腹腔镜与开腹肝切除术治疗肝癌疗效的Meta分析

目的：系统评价腹腔镜肝切除术（LLR）与开腹肝切除术（OLR）治疗肝癌的近、远期疗效和安全性。方法：检索相关期刊、资料、会议文献和学位论文数据库,收集比较LLR与OLR治疗肝癌疗效的病例-对照研究。按MOOSE 规范对纳入研究进行分析,提取数据并用RevMan5.3软件对数据进行Meta分析。
　　结果：最终共纳入15篇病例-对照研究,共1246例患者,LLR组499例,OLR组747例。Meta分析结果显示,LLR组与OLR组的手术时间,1、3、5年生存率,1、3、5年无瘤生存率,3年肿瘤复发率组间差异均无统计学意义（均P>0.05）;LLR与OLR相比术中出血量少、术后并发症发生率低、围手术期死亡率低、术后住院天数少（均P<0.05）。
　　结论：LLR可以达到与OLR同样的根治效果,两者近、远期疗效无明显差异,且LLR围手术期不良事件少于OLR。     

快速康复外科在右半肝切除围手术期中的应用

目的 探讨快速康复外科（ERAS）模式应用于右半肝切除围手术期的临床价值。方法 分析2017年08月~2019年08月于我院进行右半肝切除术的53例患者临床资料,按围手术期的处理方法不同分为快速康复组（ERAS组）和传统对照组（对照组）。比较两组患者术前、术中的基本资料,及术后住院时间、肛门恢复排气时间、住院总费用、并发症、术后恢复质量（15项恢复质量评分量表,QoR-15）及C反应蛋白（CRP）等方面,评价其临床价值。结果 两组患者术前基本资料无统计学意义,具有可比性（P>0.05）;在手术时间、术中出血量方面两组比较无统计学差异（P>0.05）;两组患者在术后肛门恢复排气时间、住院时间、住院总费用、并发症方面比较差异有统计学意义（P均<0.05）;ERAS组在术后恢复质量评分高于对照组（P<0.05）,而在CRP方面ERAS组数值低于后者（P<0.05）。结论 在右半肝切除的围手术期应用加速康复外科模式能够有效地缩短住院时间,降低住院费用、术后并发症及术后创伤应激反应,从而促进患者的快速康复。     

简易选择性鞘外入肝血流阻断法在腹腔镜左半肝切除术中的应用

目的 探讨简易选择性鞘外入肝血流阻断方法在腹腔镜左半肝切除术应用中的安全性和可行性。方法 回顾性分析2016年1月15日至2021年8月15日梅州市人民医院45例因左肝肿瘤行腹腔镜左半肝切除术患者的临床资料。按入肝血流阻断方式分为两组,A组采用简易选择性鞘外入肝血流阻断方法阻断（n=21）,B组采用左肝Glisson蒂鞘内分离结扎方法阻断（n=24）,比较两组病例手术时间、术中出血量、术后住院时间、近期并发症及围手术期血白细胞数、肝功能等资料。结果 两组病例手术时间、术中出血量、术后住院时间、近期并发症发生率和术后白蛋白、胆红素、凝血酶原时间比较,差异无统计学意义（P>0.05）。A组术后第1、3天白细胞数及术后第1天ALT、术后第3天AST均低于B组,差异有统计学意义（P<0.05）。结论 简易选择性鞘外入肝血流阻断方法在腹腔镜左半肝切除术操作简便、安全可行,值得临床上推广使用。     

经脐单孔腹腔镜阑尾切除术联合加速康复外科治疗急性阑尾炎的可行性研究

目的 比较腹腔镜辅助阑尾切除术（TSLAA）与传统腹腔镜阑尾切除术（LA）的临床疗效和安全性。方法 回顾性分析2017年1月至2019年10月行腹腔镜阑尾切除术且围手术接受加速康复外科（ERAS）方案的急性阑尾炎患者,并根据手术方式分为两组：TSLAA组（47例）和TLA组（92例）。分析比较两组围手术期资料的异同。结果 TSLAA组与LA组在术前一般资料方面具有可比性;TSLAA组的病人术前BMI较低,腹痛持续时间较短。两组患者手术时间及术中出血量无差异。TSLAA组患者在住院期间疼痛控制及满意度评分均优于LA组。但两组术后胃肠功能恢复情况相似。TSLAA组总并发症、感染性并发症、非感染性并发症发生率低于LA组,但并无统计学差异。TSLAA组术中、围手术期费用均明显低于LA组（P<0.05）。结论 TSLAA是一种安全可行的技术,是急性阑尾炎的另一种有效且微创的选择。     

腹腔镜手术治疗高龄肝细胞癌患者的临床疗效分析

目的:比较腹腔镜肝切除术(LLR)与开放肝切除术(OLR)治疗高龄肝细胞癌患者的近期疗效与远期生存率。方法:回顾分析2014年1月至2017年12月手术治疗的52例高龄患者的临床资料,依据手术方式分为两组,OLR组(n=26)行开腹手术,LLR组(n=26)行腹腔镜手术。比较两组手术时间、术中出血量、术后肝功能指标、术后恢复情况及远期生存率。结果:LLR组手术时间长于OLR组,术中出血量、术后引流管留置时间、住院时间、术后并发症发生率优于OLR组,差异有统计学意义。术后第5天,LLR组ALT、TBIL水平低于OLR组,ALB水平高于OLR组,差异有统计学意义。两组术后1年、3年总生存率、无瘤生存率差异无统计学意义。结论:腹腔镜手术治疗高龄肝细胞癌患者疗效可靠,术中出血少,术后并发症发生率低,术后恢复快的同时降低了对肝功能的影响。     

基于倾向性评分匹配方法的结肠癌根治术后发生吻合口漏的围术期相关危险因素分析

目的 探讨结肠癌根治术后发生吻合口漏的围术期相关危险因素。方法 回顾性收集2019年1月至2021年6月在中山大学孙逸仙纪念医院行择期结肠癌根治术的患者病历资料,按照术后是否发生吻合口漏对患者的病历资料分别作单因素分析、多因素Logistic回归分析以及倾向性评分匹配（PSM）分析,筛选出结肠癌根治术后发生吻合口漏的围术期相关危险因素。结果 本研究共纳入患者428例,其中术后发生吻合口漏有17例,发生率为3.97%。多因素分析发现：高龄、男性、手术出血量多、术前白蛋白低、开放手术与术后发生吻合口漏相关（P<0.05）;采用PSM控制年龄和性别后,发现术前白蛋白低于30 g/L、术中出血量>300 mL与吻合口漏发生相关（P<0.05）,开放手术未见显著性差异（P=0.079）。结论 手术出血量多及术前白蛋白低,是导致吻合口漏的独立危险因素。     

肝脏缺血预处理在肝癌围手术期中的作用

目的 观察缺血预处理(ischemic preconditioning,IP)在肝癌围手术期的作用.方法 IP组35例,对照组25例,IP组肝切除前采用10min/10 min的缺血预处理,肝门阻断方法(Pringle手法)、肝切除方法与步骤与对照组类似,比较两组术前、术后肝酶的变化、术中出血与输血量、术后并发症、住院天数、住院费用的区别.结果 两组术中肝门阻断时间、出血量、输血量无明显区别(P>0.05).术后两组肝酶均有明显升高,但IP组谷丙转氨酶在术后1 d、3 d、7 d的升高值明显低于对照组(P<0.025),IP组术后肝功能不全的发生率、住院天数和住院费用明显较对照组低(P<0.05).结论 肝癌手术时采用缺血预处理为一简单有效的保护肝功能的方法.     

肝切除术后抗凝治疗对预防静脉血栓形成的作用

目的 评估肝切除术后抗凝治疗对预防静脉血栓栓塞的有效性、安全性及其影响因素。方法 采用前瞻性研究方法,选择2018年5月~2020年5月于我院就诊并接受肝切除术的患者作为研究对象,将患者分为常规组（n=96）和抗凝组（n=96）,常规组采用常规治疗,抗凝组在常规组的基础上加用依诺低分子肝素钠抗凝治疗,观察记录静脉血栓发生率、出血率、手术相关指标、术后并发症、凝血功能等并对比分析。结果 两组患者基线特征的差异没有统计学意义（P>0.05）。抗凝组与常规组VTE发生率分别为2.1% vs. 5.2%（P=0.441）,两组患者术后出血、术后输血、术后感染、肝功能衰竭发生率以及Clavien-Dindo分级,差异无统计学意义（P>0.05）。抗凝组患者拔管时间和住院时间均高于常规组（P<0.05）。常规组中使用止血患者与未用止血药患者的静脉血栓发生率,差异无统计学意义（P>0.05）。高血压、手术时间≥3 h、术中出血量≥400 mL是肝切除术患者抗凝治疗后出血的独立危险因素。两组患者术后血小板、纤维蛋白原水平差异无统计学意义,抗凝组患者INR、APTT、D-二聚体水平低于常规组。结论 肝切术后抗凝治疗有降低静脉血栓发生率的趋势且安全可行。     

血友病合并胆囊结石行腹腔镜胆囊切除术探讨

目的 探讨血友病患者合并胆囊结石行腹腔镜胆囊切除术的可行性和止血处理措施.方法 采用回顾性对照研究方法,对比分析18例血友病合并胆囊结石患者行腹腔镜胆囊切除术(血友病组)与312例单纯胆囊结石患者行腹腔镜胆囊切除术(单纯组)的临床资料,观察两组患者手术时间、术中出血量、术后平均住院时间及中转开腹情况.结果 血友病组患者的手术时间、术中出血量、术后平均住院时间与单纯组患者均无统计学差异(P>0.05).结论 血友病患者合并胆囊结石行腹腔镜胆囊切除术是安全有效的.严格掌握手术适应证、围手术期凝血功能纠正、熟练的手术技巧加上可靠的止血方法,是手术成功的关键.     

急诊手术围手术期输血与术后感染及并发症的关系

目的 分析急诊手术患者围手术期输血与术后感染的关系。方法 收集2011年至2015年部分急诊手术住院患者病历资料,包括患者基线资料、围手术期临床和实验室数据以及住院期间并发症资料。输血的定义范围为从患者入院到出院的任何输血事件。主要记录术后感染性事件,包括切口和手术部位感染、伤口裂开、尿路感染、肺炎、败血症和感染性休克;次要记录包括住院时间、非计划气管插管、呼吸机使用超过48小时、急性肾衰竭,任何血栓栓塞事件和意外再次手术探查等。结果 在收集到的3153例急诊手术患者中,共242例（7.7%）接受输血治疗,接受输血患者年龄大于无输血患者,输血组BMI低于未输血组;输血患者ASA分类3级和4级低于未输血组;输血患者的平均总手术时间、总住院时间比无输血组长;输血患者发生血栓栓塞并发症的风险,如肺栓塞、深静脉血栓、呼吸功能障碍的风险增高;输血患者更有可能进行非计划气管插管。本组病例共594例患者（18.83%, 594/3135）发生术后感染事件,其中输血患者的感染率占所有输血者的39.7%（96/242）;糖尿病、COPD、慢性心脏病和高血压等慢性疾病史有显著性差异;体重减轻超过10%、较高ASA评分及污染严重伤口更容易感染;皮质类固醇使用、出血性疾病的也更容易感染。此外,低蛋白血症、低血细胞比容和也存在显著差异;开放手术感染率高于腹腔镜手术。结论 急诊手术患者接受输血与术后感染性并发症的风险增加有关。     

Laparoscopic liver resection for hepatocellular carcinoma with cirrhosis in a single institution

Background

In a statement by the second International Consensus Conference for Laparoscopic Liver Resection (LLR), minor LLR was confirmed to be a standard surgical practice, as it has become adopted by an increasing proportion of surgeons. However, it is unclear whether this applies to the more complex group of patients suffering from cirrhosis. Therefore, the aim of this retrospective study was to compare the feasibility and safety of LLR for hepatocellular carcinoma (HCC) between non-liver cirrhosis (NLC) patients and liver cirrhosis (LC) patients at a single high-volume laparoscopy center.

Methods

From the beginning of 2000 to the end of 2013, open liver resection (OLR) was performed in 99 HCC patients, and LLR was in 118. The HCC patients who underwent LLR were divided into NLC-LLR (n=60) and LC-LLR (n=58) groups, and we compare the short-term outcomes between them.

Results

There was no significant difference in the incidence of blood loss and transfusion requirements between the NLC-LLR group and the LC-LLR group, although wedge resection was mainly performed in the LC-LLR group. There was no significant difference in the complication rate between the two groups, and the remarkable finding was that there was a significantly lower incidence of postoperative ascites in the LC-LLR group than in the NLC-LLR group.

Conclusions

According to our experience, it appears that LLR for selected HCC patients with cirrhosis is a feasible and promising procedure that is associated with less blood loss and fewer postoperative complications, especially the incidence of postoperative ascites. Further investigations are clearly warranted.     

Laparoscopic liver resection facilitates salvage liver transplantation for hepatocellular carcinoma

Background/Purpose  In patients with hepatocellular carcinoma (HCC), a previous liver resection (LR) may compromise subsequent liver transplantation (LT) by creating adhesions and increasing surgical difficulty. Initial laparoscopic LR (LLR) may reduce such technical consequences, but its effect on subsequent LT has not been reported. We report the operative results of LT after laparoscopic or open liver resection (OLR). Methods  Twenty-four LT were performed, 12 following prior LLR and 12 following prior OLR. The LT was performed using preservation of the inferior vein cava. Indication for the LT was recurrent HCC in 19 cases (salvage LT), while five patients were listed for LT and underwent resection as a neoadjuvant procedure (bridge resection). Results  In the LLR group, absence of adhesions was associated with straightforward access to the liver in all cases. In the OLR group, 11 patients required long and hemorrhagic dissection. Median durations of the hepatectomy phase and whole LT were 2.5 and 6.2 h, and 4.5 and 8.3 h in the LLR and OLR groups, respectively (P < 0.05). Median blood loss was 1200 ml and 2300 ml in the LLR and OLR groups, respectively (P < 0.05). Median transfusions of hepatectomy phase and whole LT were 0 and 3 U, and 2 and 6 U, respectively (P < 0.05). There were no postoperative deaths. Conclusions  In our study, LLR facilitated the LT procedure as compared with OLR in terms of reduced operative time, blood loss and transfusion requirements. We conclude that LLR should be preferred over OLR when feasible in potential transplant candidates.     

Perioperative analysis of laparoscopic versus open liver resection

Background   Over the past decade there has been an increasing trend toward minimally invasive liver surgery. Initially limited by technical challenges, advances in laparoscopic techniques have rendered this approach safe and feasible. However, as health care costs approach 50% of some provincial budgets, surgical innovation must be justifiable in costs and patient outcomes. With introduction of standardized postoperative liver resection guidelines to optimize patient hospital length of stay, the advantages of laparoscopic liver resection (LLR) compared with open liver resection (OLR) measured by perioperative outcomes and resource utilization are not well defined. It remains to be established whether LLR is superior to OLR by these measurements. Methods  Eighteen LLRs performed at the Vancouver General Hospital from 2005 to 2007 were prospectively analyzed. These data were compared with an equivalent group of 12 consecutive OLRs undertaken immediately prior to the introduction of LLR. Outcomes were evaluated for differences in perioperative morbidity, hospital length of stay, and operative costs. Results  There were no differences between LLRs and OLRs in demographics, pathology, cirrhosis, tumour location or extent of resection. There were no deaths. LLRs had significantly decreased intraoperative blood loss (287 ml versus 473 ml, p = 0.03), postoperative complications (6% versus 42%, p = 0.03), and length of stay (4.3 versus 5.8 days, p = 0.01) compared with OLRs. There were no differences in operating time for LLRs compared to OLRs (135 min versus 138 min, respectively), total time in the operating theatre (214 min versus 224 min), or costs related to stapler/trocar devices (CA $1267 versus CA $1007). Conclusions  LLR is associated with decreased morbidity and decreased resource utilization compared with OLR. Perioperative patient outcomes and cost-effectiveness justify LLR despite introduction of standardized postoperative liver resection guidelines and decreased length of stay for OLR.     

Laparoscopic vs open hepatic resection: a comparative study

Background: Although the feasibility of minor laparoscopic liver resections (LLR) has been demonstrated, data comparing the open vs the laparoscopic approach to liver resection are lacking. Methods: We compared 30 LLR with 30 open liver resections (OLR) in a pair-matched analysis. The indications for resection were malignant disease in 47% of the LLR and 83% of the OLR. The average size of the lesions was 42 mm for LLR and 41 mm for OLR. Five wedge resections, 12 segmentectomies, and 13 bisegmentectomies were performed in each group. Results: The conversion rate for LLR was nil. The mean operative time was 148 min for LLR and 142 min for OLR. Mean blood loss was minimal in the LLR group (320 vs 479 ml; p < 0.05). Postoperative complications occurred in 6.6% of the patients in each group; there were no deaths. The mean postoperative hospital stay was shorter for LLR patients (6.4 vs 8.7 days; p < 0.05). In tumors, the resection margin was <1 cm in 43% of the LLR patients and 40% of the OLR patients (p = NS). Conclusions: Minor LLR of the anterior segments has the same rates of mortality and morbidity as OLR. However, the laparoscopic approach reduces blood loss and postoperative hospital stay.     

结直肠癌肝转移同期腹腔镜与开腹手术的疗效比较：倾向性评分匹配分析

目的 比较倾向性评分匹配后的结直肠癌肝转移患者同期腹腔镜手术与开腹手术的安全性及近期疗效。方法 回顾性分析2011年1月至2020年8月温州医科大学附属第一医院收治的79例行一期联合切除手术的结直肠癌肝转移（CRLM）患者的临床资料。采用倾向性评分匹配方法将开腹组患者与腔镜组进行匹配,每组纳入24例,比较两组围手术期的临床指标。结果 两组患者并发症发生率、围手术期病死率、二次手术率、术中输血率、开始流质饮食时间、腹腔引流管留置时间、术后住院时间和住院费用差异均无统计学意义（P＞0.05）。相比开腹组,腔镜组手术时间更长[（274±57）min vs（190±53）min,P＜0.001],术后肛门排气时间更短[（4（2～11）d vs 5（3～15）d,P=0.005],术后第1天白细胞计数更低 [（10.3±3.7）×109 /L vs （12.4±3.5）×109 /L,P=0.047]。结论 结直肠癌肝转移同期腹腔镜手术是安全、可行的,与开腹手术相比,具有一定的临床优势。     

不规则肝切除术和规则肝切除术在肝癌手术切除中的比较

【摘要】 目的〓探究不规则肝切除术和规则肝切除术在巨大肝癌手术切除中的临床应用及比较。方法〓本研究回顾性分析2006年6月至2014年6月罗定市人民医院收治的原发性肝癌肝切除手术患者,对已实施的不规则性肝切除术与规则性肝切除术两组病例进行比较。包括两组手术的围手术期各个指标及术中、术后各个指标进行比较。结果〓规则肝切除组中的手术时间、术中出血、输血浆、输红细胞量、住院时间及并发症发生率均明显地高于不规则肝切除组的情况,差异有统计学意义(P<0.05),而肿瘤能完整切除的最大直径显著小于不规则肝切除(P<0.05);二者在死亡率的比较上无明显差异,无统计学意义(P>0.05)。结论〓与规则肝切除相较,不规则肝切除在腹部手术史引起严重腹腔内组织粘连、肝功能分级较差、肿瘤数目较多及小肝癌中均体现了明显的优势。而对于肿瘤体积较大的肝癌患者,规则肝切除则更为有效。