选择性肝血流阻断肝切除术的应用

目的 探讨选择性肝血流阻断肝切除术的安全性和可行性.方法 回顾性分析我院2002年3月至2006年10月行肝切除术65例,分为选择性肝血流阻断组(HVC, n＝28)和第一肝门阻断组(Pringle, n＝37);比较两组病人术中出血量、手术时间、术后肝功能的恢复、术后两天的平均引流量以及术后并发症.结果 两组病人术中出血量和手术时间均无显著性差异;HVC组术后3天和7天的血清谷丙转氨酶明显低于Pringle组,术后2天的平均引流量HVC组明显少于Pringle组;Pringle组有两例出现肝功能衰竭,其中1例死亡,HVC组没有肝功能衰竭及死亡病例.结论 选择性肝血流阻断肝切除术安全、可行,较第一肝门阻断更有利于肝功能的恢复,减少肝功能衰竭的发生.     

选择性肝血流阻断肝切除术的应用

目的探讨选择性肝血流阻断肝切除术的安全性和可行性。方法回顾性分析我院2002年3月至2006年10月行肝切除术65例,分为选择性肝血流阻断组（HVC,n=28）和第一肝门阻断组（Pringle,n=37）;比较两组病人术中出血量、手术时间、术后肝功能的恢复、术后两天的平均引流量以及术后并发症。结果两组病人术中出血量和手术时间均无显著性差异;HVC组术后3天和7天的血清谷丙转氨酶明显低于Pringle组,术后两天的平均引流量HVC组明显少于Pringle组;Pringle组有两例出现肝功能衰竭,其中1例死亡,HVC组没有肝功能衰竭及死亡病例。结论选择性肝血流阻断肝切除术安全、可行,较第一肝门阻断更有利于肝功能的恢复,减少肝功能衰竭的发生。     

第二肝门区域肿瘤切除中两种肝血流阻断方法的比较

目的比较入肝血流加肝静脉血流阻断术与单纯第一肝门阻断术在第二肝门区域肿瘤切除中的作用。方法从2000年1月至2005年10月,共施行2100例肝脏肿瘤切除术,其中235例肿瘤紧贴或压迫1根以上主肝静脉,根据肝血流阻断方法的不同,将235例患者分为两组：选择性肝血流阻断组（SHVE组,125例）和第一肝门阻断组（Pringle组,110例）。分析两组患者的术中及术后情况。在SHVE组,完全SHVE（阻断第一肝门和所有主肝静脉）25例,部分SHVE（阻断第一肝门和部分主肝静脉）100例。肝静脉阻断方法有3种：丝线结扎肝静脉,止血带阻断和辛氏钳阻断。结果两组间年龄、性别、肿瘤大小、肝硬化发生率、HBsAg阳性率、术中热缺血时间和手术时间的差异均无统计学意义（P〉0．05）。SHVE组的术中失血量及输血量明显少于Pringle组（P〈0．05）。Pringle组有17例发生主肝静脉破裂,其中大出血14例,空气栓塞3例。而SHVE组无1例肝静脉破裂、大出血或空气栓塞发生。Pringle组术后再出血、再次手术和肝功能衰竭等并发症发生率高于SHVE组,ICU时间和住院时间长于SHVE组（P〈0．05）。结论SHVE较Pringle法能更有效地控制术中大出血,防止肝静脉破裂导致的大出血和空气栓塞,降低术后并发症和手术病死率。用辛氏钳阻断肝静脉较结扎法和止血带阻断法更安全和简便。     

选择性肝血流阻断技术在肝肿瘤切除术中的应用

目的 探讨选择性肝静脉血流阻断术(SHVE)在复杂肝肿瘤切除术中的有效性和安全性.方法 在246例复杂肝肿瘤切除手术中采用选择性肝血流阻断技术,统计分析患者术前一般情况、术中情况、病理诊断、术后并发症等.结果 从2000年1月～2007年7月,在复杂肝肿瘤切除手术中246例肿瘤采用了选择性肝血流阻断技术.根据肝血流阻断方法的不同,完全SHVE(阻断第一肝门和所有主肝静脉,Total SHVE)145例,部分SHVE中阻断第一肝门和右肝静脉54例,阻断第一肝门和左中肝静脉47例.3例因术中发现瘤体侵犯下腔静脉壁而改为全肝血流阻断.结果 显示血流阻断过程中患者均保持血流动力学稳定,仅外周循环阻力和肺循环阻力轻度升高.术后患者无死亡发生,总并发症率为24.8%,平均住院天数为9.6 d.结论 选择性肝血流阻断技术是一种安全、有效的血流阻断技术,尤其适合用于位于第二肝门未侵犯下腔静脉的肿瘤切除.     

选择性半肝血流阻断在肝海绵状血管瘤切除中的应用

目的:探讨选择性半肝血流阻断在肝海绵状血管瘤切除中的应用效果。方法:回顾性分析2006年1月—2011年1月经手术切除的104例肝海绵状血管瘤患者的临床资料。其中26例行选择性半肝血流阻断(A组),78例行第一肝门阻断(Pringle法)(B组)。比较并分析两种方法对术中情况、术后肝功能恢复、并发症发生率等指标的影响。结果:104例手术均顺利完成。两组间术中失血量、输血量、阻断时间、血氧饱和度以及术后肠道恢复时间、并发症等指标的差异均无统计学意义(均P>0.05),但B组术中外周动脉血压及术中脉搏变化明显大于A组(均P<0.01)。术后肝功能指标如ALT,AST,ALB,TBIL等改变,B组优于A组,差异均有统计学意义(P<0.05或P<0.01)。结论:肝海绵状血管瘤切除术中采用选择性半肝血流阻断,能有效地减轻肝血流阻断对全身血流动力学的影响,减轻缺血再灌注损伤,有利于术后肝功能恢复。     

半肝血流阻断在肝硬化肝癌半肝切除术中的意义

目的探讨半肝血流阻断在肝硬化肝癌半肝切除术中的意义。方法将26例肝癌合并肝硬化行半肝切除的病人分为半肝血流阻断组(HVC,n=14)和第一肝门阻断组(Pringle,n=12)。比较两组病人术中出血量和手术时间,术后肝功能的恢复,以及术后并发症。结果两组病人术中出血量和手术时间均无显著差异。HVC组术后3天和7天的血清谷丙转氨酶明显低于Pringle组,且下降程度也较后者明显。Pringle组有2例死于肝功能衰竭。Pringle组病人术后并发腹水显著高于HVC组。结论半肝血流阻断法比第一肝门阻断更利于术后肝功能恢复,减少手术并发症,降低死亡率。     

选择性出入肝血流阻断在巨大肝癌肝切除术中的应用

目的 探讨行巨大肝癌肝切除术时选择性出入肝血流阻断技术对患者预后的影响.方法 回顾性分析2005年1月至2010年1月浙江省人民医院收治的49例巨大肝癌行肝切除术患者的临床资料.根据肝脏血流阻断技术不同,分为第一肝门血流阻断组(第一肝门组,24例)和选择性出入肝血流阻断组(选择阻断组,25例).分析两组患者手术情况、肝肾功能、并发症、生存率和肝癌复发情况.计量资料采用t检验,计数资料比较采用x2检验或Fisher确切概率法,采用Kaplan-Meier法绘制生存曲线,生存情况比较采用Log-rank检验.结果 两组患者均顺利施行肝切除术,第一肝门组患者的肝血流阻断时间为(32±19) min,选择阻断组为(34±22) min,两组比较,差异无统计学意义(t=2.45,P＞0.05).第一肝门组患者的术中出血量为(736±543) ml,明显多于选择阻断组(273 ±298)ml(t =6.87,P＜0.05).第一肝门组患者肝静脉损伤的发生率为21％(5/24),选择阻断组为24％(6/25),两组比较,差异无统计学意义(x2=1.45,P＞0.05).第一肝门组有3例患者出现肝静脉破裂大出血,1例患者发生空气栓塞抢救无效死亡;选择阻断组未发生上述情况.第一肝门组患者中4例发现肿瘤侵犯血管,选择阻断组患者中3例发现肿瘤侵犯血管,两组患者切缘均为阴性.两组术前肝功能无明显差别,选择阻断组术后第1、3天ALT值较第一肝门组明显降低(t=7.12,6.35,P＜0.05);两组尿素氮、肌酐比较,差异无统计学意义(P＞0.05).第一肝门组术后发生急性肝功能衰竭4例,选择阻断组无一例发生术后急性肝功能衰竭.第一肝门组1、3年无瘤生存率分别为58％、21％,明显低于选择阻断组的72％、30％(x2=5.32,6.07,P＜0.05).第一肝门组5年无瘤生存率为21％,选择阻断组为20％,两组比较,差异无统计学意义(x2=1.78,P＞0.05).结论 选择性出入肝血流阻断肝切除术是一种安全、简便的方法,能有效预防肝静脉破裂出血和术后急性肝功能衰竭,并有助于减少巨大肝癌肝切除术后早期肿瘤复发,提高术后早期无瘤生存率.     

选择性肝血流阻断切肝术(附213例报道)

目的分析选择性肝血流阻断切肝术在防止术中肝脏大出血及术后肝功能衰竭方面的作用。方法根据肿瘤部位、大小及肝硬化情况,采用半肝血流阻断,半肝全血流阻断,交替半肝血流阻断,交替半肝全血流阻断,单纯门静脉阻断及肝褥式缝合等区域性肝血流阻断技术切除肝肿瘤共213例。观察肝门阻断时间、出血量、术后肝功能恢复情况及并发症发生率。结果半肝血流阻断144例,其中左肝门阻断32倒,右肝门阻断112例。半肝全血流阻断39例,其中右肝门 右肝静脉阻断26例,左肝门 左、中肝静脉阻断13例。交替半肝血流阻断7例,交替半肝全血流阻断5例,单纯门静脉阻断8例,局部褥式缝扎10例。肿瘤切除率100%, 第一肝门及肝静脉分离均成功。无一例发生肝静脉破裂出血及空气栓塞,术后无一例发生肝功能衰竭。术后胆漏6例,保守治疗痊愈。结论区域性肝血流阻断切肝术是一种安全、简便的方法,对防止肝静脉破裂出血,降低术后肝功能衰竭发生率具有重要作用。     

腹腔镜Glisson鞘外半肝血流阻断技术联合肝下下腔静脉阻断术在肝切除应用价值

目的探讨腹腔镜Glisson鞘外半肝血流阻断技术联合肝下下腔静脉阻断术在肝切除应用价值。方法分析2015年8月~2016年12月行腹腔镜肝切除32例病例资料,根据手术方式分为A、B两组,A组为Pringle法全肝入肝血流阻断联合肝下下腔静脉阻断技术12例,B组为Glisson鞘外半肝血流阻断联合肝下下腔静脉血流阻断技术20例。结果 A组1例,B组3例手术未能成功,中转开腹行肝叶切除术,余均成功实施腹腔镜肝切除。总体手术时间、第一肝门处理时间B组显著延长;A组全肝入肝血流阻断时间及次数少于B组半肝入肝血流阻断时间、次数;两组术中出血量比较差异无统计学意义(P0.05);A组术后第一天肝功能丙氨酸转氨(ALT)、谷草转氨酶(AST)显著升高;术后胃肠道恢复时间A组较长,并发症的发生率B组较少。全部病人术后未发生腹腔出血、肝功能衰竭及死亡。结论 Glisson鞘外半肝血流阻断联合肝下下腔静脉阻断技术在腹腔镜肝切除中能可增加阻断次数,延长阻断时间,防止肝功能衰竭,降低并发症,该技术在腹腔镜肝切除是安全可行的,有较高的应用价值。     

全肝与选择性肝静脉阻断术在肝切除术中的应用比较

目的累及肝静脉或下腔静脉的肝肿瘤切除最严重的并发症是术中大出血,全肝血流阻断术（THVE）能有效控制术中大出血,但由于阻断下腔静脉,易引起全身血流动力学紊乱。选择性肝血流阻断术（SHVE）仅阻断入肝与出肝血流而保持下腔静脉通畅,不会引起全身血流动力学紊乱。本文就这两种肝血流阻断技术在肝切除术中的应用作一比较。方法2000年1月至2006年6月,共施行包括入肝与出肝血流同时阻断切肝术197例,其中THVE87例,SHVE110例。比较两组病人术前情况、肝切除范围、术中情况、术后并发症等指标。结果所有肿瘤均压迫或侵犯1根以上主肝静脉或下腔静脉,两组病人术前一般情况、肝切除范围、肿瘤病理类型无明显差别,术中出血量、肝热缺血时间、手术时间,THVE组明显高于SHVE组。THVE组有15例同时行下腔静脉癌栓取出术,4例肝静脉癌栓取出术,7例行下腔静脉壁修补术,SHVE组有7例同时行肝静脉取栓术,有1例因肿瘤侵犯下腔静脉壁而改行THVE。术后并发症THVE组明显高于SHVE组,前者有2例术后死于肝功能衰竭,SHVE组无1例死亡。术后ICU时间及住院时间THVE组明显高于SHVE组。结论THVE与SHVE均能有效控制术中肝静脉破裂大出血,THVE对伴有下腔静脉癌栓或静脉壁受侵犯的病人是唯一的选择方法,但THVE对全身血流动力学影响大,对未侵犯下腔静脉而仅侵犯肝静脉的病人更适合采用SHVE。     

Selective Hepatic Vascular Exclusion versus Pringle Maneuver in Major Liver Resections: Prospective Study

Selective hepatic vascular exclusion (SHVE) and the Pringle maneuver are two methods used to control bleeding during hepatectomy. They are compared in a prospective randomized study, where 110 patients undergoing major liver resection were randomly allocated to the SHVE group or the Pringle group. Data regarding the intraoperative and postoperative courses of the patients are analyzed. Intraoperative blood loss and transfusion requirements were significantly decreased in the SHVE group, and postoperative liver function was better in that group. Although there was no difference between the two groups regarding the postoperative complications rate, patients offered the Pringle maneuver had a significantly longer hospital stay. The application of SHVE did not prolong the warm ischemia time or the total operating time. It is evident from the present study that SHVE performed by experienced surgeons is as safe as the Pringle maneuver and is well tolerated by the patients. It is much more effective than the Pringle maneuver for controlling intraoperative bleeding, and it is associated with better postoperative liver function and shorter hospital stay.     

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??Laparoscopic hepatectomy: Pringle maneuver versus tourniquet method ZHANG Deng-ming, ZHEN Zuo-jun, CHEN Huan-wei, et al. Department of Hepatobiliary Surgery, the First People's Hospital of Foshan City, Foshan 528000, China
Corresponding author??ZHEN Zuo-jun??E-mail??zzjun@fsyyy.com
Abstract Objective To evaluate the feasibility of tourniquet method in laparoscopic hepatectomy compared with Pringle maneuver. Methods Sixty-two patients performed laparoscopic hepatectomy between January 2003 and January 2011 in the Department of General Surgery, the First People’s Hospital of Foshan City were divided into Pringle group (30 patients) and tourniquet group (32 patients) randomly. The changes of preoperative and postoperative liver function, intraoperative blood loss, complications, operation time and hospital stay between the two groups were compared. Results No significant difference was found in operative blood loss, perioperative complications, the TBIL and ALB before operation and on the first, third and seventh day after operation between two groups (P>0.05). There was significant difference in ALT and AST before operation and on the first, third and seventh day after operation between two groups (P??0.05). Patients in tourniquet group had significantly faster recovery of liver function than those in Pringle group (P??0.05). The postoperative hospital stay of tourniquet group was significantly shorter than that of Pringle group (P??0.05). Conclusion Tourniquet method can limit operative blood loss effectively with quicker recovery and shorter hospital stay, which is safe, efficient and feasible for patients performed laparoscopic hepatectomy.     

The role of central venous pressure and type of vascular control in blood loss during major liver resections

BACKGROUND: Blood loss during liver resection constitutes the primary determinant of the postoperative outcome. Various techniques of vascular control and maintenance of a low central vein pressure (CVP) have been used in order to prevent intraoperative blood loss and postoperative complications. Our study aims at assessing the effects of different levels of CVP in relation to type of vascular control on perioperative blood loss and patient outcome. METHODS: The records of 102 consecutive patients who underwent a major hepatectomy were retrospectively analyzed. Forty-two patients were operated on with a CVP of 6 mm Hg or more and 60 patients had a CVP of 5 mm Hg or less. The Pringle maneuver was used in 45 patients and selective hepatic vascular exclusion (SHVE) in 57 patients. Blood loss, complications, and mortality were analyzed comparing the two CVP groups in relation to type of vascular control. RESULTS: The Pringle maneuver is associated with more blood loss when CVP is 6 mm Hg or more compared with CVP 5 mm Hg or less (1,250 mL [250 to 2,850] versus 780 mL [150 to 3,100]; P <0.05). Conversely, blood loss during SHVE is independent of the CVP levels. A significant difference in blood loss between the Pringle maneuver and SHVE was observed, only when CVP was 6 mm Hg or more (1,250 mL [250 to 2,850] versus 680 mL [150 to 1,260]; P <0.05). Hospital stay was also significantly longer in patients operated on with CVP 6 mm Hg or more (15 days [4 to 38] than in patients with CVP 5 mm Hg or less (10 days [4 to 32]; P <0.05). CONCLUSIONS: Elevated CVP during major liver resections results in greater blood loss and a longer hospital stay. The Pringle maneuver with CVP 5 mm Hg or less is associated with blood loss not significantly different from that with SHVE. The latter, though, has been shown not to be affected by CVP levels and should be used whenever CVP remains high despite adequate anesthetic management.     

Total versus selective hepatic vascular exclusion in major liver resections

BACKGROUND: Total hepatic vascular exclusion (THVE) and selective hepatic vascular exclusion (SHVE) are two effective techniques for bleeding control in major hepatic resections. Outcomes of the two procedures were compared. METHODS: Patients undergoing major liver resection were randomly allocated to the THVE and SHVE groups. Intraoperative hemodynamic changes and the postoperative course of the two groups were compared. RESULTS: During vascular clamping, the THVE group showed a significant elevation in pulmonary vascular resistance, systemic vascular resistance, intrapulmonary shunts, and a significant reduction in cardiac index, compared with the SHVE group (P <0.05). Patients undergoing THVE received more crystalloids and blood, showed more severe liver, renal and pancreatic dysfunction, and had a longer hospital stay than the SHVE group (P <0.05). CONCLUSIONS: Both techniques are equally effective in bleeding control in major liver resections. THVE is associated with cardiorespiratory and hemodynamic alterations and may be not tolerated by some patients. SHVE is well tolerated with fewer postoperative complications and shorter hospitalization time.     

腹腔镜捆绑式肝局部血流阻断技术与Pringle法随机对照研究

目的 通过捆绑式阻断法与Pringle法对比,探讨捆绑式肝局部血流阻断法在腹腔镜肝切除术中的可行性。 方法 2003年1月至2011年1月佛山市第一人民医院肝胆外科将收治的62例行腹腔镜肝肿瘤切除术的病人随机分为Pringle组（30例）与捆绑式阻断组（32例）,对比分析两组在术中出血量、术前与术后肝功能变化、局部及全身并发症发生率、手术时间、住院时间的差异。 结果 两组术中出血量、围手术期并发症发生率、术前及术后1、3、7 d白蛋白（ALB）、总胆红素（TBIL）比较,差异无统计学意义（P>0.05）。捆绑式阻断组术前及术后1、3、7 d丙氨酸转氨酶（ALT）、天冬氨酸转氨酶（AST）比较差异有统计学意义（P<0.05）。两组住院时间比较,捆绑式阻断组明显低于Pringle组（P<0.05）。 结论 捆绑式阻断法止血效果确切,对肝功能的损害轻,术后恢复快,缩短住院时间,是一种安全、可靠、可行的血流阻断方法。     

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目的探讨肝下下腔静脉(IVC)阻断联合入肝血流阻断(Pringle法)在复杂肝切除术中的应用价值。方法回顾分析第二军医大学东方肝胆外科医院特需治疗一科、肝移植科2010年3月至2011年12月同一手术组收治的91例符合条件的手术病人的临床资料。结果行Pringle法+肝下IVC阻断43例(A组),行Pringle法48例(B组)。两组的术中总出血量分别为50～1150(312.79±267.28)mL和100～1400(471.04±317.80)mL,断肝过程中出血量分别为10～300(80.70±79.77)mL和50～650(200.21±165.09)mL,A组术中总出血量及断肝过程中的出血量均明显低于B组(P<0.05)。两组阻断前的中心静脉压(CVP)无差别[(8.47±2.60)cmH2Ovs.(7.94±2.30)cmH2O(1cmH2O=0.098kPa)],A组阻断后的CVP明显低于B组[(1.81±2.34)cmH2Ovs.(7.21±2.27)cmH2O,P<0.05]。两组术后并发症发生率差异无统计学意义,术前及术后肝肾功能比较差异无统计学意义。结论肝下IVC阻断联合Pringle法应用在复杂肝切除术中可明显降低CVP,显著减少术中失血量。对肝肾功能无不良影响,不增加并发症的发生率和病死率。     

Effects of hepatovenous back flow on ischemic- reperfusion injuries in liver resections with the pringle maneuver

BACKGROUND: Experimental findings have demonstrated a beneficial role of retrograde blood flow from hepatic veins that takes place during the Pringle maneuver in liver resections. The cytoprotective effect of hepatovenous back-perfusion has not been evaluated in humans. A randomized prospective study was designed to compare the response of liver cells to ischemic-reperfusion injury during the application of two different ischemic procedures: inflow versus inflow plus outflow vascular occlusion of the liver. STUDY DESIGN: Forty patients were randomly allocated to undergo liver resection using the continuous Pringle maneuver (n = 20) or inflow plus outflow vascular occlusion of the liver by selective hepatic vascular exclusion (n = 20). Liver function was assessed on postoperative days 1 to 6. Response of liver cells to I/R injury was evaluated by measuring interleukins IL-6 and IL-8 at 3, 12, 24, and 48 hours after reperfusion. Oxidative stress was assessed by measuring malondialdehyde levels. RESULTS: Both groups were comparable regarding ischemic time, operative time, and extent of liver resection. Patients in whom retrograde blood flow to the liver took place during the Pringle maneuver showed better liver function postoperatively and less severe hepatic I/R injuries compared with those undergoing liver resection using both inflow and outflow vascular occlusion. Oxidative stress was significantly lower in the Pringle maneuver group compared with the inflow plus outflow vascular occlusion group (mean [+/- SD] malondialdehyde 8 +/- 2.1 micromol/L in the Pringle group versus 14.7 +/- 1.8 micromol/L in the selective hepatic vascular exclusion group 30 min after reperfusion, p < 0.01). CONCLUSIONS: Back perfusion via hepatic veins contributes to attenuation of I/R damage during the Pringle maneuver and should be preferred if possible during liver resection.     

合理阻断肝脏血流切除累及肝门区肿瘤

目的探讨肝脏血流阻断技术在累及肝门区肿瘤切除中的合理应用。方法对采用第一肝门阻断法（Pringle法）和常温下全肝血流阻断法（THVE）相结合切除14例累及肝门区肿瘤的临床资料进行回顾性分析,统计肿瘤和肝门区血管的毗邻关系、阻断次数、阻断时间、术中出血量、输血量、术后并发症等指标。结果本组Pringle法平均阻断（4.2±2.0）次,第一肝门平均阻断时间（49.6±30.8）min;THVE平均阻断（1.8±0.4）次,平均阻断时间（18.8±7.4）min;术中出血量平均（1100±360）ml,输血量平均（800±220）ml;术中修补下腔静脉4次,主肝静脉2次,门静脉主干2次;术后检测ALT、胆红素有不同程度升高,经治疗2～3周后恢复正常,未发生肝功能衰竭、肝肾综合征等严重并发症。结论Pringle法与THVE法分步结合使用可增加肝门区肿瘤切除的安全性。