1513.
[18]Rahbail NN,Koch M,Zimmermann JB,et a1.Infrahepatic inferior vena cava clamping for reduction of central venous pressure and blood loss during hepatic resection:a randomized controlled trial[J].Ann Surg,2011,253(6):1102-1110.
[19]周存才,张峰.清晰肝切除[J/CD].中华临床医师杂志(电子版),2015,9(14):2635-2638.
[2]陈江明,耿小平.肝脏外科的永恒话题:出血与止血[J].中华普通外科杂志,2018,33(5):439-441.
[3]Shi J,Lai EC,Li N,et al.Surgical treatment of hepatocellular carcinoma with portal vein tumor thrombus[J].Ann Surg Oncol,2010,17(8):2073-2080.
[4]周存才,杨小敏,周新文,等.陈氏简易全肝血流阻断技术的临床应用:附280例报道[J].中国普通外科杂志,2014,23(1):6-12.
[5]Lee KF,Cheung YS,Wong J,et al.Randomized clinical trial of open hepatectomy with or without intermittent Pringle manoeuvre[J].Br J Surg,2012,99(9):1203-1209.
[6]Sanjay P,Ong I,Bartlett A,et al.Meta-analysis of intermittent Pringle manoeuvre versus no Pringle manoeuvre in elective liver surgery[J].ANZ J Surg,2013,83(10):719-723.
[7]刘允怡,赖俊雄.肝癌肝切除手术方式的理论基础及临床价值[J].中国实用外科杂志,2018,38(4):345-348.
[8]陈孝平,张志伟,张必翔,等.大范围肝切除术中合理应用控制出血技术的路线图[J].中华外科杂志,2013,51(1):87.
[9]董家鸿,黄志强.精准肝切除--21世纪肝脏外科新理念[J].中华外科杂志,2009,47(21):1601-1605.
[10]张志伟,陈孝平.肝血流阻断技术的发展[J].肝胆外科杂志,2007,15(4):245-246.
[11]曲度,胡葆枫,张弦,等.无血肝切除术临床原理及肝血流阻断各种术式安全时限--附关于“肝血流阻断下肝切除术各式”统一命名建议方案[J].中国医师进修杂志,2008,31(29):73-76.
[12]Torzilli G,Procopio F,Donadon M,et al.Safety of intermittent Pringle maneuver cumulative time exceeding 120 minutes in liver resection:a further step in favor of the"radical but conservative"policy[J].Ann Surg,2012,255(2):270-280.
[13]彭承宏,陈皓.肝脏手术中肝血流阻断与肝脏缺血-再灌注损伤[J].中国实用外科杂志,2007,27(1):53-57.
[14]吴路鹏,冯柳兴,刘育键,等.前入路联合肝下下腔静脉阻断切除右肝巨大肝细胞癌[J].肝胆外科杂志,2017,25(4):292-294.
[15]吴超,陈孝平,喻晶晶,等.肝下下腔静脉阻断与选择性肝静脉阻断在肝切除术中的应用比较[J/CD].中华肝脏外科手术学电子杂志,2016,5(4):244-248.
[16]隋承军,沈伟峰,陆炯炯,等.肝下下腔静脉阻断联合入肝血流阻断在复杂肝切除术中应用[J].中国实用外科杂志,2012,32(9):771-774.
[17]Ueno M,Kawai M,Hayami S,et al.Partial clamping of the infrahepatic inferior vena cava for blood loss reduction during anatomic liver resection:a prospective,randomized,controlled trial[J].Surgery,2017,161(6):1502-1513.
[18]Rahbail NN,Koch M,Zimmermann JB,et a1.Infrahepatic inferior vena cava clamping for reduction of central venous pressure and blood loss during hepatic resection:a randomized controlled trial[J].Ann Surg,2011,253(6):1102-1110.
[19]周存才,张峰.清晰肝切除[J/CD].中华临床医师杂志(电子版),2015,9(14):2635-2638.
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