肝癌切除术后并发症的多元回归分析

目的研宛与肝癌切除术后并发症发生有关的因素，并探讨减少肝癌切除术后并发症的技术要点。方法回顾性总结1988年6月至2005年4月间连续施行的378例肝癌切除病例，采用单因素分析和多元退步回归模型分析与肝癌切除术后并发症有关的因素。结果肝癌切除术后总的并发症发生率为17．7％，手术死亡率为1．3％。单因素分析显示，年龄、肝门阻断、出血量以及术中输血等4项指标与并发症发生有关。多元逐步回归分析显示年龄、肝门阻断和术中输血这3项指标是决定肝癌切除术后并发症发生的独立的危险因素。结论降低肝癌切除术后并发症发生率的关键在于术中有效地控制出血厦输血量，同时对伴存肝硬化的病人应尽量缩短肝门阻断时间。     

输血对大肝癌切除术后近远期预后的影响

目的研究输血对大肝癌切除术后近期并发症和远期存活率的影响。方法回顾性分析177例大肝癌切除术病例，结合随访分析输血对近期并发症和远期存活率的影响。结果本组大肝癌围手术期输血率为74．6％。近5年输血量及输血率较5年前显著减少（P〈0．01）。不输血组并发症率低于输血组（P〈0．05）。单因素分析显示，年龄、肝门阻断、术中出血量、输血量以及手术时间与术后并发症发生有关。多因素分析显示，年龄、肝门阻断、输血量以及手术时间是决定术后并发症的4个独立的预测指标。本组大肝癌1、3、5年总存活率为67％、44％和34％，1、3、5年无瘤存活率为51％、31％和31％。不输血组和输血组的总存活率以及无瘤存活率无显著差别。结论输血是决定大肝癌切除术后并发症发生的独立危险因素之一，但输血对大肝癌切除术后存活率无显著影响。肝脏外科医生应积极采取各种方法尽可能避免大肝癌切除术围手术期的输血。     

中肝叶巨大原发性肝癌的手术切除

目的 探讨中肝叶巨大肝癌的手术切除技术。方法 回顾性分析1996年10月至2001年12月施行肝切除术的166例中肝叶巨大肝癌的术中处理，术后并发症及原因。结果 全组均为常温间歇性第一肝门阻断下切肝，单例总阻断时间最长68min，最短7min，平均24.5min；输血量最多为5200ml ,54例未输血；肿瘤切除123例（74．1％），规则性肝叶切除43例（25．9％）；术后并发症9例（5．4％），手术死亡2例（1．2％）。结论 术前良好的肝功能储备是保证中肝叶巨大肝癌手术切除术后顺利恢复的首要条件，术中仔细操作是降低术后并发症的关键。     

中肝叶巨大原发性肝癌的手术切除

目的　探讨中肝叶巨大肝癌的手术切除技术。方法　回顾性分析 1996年 10月至 2 0 0 1年 12月施行肝切除术的 16 6例中肝叶巨大肝癌的术中处理、术后并发症及原因。结果　全组均为常温间歇性第一肝门阻断下切肝 ,单例总阻断时间最长 6 8min ,最短 7min ,平均 2 4 .5min ;输血量最多为5 2 0 0ml,5 4例未输血 ;肿瘤切除 12 3例 (74 .1% ) ,规则性肝叶切除 4 3例 (2 5 .9% ) ;术后并发症 9例(5 .4 % ) ,手术死亡 2例 (1.2 % )。结论　术前良好的肝功能储备是保证中肝叶巨大肝癌手术切除术后顺利恢复的首要条件 ,术中仔细操作是降低术后并发症的关键     

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目的 研究大肝癌的手术切除和围术期处理技术。方法 回顾性总结分析1990年1月至2000年9月施行肝切除术的114例大肝癌病例。结果 大肝癌手术中输血量及术后并发症发生率均较小肝癌显著高,两两组间肝门阻断时间、术中出血量、术时、住院天数及病死率差异无显著性。1996-2000年所施行的大肝癌手术切除较1990-1995年而言,术中输血量、肝门阻断时间及住院天数均有明显下降。多元回归分析显示术中出血量是决定术后并发症发生率之独立的危险因素。结论 大肝癌的手术切除和围术期处理技术较前已有明显进步。只要术前准确判断肝脏储备功能及术中有效控制出血,大肝癌的切除仍是安全可行的。     

肝癌肝切除术后并发胸腔积液影响因素临床分析

目的分析肝癌肝切除术后胸腔积液的发生率及其影响因素,探讨防治肝切除术后并发胸腔积液的可能措施,方法回顾性分析我院2002年1月～2007年7月间行肝切除术的226例肝癌的临床资料。运用x2检验分析其年龄、性别、病理类型、术前肝功能分级、肿瘤直径、肿瘤部位、手术时间、失血量、肝门阻断时间、切除方式、术后腹水量与术后胸腔积液发生率的关系。结果肝癌肝切除术后胸腔积液发生率为23．01％。从X2检验的结果可见：在α=0．05水平上,术后并发胸腔积液的主要影响因素为：肿瘤部位、手术时间、术中失血量、肝门阻断时间、肝切除术式、术后腹水量（P〈0．01）。结论严格掌握手术适应证,加强术前及术后护肝治疗;术中不盲目扩大切除范围,尽可能在较短的时间内完成肝癌的切除;尽量缩短肝门阻断时间,可以减少术后胸腔积液的发生。     

中肝叶切除治疗中央型大肝癌

目的 评估中肝叶切除治疗中央型大肝癌的临床结果.方法 回顾性分析我院2001-2007年采用中肝叶切除治疗的136例直径＞5 cm的中肝叶大肝癌病例资料,并对所有手术患者均进行临床随访.结果 中肝叶切除术的肝门阻断时间、手术时间、术中出血量、术中输血量及住院时间分别为(13.3±9.1) min、(173.1±41.1) min、(548.7±320.5)ml、(511.4±231.7) ml和(18.6±8.8)d.11例患者术中未输血.全组无手术死亡,仅4例(2.9％)患者发生主要并发症.中肝叶切除术术后患者1、3、5年总生存率分别为71％、46％、29％,1、3、5年无瘤生存率分别为65％、40％、24％.结论 中肝叶切除术治疗中央型大肝癌安全可行,能最大限度地保留有功能的肝实质,可作为首选术式.     

肝癌切除术中肝血流控制方法的选择

目的：探讨肝癌切除术中不同肝血流控制方法的合理选择。方法：回顾性分析94例肝癌患者行肝切除时采用4种不同肝血流控制方法对术后肝功能、手术时间、术中出血量、输血量、术后引流量及其并发症的影响。结果：38例（40.4%）行常规第一肝门阻断，34例（36.2%）行选择性半肝阻断，4例（4.3%）行全肝血流阻断，18例（19.1%）未阻断肝门。全部成功切除肿瘤，手术顺利，术后并发症24例次，术后死亡2例（2.1%）。结论：大肝癌切除时肝血流控制方法的选择应根据病变的大小、部位、肝功能、切肝难易程度及术中探查结果等因素综合决定。合理的肝血流控制方法是保证肝切除手术成功、患者术后顺利恢复的关键。     

大肝癌外科治疗时肝血流阻断的合理应用

目的 探讨较大肝癌病人外科治疗时肝血流阻断方法的合理应用及累及下腔静脉肝癌切除的可行性。方法 观察分析我科近3年47例大肝癌病人行肝切除时入肝血流阻断的不同方式对手术能否切除的影响及病人术后恢复的情况。结果 47例病人中行常规肝门阻断27例，选择性半肝血流阻断16例，综合性肝门阻断4例，全部病人手术治疗都成功切除肿瘤，手术顺利，术后无严重并发症，术后恢复良好。结论 对大肝癌病人，术前根据影像学检查资料及肝功能等级，术中熟练的切肝技术等综合因素，合理选用一种肝血流阻断法是保证手术成功，术后病人顺利恢复，提高中晚期肝癌人群疗效的关键。     

不阻断肝血流状态下的肝癌肝切除术

目的 探讨不阻断肝血流状态下的肝癌肝切除术的可行性。方法 回顾性分析1988年－1998年采用不阻断肝脏血运状态下的肝癌肝切除术194例患者,就患者的肝病背景,癌灶资料,手术情况和治疗效果等方面进行分析。结果 （1）本组行不规则肝切除98例（50．5％）,肝叶切除41例（21．1％,其中方叶切除6例）,联合脏器切除30例（16．5％）,肝段切除22例（11．3％,其中Ⅳ段切除11例）;左半肝切除3例（1．5％）。（2）行肝癌切除手术时间2．4h,术中平均输血649ml,61例未输血（31．4％）。（3）本组手术并发症18％（34／194）,无手术死亡和住院死亡。结论 （1）完整血运状态下可行包括半肝,方叶,Ⅷ段等大块及复杂疑难部位的肝切除。（2）手术时间短,失血少。（3）对肝脏的损害轻,手术并发症少,该方法是一简便,有效的肝外科技术。     

持续肝动脉阻断预防破裂性肝癌肝切除术中大出血

目的 探讨应用持续肝动脉阻断技术对预防破裂性肝癌肝切除术中大出血的价值.方法 回顾性分析2006年5月至2010年4月第三军医大学西南医院收治的36例应用Pringle法+持续肝动脉阻断技术对破裂性肝癌患者(研究组)行肝切除术的临床资料.在肝癌数据库中配对选取同期36例采用纱布压迫止血的肝癌破裂出血手术患者(对照组).对两组患者术中和术后的相关指标采用方差分析、x2检验、Fisher确切概率法进行对比分析.结果 研究组患者动脉持续阻断中位时间为58 min(36～98 min);术中中位出血量为400ml,明显少于对照组的750ml(F=16.47,P＜0.05);研究组78%(28/36)的患者未进行输血治疗,明显优于对照组的53%(19/36),两组比较,差异有统计学意义(x2=6.01,P＜0.05).两组患者围手术期AST、TBil均在术后第2天达到最高值,然后逐渐下降,1周左右降至正常范围.两组患者的术后并发症发生率和并发症分级比较,差异无统计学意义(x2=1.83,0.89,P＞0.05).结论 应用持续肝动脉阻断技术可明显减少破裂性肝癌肝切除术的术中出血量,且不会对肝功能产生明显的不良影响.     

大肝癌手术切除术中不同肝血流阻断方法的临床研究

目的：比较大肝癌手术切除术中3种不同的入肝血流阻断法的临床效果。
　　方法：回顾性分析2011年1月—2013年3月期间218例大肝癌（>5cm）手术患者的临床资料,术中88例采用Pringle法间断阻断全肝血流（肝门阻断组）,51例行选择性的半肝血流阻断（半肝阻断组）,79例行肝下下腔静脉阻断联合Pringle法阻断入肝血流（联合阻断组）。比较3组患者的术中与术后的相关指标。
　　结果：3组患者的术前情况、手术时间、入肝血流阻断时间及肝切除量的差异均无统计学意义（均P>0.05）;半肝阻断组与联合阻断组的术中出血量、输血量、输血率均明显低于肝门阻断组,且联合阻断组的输血量、输血率明显低于半肝阻断组（均P<0.05）;3组患者术后第1天肝功能指标差异无统计学意义（均P>0.05）,但半肝阻断组与联合阻断组第3、7天的转氨酶和总胆红素水平均明显低于肝门阻断组（均P<0.05）;3组术后并发症的发生率差异无统计学意义（P>0.05）。
　　结论：大肝癌切除术术中采用肝下下腔静脉阻断联合Pringle法阻断入肝血流不仅能够有效减少术中失血量,而且有利于术后肝功能的恢复。     

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.     

Extraparenchymal control of hepatic veins during mesohepatectomy

BACKGROUND: Bleeding is the most relevant operative risk during mesohepatectomy because of the wideness of the resection surfaces and the exposure of main intrahepatic vascular structures. Preliminary extraparenchymal exposure of the main hepatic veins, with the possibility of clamping them in association with the Pringle maneuver, and the maintenance of a low central venous pressure during mesohepatectomy, can contribute to substantially reducing operative bleeding. STUDY DESIGN: We report the results obtained in 18 mesohepatectomies, performed for liver metastases (13 patients) and for hepatocellular carcinoma (5 patients). Liver resection was performed without preliminary exposure of the main hepatic veins in nine patients (group A) and with preliminary looping of the main hepatic veins in nine patients (group B), without complications related to the maneuver. RESULTS: Intermittent pedicle clamping was used in all patients; in six patients in group B (66.7%), clamping of the main hepatic veins was also performed (mean duration, 37 minutes; range 16 to 68 minutes). Intraoperative blood transfusions were needed in 5 patients (5 of 18, 27.8%): 4 belonged to group A (44.4%) and 1 to group B (11.1%). Mortality was nil and morbidity was 33.3%, involving four patients in group A and two in group B (none related to the exposure, looping, and clamping of the main hepatic veins). CONCLUSIONS: Preliminary control of the main hepatic veins is a safe maneuver. During mesohepatectomy, clamping of these veins, associated with pedicle clamping, is effective in reducing operative bleeding. In our patients, this resulted in a low blood transfusion rate, similar to that of classic major hepatectomies, despite the higher complexity of mesohepatectomy.     

Hilar glissonean access to vascular-secretory elements in anatomical segmental liver resections

It still remains unclear which patients with hepatic tumors can favour anatomical segmental liver resections instead of major liver resection. Short term results of anatomical segmental liver resection are evaluated and analyzed. Ten patients underwent the anatomical segmental liver resection performed by posterior approach with taping of anterior right hepatic vein. Seven patients had liver metastases of colorectal cancer, one had primary hepatic carcinoma and two had benign lesions, anatomical segmental liver resection were performed without Pringle maneuver. There was no significant difference in blood loss, duration of the procedure, postoperative hospital stay and morbidity in comparison with the segmental liver resection performed by anterior approach. Multiple, large and deep-embedded lesions were removed completely, with tumor-free resection margins. Anatomical segmental liver resection performed by hilar glissonean approach is recommended in patients with compromised liver function "unfavourable" liver anatomy to replace major liver resection provides removal of only affected part of the liver accordingly to its true anatomical borders.     

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??Objective:To study the factors associated with postoperative complications of resection of hepatocellular carcinoma. Methods:Consecutive 378 cases of hepatocellular carcinoma between June 1988 and April 2005 at Xiangya Hospital were summarized retrospectively.Single??variant and multivariate stepwise regression model were used to analysis the factors associated with postoperative complications of resection of hepatocellular carcinoma. Results:The overall morbidity rate and mortality rate were 17.7% and 1.3% respectively.Single??variant analysis showed that the age,pringle maneuver,intraoperative blood loss and blood transfusion were associated with postoperative complications.Furthermore,multivariate stepwise regression analysis revealed that the age,pringle maneuver,intraoperative blood loss and blood transfusion volume were the independent risk factors of morbidity rate of resections of hepatocellular carcinoma. Conclusion:The surgical excisions of hepatocellular carcinomas are safe and feasible only if the liver function reserve could be judged accurately before operation and the intraoperative hemorrhage and blood transfusion could be controlled effectively and the duration of portal clamping could be shortened during the operation.     

The role of the ultrasonically activated shears and vascular cutting stapler in hepatic resection

Hemorrhage and liver failure are the two greatest concerns for patients undergoing major liver resection. Inflow occlusion (Pringle maneuver) is often used to minimize blood loss, but hepatic ischemia results in an increased risk of postoperative hepatic dysfunction. We report our experience with the Harmonic Scalpel ultrasonically activated shears (UAS; Ethicon Endo-Surgery, Cincinnati, OH) and a vascular stapler for hepatic resection as technological advances that aid in minimizing blood loss and thereby reduce the need for inflow occlusion. We retrospectively reviewed liver resections performed from September 1997 through July 1998, in which the UAS and articulating vascular endoscopic linear cutting stapler were used. The vascular stapler was used to divide the appropriate portal vein branch and hepatic vein(s) before parenchymal transection. Parenchymal dissection was performed with UAS to a depth of approximately 2 to 3 cm, and the remainder of the liver parenchyma was divided by a clamp crush and clip and suture ligate technique. Patients underwent segmental resection (n = 12), lobectomy (n = 13), or extended lobectomy (n = 11). Resection was performed for metastatic disease, primary liver tumors, or benign disease in 21, 8, and 7 patients, respectively. A Pringle maneuver was performed in 7 of 36 patients (mean clamp time, 8 minutes). The median required intraoperative blood transfusion was 0 units of packed red blood cells. Major and minor complications occurred in 12 and 3 patients, respectively. Two deaths were related to pneumonia and abdominal infection. The vascular stapler safely and securely divides portal vein branches and hepatic veins. The UAS initiates parenchymal transection with minimal blood loss. These two technologies facilitate the surgeon's aim of liver resection without blood transfusion or Pringle maneuver.     

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。