Major hepatic resection under total vascular exclusion.

Over a 9-year period, major resection was successfully performed on 51 occasions with total vascular exclusion using supra- and infrahepatic caval and portal vein clamping. The main indications for hepatic resection were centrally located tumor in liver metastases (62%) and hepatocellular carcinoma with no evidence of co-existing cirrhosis (25%). Major resections included extended and regular right hepatectomy, extended left hepatectomy, and segmentectomy. The mean duration of vascular exclusion was 46.5 +/- 5.0 minutes (range 20 to 70 minutes) and mean blood transfusion requirement was 1.4 +/- 0.4 units during vascular exclusion. There were significant correlations between postoperative fall in factor II levels and the number of segments removed (r = 0.37, p = 0.015) and between serum alanine aminotransferase levels at day 2 and the duration of vascular exclusion (r = 0.35, p = 0.02). One patient died 45 days after the procedure of multi-organ failure and sepsis. Nonfatal complications occurred in 7 patients (14%) and included respiratory infection (7 patients), biliary fistula (3 patients), and collection at the site of hepatic resection (3 patients). Total vascular exclusion is a safe and useful technique in resection of major hepatic lesions that involve hepatic veins.     

全肝血流阻断对胆道梗阻兔肝脏损伤的研究

目的　研究全肝血流阻断对胆道梗阻兔肝脏缺血 /再灌注损伤。方法　将 30只兔随机均分为 3组 :A组 (对照组 )、B组 (胆道梗阻组 )和C组 (全肝血流阻断组 )。组织气体分析仪持续测定兔肝组织氧压 (PtiO2 ) ;光镜观察肝脏病理改变 ;全自动生化仪测定血清总胆红素 (TBIL)丙氨酸氨基转氨酶 (ALT)。结果　B、C组在全肝血流阻断后 ,肝PtiO2 值均明显下降 ,再灌注 60min后 ,肝PtiO2 值仍未恢复 ,与缺血前PtiO2 值差异有显著性 (P <0 .0 5) ,且在再灌注 60min时 ,B组较C组肝PtiO2 值恢复更慢 (P <0 .0 5) ;B、C组肝缺血再灌注 2 4h的不同时相 ,ALT值均进一步升高 ,B组较C组升高更为明显。至第 7d ,B、C两组ALT值均恢复到近于正常值 ,肝细胞损伤的病理改变也恢复近似正常。结论　胆道梗阻时肝脏能耐受全肝血流阻断 (2 0min)所致的肝缺血再灌注损伤。     

Haemodynamic and metabolic changes during major liver resection with use of hepatic total vascular exclusion

We evaluated haemodynamic changes during major liver resection that involved total hepatic vascular exclusion (HVE) carried out through clamping hepatic pedicle and inferior caval vein upper and above the liver. Fourteen patients, undergoing different procedures of major liver resection, were enrolled in this study which used complete cardiovascular monitoring. Haemodynamic parameters were measured and calculated at five different times during the operation. Changes such as reduction in cardiac output and increase in systemic vascular resistance, though significant, were well tolerated in all patients, allowing the execution of major liver surgery. HVE offers a significant reduction in haemorrhagic and air embolus risk, but it requires the use of complete haemodynamic monitoring to evaluate tolerance to clamping and correction of unavoidable cardiovascular changes.     

入肝血流阻断和全肝血流阻断对胆道梗阻兔肝脏损伤的研究

目的 研究入肝血流阻断和全肝血流阻断对胆道梗阻兔肝脏的缺血-再灌注损伤。方法 36只兔随机均分为3组:胆道梗阻组(A组,BCDL)、入肝血流阻断组(B组,PTC)和全肝血流阻断组(C组,THVE)。组织气体分析仪持续测定肝组织氧分压(P_(ti)O_2);全自动生化仪测定血流总胆红素(TBIL)、丙氨酸氢基转氨酶(ALT);光镜观察肝脏病理改变。结果 B、C组在肝血流阻断后,肝 P_(ti)O_2值均明显下降,再灌注 60 min仅恢复到缺血前的 87.5％和 73.4％(P<0.05),C组较 B组肝P_(ti)O_2 值恢复更慢(P<0.05)。B、C两组 ALT值在肝缺血-再灌注期间均有不同程度升高,C组ALT值升高更明显,且与肝细胞损伤的病理学改变相一致。结论 急性胆道梗阻兔行PTC和THVE均可导致肝脏缺血-再灌注损伤,PTC较THVE对肝脏的损伤明显减轻。     

原发性肝癌全肝血流阻断肝脏切除术后并发症的观察和护理

目的探讨原发性肝癌患者在常温全肝血流阻断下行肝脏切除术并发症的观察和护理。方法回顾性分析我院4年来原发性肝癌患者在改良全肝血流阻断下行肝脏切除术33例，其中15例肿瘤合并右门静脉、左肝静脉甚至下腔静脉癌栓，同时施行癌栓取出术。结果术后两个月内无死亡病例，发生上消化道出血1例、胸腔积液4例，经处理后全部治愈。结论全肝血流阻断下行肝癌切除术对术后的护理要求高，术后针对此术式容易发生的并发症，做好细致的观察及护理，有助于避免严重并发症的发生及降低死亡率。     

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.     

Technique of hepatic vascular exclusion for extensive liver resection.

Hepatic vascular exclusion, which includes clamping of the portal pedicle along with the inferior vena cava below and above the liver, may be a useful procedure for resection of liver tumors close to the hepatic veins or the vena cava that are usually considered unresectable by conventional techniques. Since complete caval exclusion is the key to good hemodynamic tolerance and a bloodless transection of the liver parenchyma, several technical aspects of the procedure must be accomplished and are detailed.     

全肝血流阻断和肝静脉阻断对肝肿瘤切除术中血流动力学的影响比较

目的探讨阻断下腔静脉的全肝血流阻断(total hepatic vascular exclusion,THVE)和肝静脉阻断(selective hepatic vascular exclusion,SHVE)对肝肿瘤切除术中血流动力学的影响。方法 40例肝切除术患者随机分为THVE组和SHVE组,术中置入Swan-Ganz导管记录肝切除术血管阻断前后的血流动力学变化,比较两组临床资料。结果 THVE组外围循环阻力(SVR)和肺循环阻力(PVR)与SHVE组比较有明显的升高,而心脏指数(CI)、平均动脉压(MAP)和平均肺动脉压(MPAP)则有明显的下降(P0.05)。前者术中输液量较后者多,两组术后肝肾功能及并发症差异无统计学意义(P0.05)。结论肝切除术中SHVE和THVE均能有效控制出血和避免空气栓塞,而前者在保持全身血流动力学稳定并减少术中输液量方面更有优势。     

选择性肝血流阻断技术在腹腔镜左肝外叶切除术中的应用

目的 探讨选择性肝血流阻断技术在腹腔镜左肝外叶切除术中应用的可行性和有效性。方法 回顾分析18例术中采用选择性肝血流阻断技术实施腹腔镜左肝外叶切除术患者的临床资料。结果 全组均在腹腔镜下完成手术,无中转开腹,无围手术期死亡。平均手术时间（140±58）min,平均术中出血量（160±148）mL,均未术中输血。术后1例患者发生左膈下积液,术后并发症发生率为5.56%（1/18）,平均术后住院时间（6.4±2.5）d。结论 腹腔镜左肝外叶切除术中采用选择性肝血流阻断技术可有效减少术中出血和术后并发症,安全可行。     

Significance of total vascular exclusion for hepatic cryotherapy: an experimental study

BACKGROUND: In the liver, efficacy of cryosurgical ablation of tumors located near the retrohepatic vena cava is impaired by the heat-sink effect. This could be overcome by total vascular exclusion (TVE) of the liver. In this study, the effect of TVE on cryosurgical ablation of liver tissue close to the retrohepatic vena cava was investigated with regard to the extent of the cryolesion and complications arising from necrosis of the caval wall. METHODS: Of a total of 28 pigs, 14 underwent cryotherapy with TVE compared to 14 without TVE, both involving the vena cava. 7 animals in each group were subjected to one freeze cycle and 7 in each group to two freeze cycles. Temperatures in the cryolesion were monitored and cryolesions were documented sonographically. Laboratory parameters were determined pre- and postoperatively. Follow-up was 14 days. Morphology, extent of the cryolesion, damage to the vena cava and complications were assessed after autopsy. RESULTS: With TVE, freezing rates were increased and cryolesions were significantly larger than without TVE. Transmural necroses of the vena cava with complete necrosis of the intima occurred significantly more frequently after TVE. Macro- and microscopically, the damage to the caval wall was considerably more marked after cryotherapy under TVE but in all cases the continuity of the vessel wall remained intact. There were no ruptures, thrombosis, or strictures of the vena cava. CONCLUSIONS: The combination of cryotherapy and TVE increases the effectiveness of cryoablation in the liver involving the retrohepatic vena cava without any severe vascular complications occurring in the pig.     

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。     

经腹经心包全肝血流阻断肝切除术患者的护理

目的探讨经腹经心包全肝血流阻断肝切除术患者的围术期护理方法。方法对18例肝肿瘤患者采取经腹经心包全肝血流阻断肝切除术,同时做好术前准备,术后密切监护病情变化、管道护理及并发症的护理。结果所有患者成功切除肿瘤,仅1例因术后肝功能损害持续加重,严重低蛋白血症,出现胸腹水转院治疗,其余患者经精心治疗护理,住院11～27d康复出院。结论经腹经心包全肝血流阻断肝切除术可提高肿瘤切除率;细致的护理可提高手术成功率,降低术后并发症的发生率,改善患者预后。     

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。     

Nursing care of patients treated with transabdominal total hepatic vascular exclusion for hepatectomy

目的 探讨经腹经心包全肝血流阻断肝切除术患者的围术期护理方法.方法 对18例肝肿瘤患者采取经腹经心包全肝血流阻断肝切除术,同时做好术前准备,术后密切监护病情变化、管道护理及并发症的护理.结果 所有患者成功切除肿瘤,仅1例因术后肝功能损害持续加重,严重低蛋白血症,出现胸腹水转院治疗,其余患者经精心治疗护理,住院11～27 d康复出院.结论 经腹经心包全肝血流阻断肝切除术可提高肿瘤切除率;细致的护理可提高手术成功率,降低术后并发症的发生率,改善患者预后.     

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.     

Usefulness of image-navigated surgery in liver surgery

Previously, computed tomography (CT) yielded cross-sectional images reconstructed from single-slice CT. However, the recently developed multidetector-row spiral CT provides isotropic voxel data sets, giving clear and precise three-dimensional images of the intrahepatic vascular structure. The vascular anatomy of the liver and relationship between liver tumors and intrahepatic vascular structure can thus be determined. We have developed software for an image-navigated surgery system with which vessels supplying blood to tumors and main hepatic vein drainage can be identified in patients preoperatively. Virtual liver resection can then be performed on a computer using this software. This simulation surgery contributes to making subsequent actual hepatic resection safer and less invasive.     

In situ hypothermic perfusion of the liver versus standard total vascular exclusion for complex liver resection

SUMMARY BACKGROUND DATA: We compare the results of liver resection performed under in situ hypothermic perfusion versus standard total vascular exclusion (TVE) of the liver <60 minutes and > or =60 minutes in terms of liver tolerance, liver and renal functions, postoperative morbidity, and mortality. The safe duration of TVE is still debated. Promising results have been reported following TVE associated with hypothermic perfusion of the liver with durations of up to several hours. The 2 techniques have not been compared so far. METHODS: The study population includes 69 consecutive liver resections under TVE <60 minutes (group TVE<60', 33 patients), > or =60 minutes (group TVE> or =60', 16 patients), and in situ hypothermic perfusion (group TVEHYOPOTH, 20 patients). Liver tolerance (peaks of transaminases), liver and kidney function (peak of bilirubin, minimum prothrombin time, and peak of creatinine), morbidity, and in-hospital mortality were compared within the 3 groups. RESULTS: The postoperative peaks of aspartate aminotransferase (IU/L) and alanine aminotransferase (IU/L) were significantly lower (P[r] < 0.05) in group TVE HYPOTH (450 +/- 298 IU/L and 390 +/- 391 IU/L) compared with the groups TVE<60' (1000 +/- 808; 853 +/- 743) and TVE> or =60' (1519 +/- 962; 1033 +/- 861). In the group TVEHYPOTH, the peaks of bilirubin (micromol/L) (84 +/- 31), creatinine (micromol/L) (75 +/- 22), and the number of complications per patient (1.2 +/- 0.9) were comparable to those of the group TVE<60' (80 +/- 111; 109 +/- 77; and 0.8 +/- 1.1 respectively) and significantly lower to those of the group TVE> or =60' (196 +/- 173; 176 +/- 176, and 2.6 +/- 1.8). In-hospital mortality rates were 1 in 33, 2 in 16, and 0 in 20 for the groups TVE<60', TVE> or =60', and TVEHYOPOTH, respectively, and were comparable. On multivariate analysis, the size of the tumor, portal vein embolization, and a planned vascular reconstruction were significantly predictive of TVE > or =60 minutes. CONCLUSIONS: Compared with standard TVE of any duration, hypothermic perfusion of the liver is associated with a better tolerance to ischemia. In addition, compared with TVE > or =60 minutes, it is associated with better postoperative liver and renal functions and a lower morbidity. Predictive factors for TVE > or =60 minutes may help to indicate hypothermic perfusion of the liver.