控制性低中心静脉压在原发性肝癌伴肝炎后肝硬化患者腹腔镜肝切除中的应用

背景与目的:在肝脏切除手术中采用控制性低中心静脉压(CLCVP)技术可有效减少肝断面出血,然而,低中心静脉压(CVP)所产生的相对低血压和潜在低灌注可能造成不良影响,这使其推广应用受到一定程度的限制。本研究探讨CLCVP技术在原发性肝癌伴肝炎后肝硬化患者腹腔镜肝切除手术中的应用效果和安全性。方法:回顾性分析2017年4月—2019年3月在安徽医科大学第一附属医院肝胆胰外科行全腹腔镜解剖性肝切除手术的44例原发性肝癌伴肝炎后肝硬化患者临床资料,所有患者均接受同一组医生手术,其中24例患者术中采用CLCVP技术(观察组),另外20例患者术中未采用CLCVP对照组(对照组),分析并比较两组术前、术中、术后的相关临床资料。结果:两组患者术前资料包括性别、年龄、BMI、Child分级、肝硬化程度、肝肾功能指标差异均无统计学意义(均P>0.05)。两组手术均顺利完成,无围手术期死亡病例。观察组术中、术后均未见低CVP相关气栓、肝肾损伤等并发症。与对照组比较,观察组术中动脉收缩压、CVP明显降低,手术时间与肝门阻断时间明显缩短、术中出血和手术输血率明显降低,但术中乳酸指标明显升高(均P<0.05)。两组的术后出血、感染、胸腔积液、胆汁漏的发生率以及肝肾功能指标、拔管时间、住院时间方面均无统计学差异(均P>0.05),但观察组患者术后引流量多于对照组(P<0.05);两组术后复发率亦无统计学差异(P>0.05)。结论:在做好术前肝功能评估和术中密切观测患者灌注指标的前提下,CLCVP技术对肝炎后肝硬化患者腹腔镜肝切除手术是安全可靠的,虽然低CVP会使机体灌注减少,机体无氧代谢增强,乳酸含量增高,但对肝肾功能及肝癌的复发无明显影响,而且较低的CVP能够有效减少术中出血量和输血量,缩短手术时长和肝门阻断时间,降低长时间缺血缺氧对肝脏的打击。总之,在无严重心、肺、脑、肾基础疾病的肝炎后肝硬化患者腹腔镜肝切除手术中,CLCVP是一种值得推荐的控制肝断面出血技术。

Application of controlled low central venous pressure in laparoscopic hepatectomy for patients with primary liver cancer and post-hepatitis cirrhosis

Background and Aims: Application of controlled low central venous pressure (CLCVP) in hepatectomy can effectively reduce the liver cut surface bleeding. However, the relative low blood pressure and potential hypoperfusion resulted from low central venous pressure (CVP) may probably cause harmful effects, which impose certain restrictions on its promotion. The aim of this study was to investigate the effectiveness and safety of using CLCVP technique in laparoscopic hepatectomy for patients with primary liver cancer and concomitant post-hepatitis cirrhosis.   Methods: The clinical data of 44 patients with primary liver cancer associated post-hepatitis cirrhosis undergoing laparoscopic anatomical hepatectomy in the Department of Hepatobiliary and Pancreatic Surgery of the First Affiliated Hospital of Anhui Medical University from April 2017 to March 2019 were retrospectively analyzed. All patients were operated by the same surgical team, of whom, 24 cases received CLCVP (observation group) and 20 cases did not receive CLCVP (control group) during surgery. The main pre- intra- and postoperative clinical variables of the two groups of patients were analyzed and compared. Results: There were no significant differences in preoperative data that included the sex, age, BMI, Child classification, degree of cirrhosis between and parameters for liver and renal functions between the two groups of patients (all P>0.05). The operations were uneventfully performed in both groups of patients without perioperative death. No complications associated with low CVP such as gas embolism or liver and renal function injuries occurred in observation group during and after the operation. In observation group compared with control group, the intraoperative arterial systolic blood pressure and CVP were significantly decreased, the operative time and time for hepatic portal occlusion were significantly shortened, and the intraoperative blood loss and blood transfusion rate were significantly reduced, but the intraoperative lactic acid concentration was significantly increased (all P<0.05). There were no significant differences in the incidence rates of postoperative bleeding, infection, pleural effusion and bile leakage as well as the parameters for liver and renal functions, time to tube removal and length of hospital stay between the two groups (all P>0.05), while the postoperative drainage volume in observation group was significantly higher than that in control group (P<0.05). The postoperative tumor recurrence rates showed no significant difference between the two groups (P>0.05). Conclusion: Based on the premise of accurate evaluation of preoperative liver function and carefully observation of intraoperative perfusion index, CLCVP technique is safe and reliable for laparoscopic hepatectomy in patients with post-hepatitis cirrhosis. Although low CVP can reduce the perfusion, enhance the anaerobic metabolism, and increase the lactic acid content of the body, it has no effect on liver and renal functions as well as the recurrence of the liver cancer. Moreover, the low CVP can effectively reduce intraoperative blood loss and transfusion volume, shorten the operative time and portal occlusion time, and thereby reduce the impact of long-term ischemia and hypoxia on the liver. So, LCVP is a recommended technique for controlling the liver cut surface bleeding in liver cancer patients with post-hepatitis cirrhosis without underlying cardiopulmonary, cerebral and renal diseases.