微创化技术在精准肝切除中的应用

目的 分析微创化技术对肝切除患者围手术期的影响.方法 收集南京医科大学第一附属医院肝移植中心单个手术小组于2003年8月至2008年8月间所开展的338例肝切除手术患者的临床资料,分析应用微创化技术对患者术中出血量、并发症发生率、围手术期病死率的影响.结果 338例肝切除术的病例中,255例(75.4%)患者进行解剖性肝叶或肝段的精准肝切除术.手术平均时间150 min(45～650 min);术中出血量300 ml(100～4600 m1),211例(62.4%)术中未输血.围手术期总并发症发生率为18.1%,病死率为0.6%.多因素Logistic回归分析表明,围手术期输血和低血小板血症足肝切除围手术期并发症发生的独立预后因子.结论 体现微创化技术的精准肝切除术可使患者获得较好的临床结果 ,并发症发生率和病死率处于较低的水平.减少术中出血是获得围手术期良好临床结果 的重要因素.     

合理利用外科新技术,减少肝切除术中出血量

上世纪60年代,肝切除手术的死亡率高达30%~40%,死亡的主要原因是大出血。近20年来,随着人们对肝脏解剖认识的加深、影像学技术的发展、手术技术水平的不断提高以及围手术期处理的进步,肝切除术中大出血的发生率已明显下降。在不少作者近几年报告的病例中,约有50%左右的病例术中及围手术期可以不需要输血。尽管如此,由于术中大出血所导致的肝切除手术失败的病例仍时有发生。肝切除术中出血量仍然是决定手术成功与否的关键。控制术中出血的技术也是肝切除术中最关键的技术。物理止血是减少术中肝切缘出血的有效技术。高频电凝止血的原理是高频…     

肝切除术后肝功能衰竭的危险因素

随着肝脏外科技术的发展,围手术期管理和患者筛选标准的进步使可以接受半肝切除术或扩大肝切除术的患者数量大大增加.而肝切除术后肝功能衰竭是肝切除术后严重的并发症之一,肝切除术后肝功能衰竭患者相关风险中糖尿病及已有肝脏疾病如肝硬化、脂肪肝、胆汁淤积等是最重要的危险因素.手术相关风险中残肝体积及术中大出血是影响肝切除术后肝功能衰竭发病率及病死率的关键因素.而到目前为止还没有很好的方法治疗肝功能衰竭,所以预防显得尤为重要.     

肝切除术围手术期管理专家共识

正自1888年世界首例肝切除术成功开展以来,肝脏外科已经历了从局部肝切除到扩大半肝切除再到活体肝脏移植等漫长的发展历程。近年来随着对肝脏解剖的不断认识和血流控制技术的逐渐完善,以及新型断肝器械的相继发明,肝切除技术已日臻成熟。然而,国内外肝切除术的手术死亡率虽已下降至5%以下,但术后并发症发生率仍高达15%~50%~([1])。如何进一步降低并发症发生率仍然是肝脏外科面临的重要课题。肝切除术的围手术期管理与术     

肝硬变患者部分肝切除术后肝功能衰竭的预防

部分肝切除术的主要适应证是原发性肝细胞性肝癌（ＨＣＣ）。文献报告,７４．７％～８９．２％ＨＣＣ合并有不同程度的肝硬变。ＨＣＣ行部分肝切除人多数是在有肝硬变或慢性肝病基础上进行的,肝硬变、肝切除、术后肝功能衰竭（肝衰）之间有密切的联系。１ 肝硬变与部分肝切除术后肝功能衰竭的关系１．１ 肝硬变一部分肝切除术后肝功能衰竭发生的高危险因素 部分肝切除超过一定极限量,便会导致术后发生肝衰。术后肝衰是临床肝切除术后致命并发症,也是引起术后早期死亡的主要原因之一。目前对术后肝衰的治疗颇为困难。临床上,肝切除术后…     

肝切除术围手术期过度炎症反应调控的多学科专家共识(2014版)

随着肝脏外科技术的成熟,围手术期管理的重要性也日益彰显.大量的研究结果表明:肝切除术后过度炎症反应是导致各种并发症的重要原因,严重时可能危及患者生命.为此,中国抗癌协会肝癌专业委员会多次组织国内肝胆外科、麻醉科和重症医学领域的专家经过广泛和深入地研讨,在综合国内外相关领域的最新研究进展和专家经验的基础上制订了《肝切除术围手术期过度炎症反应调控的多学科专家共识(2014版)》.本共识涵盖了肝切除术围手术期过度炎症反应的发生、危害、评估方法和处理原则等方面内容,供临床医师参考,希望能有助于减少肝切除术后并发症的发生,促进患者康复.     

肝恶性肿瘤两种肝切除手术方式围手术期相关因素的对比研究

目的 探讨肝脏恶性肿瘤实施规则性肝切除或非规则性肝切除的围手术期因素,比较二者在围手术期中的优越性.方法 回顾性分析研究解放军空军总医院和解放军总医院1986～2009年1019例肝脏恶性肿瘤肝切除的手术期和围手术期因素.结果 多因素分析表明,对于肝脏恶性肿瘤患者,规则性肝切除在术中失血量、术后并发症、住院死亡率、术后住院天数等方面与非规则性肝切除无显著差异,但规则性肝切除术的手术时间显著多于非规则性肝切除术(P＜0.001,OR=1.004).结论 虽然从肿瘤学上讲对肝恶性肿瘤实施规则性肝段切除比非规则性肝切除更具优势,但在临床实践中与非规则性肝切除相比,规则性肝切除围手术期风险没有显著优势.     

肝切除术治疗肝内胆管结石20年的演变

目的 分析肝内胆管结石肝切除术的治疗效果及相关因素.方法 回顾性分析解放军总医院1986至2005年245例连续性肝内胆管结石肝切除术病例的临床资料.结果 20年间肝内胆管结石肝切除术病例数占同期所有肝切除术治疗良性肝胆疾病病例数的29.6%(245/827),其中男性88例,女性157例,平均年龄(46.9±11.3)岁.肝切除术的范围,与1963至1985年相比,涉及右肝切除和肝段切除者明显增多.术中输血者占45.3%,术后并发症发生率16.3%,其中感染性并发症3.3%,胆漏2.4%,术后平均住院时间(15.7±9.2)d,围手术期病死率0.4%(1/245).结论 个体化的肝切除术是肝内胆管结石外科治疗上的重要手段.在重视优化围手术期处理和创新手术技术的前提下,能够使肝内胆管结石肝切除术保持低并发症发生率和低病死率.     

合理利用外科新技术，减少肝切除术中出血量

肝切除术中出血量仍然是决定手术成功与否的关键。控制术中出血的技术也是肝切除术中的最关键的技术。随着肝脏外科的发展，不断涌现了新设备、新材料和新技术。笔者认为，合理利用物理止血、生物局部覆盖止血材料和选择性预先结扎肝血管等外科新技术，可使肝切除术中出血量大大减少，围手术术后并发症发生率显著减低，提高手术成功率。     

鳞状细胞癌抗原测定对食管癌手术效果的评价

我们采用微粒酶免疫荧光分析仪观察了３１例食管癌患者围手术期血清鳞状细胞瘤抗原（ＳＣＣ－Ａｇ）含量的变化。结果，根治性切除术后，异常升高的ＳＣＣ－Ａｇ在７２小时内均降至正常，姑息性切除术ＳＣＣ－Ａｇ虽有明显下降，但仍高于正常值，开胸探查术后早期ＳＣＣ－Ａｇ均有短暂性升高，７２小时又略下降，２周后恢复到术前水平或略高。认为围手术期连续检测ＳＣＣ－Ａｇ含量的变化，对食管癌手术效果的判断有重要的临床价值。     

Major hepatectomy for hepatocellular carcinoma in patients with an unsatisfactory indocyanine green clearance test.

BACKGROUND: Liver failure is the commonest cause of postoperative death in patients with hepatocellular carcinoma (HCC). With the improvement in operative technique and perioperative care, the limit of hepatic functional reserve may be lowered. The aim of this study was to evaluate the postoperative morbidity, mortality and survival rates in patients with an indocyanine green (ICG) retention value higher than 14 per cent, after major hepatectomy for HCC. METHODS: From January 1994 to December 1997, 117 patients underwent major hepatectomy for HCC; 92 patients had preoperative ICG retention at 15 min lower than 14 per cent (median 8.3 (range 1.6-13.8) per cent), while 25 patients had ICG retention greater than 14 per cent (17.4 (range 14.3-35.3) per cent). Data were collected prospectively and analysed retrospectively. RESULTS: The two groups of patients were similar in terms of age, sex ratio, preoperative platelet count, liver biochemistry, Child-Pugh status and operative procedures performed, but the prothrombin time was significantly longer in the high ICG group. The operative blood loss (1.5 litres), the amount of blood transfused and the number of patients requiring blood transfusion were similar. The postoperative complication rate (41 versus 40 per cent), duration of hospital stay (12 versus 13 days), hospital mortality rate (1 versus 4 per cent) and median survival time (47 versus 45 months) were not significantly different. CONCLUSION: With meticulous surgical technique to decrease intraoperative blood loss and good perioperative care, selected patients with limited hepatic functional reserve can achieve a good immediate postoperative result and a survival rate similar to that of patients with good hepatic functional reserve.     

Hepatectomy for hepatocellular carcinoma: toward zero hospital deaths

OBJECTIVE: The authors report on the surgical techniques and protocol for perioperative care that have yielded a zero hospital mortality rate in 110 consecutive patients undergoing hepatectomy for hepatocellular carcinoma (HCC). The hepatectomy results are analyzed with the aim of further reducing the postoperative morbidity rate. SUMMARY BACKGROUND DATA: In recent years, hepatectomy has been performed with a mortality rate of <10% in patients with HCC, but a zero hospital mortality rate in a large patient series has never been reported. At Queen Mary Hospital, Hong Kong, the surgical techniques and perioperative management in hepatectomy for HCC have evolved yearly into a final standardized protocol that reduced the hospital mortality rate from 28% in 1989 to 0% in 1996 and 1997. METHODS: Surgical techniques were designed to reduce intraoperative blood loss, blood transfusion, and ischemic injury to the liver remnant in hepatectomy. Postoperative care was focused on preservation and promotion of liver function by providing adequate tissue oxygenation and immediate postoperative nutritional support that consisted of branched-chain amino acid-enriched solution, low-dose dextrose, medium-chain triglycerides, and phosphate. The pre-, intra-, and postoperative data were collected prospectively and analyzed each year to assess the influence of the evolving surgical techniques and perioperative care on outcome. RESULTS: Of 330 patients undergoing hepatectomy for HCC, underlying cirrhosis and chronic hepatitis were present in 161 (49%) and 108 (33%) patients, respectively. There were no significant changes in the patient characteristics throughout the 9-year period, but there were significant reductions in intraoperative blood loss and blood transfusion requirements. From 1994 to 1997, the median blood transfusion requirement was 0 ml, and 64% of the patients did not require a blood transfusion. The postoperative morbidity rate remained the same throughout the study period. Complications in the patients operated on during 1996 and 1997 were primarily wound infections; the potentially fatal complications seen in the early years, such as subphrenic sepsis, biliary leakage, and hepatic coma, were absent. By univariate analysis, the volume of blood loss, volume of blood transfusions, and operation time were correlated positively with postoperative morbidity rates in 1996 and 1997. Stepwise logistic regression analysis revealed that the operation time was the only parameter that correlated significantly with the postoperative morbidity rate. CONCLUSION: With appropriate surgical techniques and perioperative management to preserve function of the liver remnant, hepatectomy for HCC can be performed without hospital deaths. To improve surgical outcome further, strategies to reduce the operation time are being investigated.     

Hepatectomy for hepatocellular carcinoma: the surgeon's role in long-term survival.

HYPOTHESIS: The surgeon can contribute substantially to the long-term survival rate of patients undergoing hepatectomy for hepatocellular carcinoma (HCC). DESIGN: The long-term survival rate of patients with HCC undergoing hepatectomy has improved, but the contribution of the surgeon to the improved survival rate is unknown. We surveyed 211 consecutive patients undergoing hepatectomy for HCC. The clinical, operative, and pathological factors were analyzed to identify factors that were important in affecting long-term survival. SETTING: A tertiary referral center. PATIENTS: From April 1989 to December 1995, 211 consecutive patients with HCC underwent 153 major and 58 minor hepatectomies. MAIN OUTCOME MEASURES: Disease-free and overall cumulative survival rate. RESULTS: The 5-year disease-free survival rate was 27%. By Cox regression analysis, blood transfusion (relative risk [RR], 1.21; 95% confidence interval [CI], 1.05-1.40) and TNM stage (RR, 1.90; 95% CI, 1.47-2.47) were shown to be independent prognostic factors in the 5-year disease-free survival rate. The 5-year overall cumulative survival rate was 37%. By Cox regression analysis, the preoperative indocyanine green retention value at 15 minutes after injection (RR, 1.03; 95% CI, 1.01-1.06), blood transfusion (RR, 1.191; 95% CI, 1.078-1.316), tumor rupture (RR, 1.48; 95% CI, 1.08-2.04), and TNM stage (RR, 1.62; 95% CI, 1.27-2.07) were shown to be significant independent factors that influenced cumulative survival rate. CONCLUSIONS: The long-term survival of patients with HCC after hepatectomy depends on tumor staging, preoperative hepatic functional reserve, history of blood transfusion, and rupture of HCC. Preoperative liver function and tumor staging cannot be altered; however, the surgeon can play an important role in improving the prognosis if blood transfusion and iatrogenic tumor rupture can be avoided and if function of the liver remnant can be preserved.     

Risk factors for perioperative morbidity and mortality after extended hepatectomy for hepatocellular carcinoma

BACKGROUND: Extended hepatectomy with resection of more than four segments is a high-risk operation, especially in patients with hepatocellular carcinoma (HCC) associated with chronic liver disease. This study evaluated the risk factors for morbidity and mortality following extended hepatectomy for HCC. METHODS: Preoperative and intraoperative variables of 155 patients who underwent extended hepatectomy for HCC were analysed to identify risk factors for postoperative morbidity and mortality. RESULTS: The overall morbidity rate was 55.5 per cent (n = 86). Most morbidity was due to ascites or pleural effusion. Significant life-threatening complications occurred in 20.0 per cent (n = 31). The perioperative mortality rate was 8.4 per cent (n = 13). Multivariate analysis found that portal clamping (P = 0.023) and perioperative blood transfusion (P < 0.001) were risk factors for morbidity, whereas perioperative blood transfusion (P < 0.001) was the only risk factor for significant morbidity. Co-morbid illness (P = 0.019) and perioperative blood transfusion (P = 0.004) were risk factors for perioperative mortality. CONCLUSION: Meticulous operative techniques to minimize blood loss and transfusion, while avoiding a prolonged Pringle manoeuvre, may help reduce postoperative morbidity. Avoidance of perioperative blood transfusion and careful preoperative selection of patients in terms of overall physiological status are important measures to reduce the postoperative mortality rate.     

107例肝细胞肝癌切除术后预后因素分析

目的 探讨影响肝细胞肝癌切除术后的预后因素。方法 回顾性分析广西医科大学肿瘤医院2002年6月~2004年5月间107例肝细胞肝癌手术切除患者的临床资料,选择38项临床病理因素分析其对生存率的影响。Kaplain-Meier法计算生存率,单因素分析采用Log-rank检验,多因素分析采用Cox模型筛选出对肝细胞肝癌切除预后有影响的临床病理因素。结果 全组1、3、5年生存率为85.0%,53.3%,43.9%。单因素分析：术前GGT,术前肝功能Child-Pugh分级,术后ALB,术后TBIL,术后ALP,术后GGT,肿瘤最大直径,门静脉癌栓,术中失血情况,围手术期输血,术后是否复发以及手术是否根治切除等。多因素分析：术后ALB,术后ALP,门静脉癌栓,术后是否复发,手术是否根治切除与预后相关。结论 术后ALB,术后ALP,门静脉癌栓,术后复发,根治性切除是影响肝细胞肝癌术后生存期的独立预后因素。     

学龄前儿童先天性脊柱侧凸矫形手术围术期输血的相关因素分析——一项单中心回顾性分析

目的回顾性分析学龄前儿童（≤72个月）行先天性脊柱侧凸矫形手术围术期血液管理的临床特点及相关影响因素。方法针对2年以来行先天性脊柱侧凸矫形手术的110例学龄前儿童（≤72个月）相关资料进行回顾性分析,组间比较采用t检验,组内比较采用重复测量的方差分析,多元Logistic回归分析被用来确定异体红细胞输注的独立预测因子。结果共有91例患儿（83％）术中输入异体红细胞,与术中异体红细胞输入量存在明显相关性的因素有患儿的体重、术前Cobb角、融合节段、手术时间、截骨数量、失血量以及术前血红蛋白（hemoglobin,Hb）浓度、红细胞比容（hematocrit,Hct）、血小板（bloodplatelet,Pit）计数,其中独立因素有Cobb角、截骨数量、术前Hb浓度、Hct、Pit计数。输血患儿与未输血患儿比较,术中截骨率、术中出血量和术后24h伤口引流量显著增加,术后住院时间也明显延长。结论可作为围术期输血评估的独立因素有Cobb角、截骨数量、术前Hb浓度、Hct、Plt计数,而与患儿的年龄、体重、融合节段及手术时间无明显相关性,有助于对学龄前儿童先天性脊柱侧凸矫形手术围术期输血需求的早期识别和准确评估,保证患儿的生命安全。     

ICG Clearance in Assessing Cirrhotic Patients with Hepatocellular Carcinoma for Major Hepatic Resection

Objective: To deWne the safety of major hepatectomy for hepatocellular carcinoma (HCC) associated with cirrhosis and the selection criteria for surgery in terms of hospital mortality. Design: Major hepatectomy for HCC in the presence of cirrhosis is considered to be contraindicated by many surgeons because the reported mortality rate is high (26% to 50%). Previous workers recommended that only selected patients with Child''s A status or indocyanine green (ICG) retention at 15 minutes of less than 10% undergo major hepatectomy. A survery was made, therefore, of our patients with HCC and cirrhosis undergoing major hepatectomy between 1989 and 1994. Setting: A tertiary referral center. Patients: The preoperative, intraoperative, and post-operative data of 54 patients with cirrhosis who had major hepatectomy were compared with those of 25 patients with underlying chronic active hepatitis and 22 patients with normal livers undergoing major hepatectomy for HCC. The data had been prospectively collected. Intervention: Major hepatectomy, defined as resection of two or more liver segments by Goldsmith and Woodburn nomenclature, was performed on all the patients. Main Outcome Measure: Hospital mortality, which was defined as death within the same hospital admission for the hepatectomy. Results: Preoperative liver function in patients with cirrhosis was worse than in those with normal livers. The intraoperative blood loss was also higher (P=.01), but for patients with cirrhosis, chronic active hepatitis, and normal livers, the hospital mortality rates (13%, 16%, and 14%, respectively) were similar. The hospital mortality rate for patients with cirrhosis in the last 2 years of the study was only 5%. Patients with cirrhosis could tolerate up to 10 L of blood loss and survive the major hepatectomy. By discriminant analysis, an ICG retention of 14% at 15 minutes was cutoff level that could maximally separate the patients with cirrhosis with and without mortality. Conclusion: Major hepatectomy for HCC in the presence of cirrhosis is associated with a mortality rate that is not different from the rate for patients with normal livers. An ICG retention of 14% at 15 minutes would serve as a better selection criterion than the 10% previously used.     

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。     

ASA 评分在肝癌患者外科治疗风险评估中的作用

目的：探讨ASA评分对肝癌患者外科治疗风险评估的价值。 方法：回顾2006年1月—2010年12月419例原发性肝癌肝切除患者围手术期临床资料,分析患者ASA评分与临床因素的关系,并对可能的相关因素作单因素筛选后行多因素回归分析,分析肝癌术后并发症及术中输血有关的影响因素。 结果：统计分析显示,肝癌患者术前并发症及术前血红蛋白影响ASA评分;随着ASA评分上升,患者术中失血量、输血量、术后并发症及住院天数明显高增加（均P<0.05）。多因素回归分析结果显示,ASA评分、失血量、肝硬化、年龄、丙氨酸转氨酶（ALT）水平是术后并发症发生的独立影响因素（均P<0.05）;ASA评分、手术时间、肿瘤直径是术中输血的独立影响因素（均P<0.05）。 结论：ASA评分是肝癌患者围手术期风险较好的早期预测指标。     

One hundred consecutive hepatobiliary resections for biliary hilar malignancy: preoperative blood donation, blood loss, transfusion, and outcome

BACKGROUND: Many reports on blood loss and transfusion requirements during hepatectomy for metastatic liver cancer or hepatocellular carcinoma have been published; however, there are no reports on these issues in hepatectomy for biliary hilar malignancy. The aim of this study was to review our experience with blood loss and perioperative blood requirements in 100 consecutive hepatectomies for biliary hilar malignancy. METHODS: One hundred consecutive hepatectomies with en bloc resection of the caudate lobe and extrahepatic bile duct for hilar malignancies were performed, including 81 perihilar cholangiocarcinomas and 19 advanced gallbladder carcinomas involving the hepatic hilus. Fifty-eight hilar resections were combined with other organ and/or vascular resection. Data on preoperative blood donation, intraoperative blood loss, and perioperative transfusion were collected and analyzed. RESULTS: Preoperative autologous blood donation was possible in 73 patients (3.4 +/- 1.2 U). Intraoperative blood loss was 1850 +/- 1000 mL (range, 677-5900 mL), and it was < 2000 mL in 62 patients. Intraoperatively, only 7 of the 73 patients (10%) who donated blood received transfusion of unheated, homologous blood products (packed red blood cells or fresh frozen plasma), whereas 18 the 23 patients (67%) without donation received homologous transfusions. Only 16 patients received transfusion postoperatively, and overall, 35 patients received unheated homologous blood products. Total serum bilirubin concentrations after hepatectomy in patients receiving autologous blood transfusion only was similar to those in patients who did not receive transfusion. The incidence of postoperative complications was higher in the 35 patients who received perioperative homologous transfusion than in 65 patients who did not (94% vs 52%; P <.0001). The mortality rate (including all deaths) was 3% (myocardial infarction, intra-abdominal bleeding, and liver failure, 1 patient each). CONCLUSIONS: Despite the technical difficulties arising from hepatectomy for biliary hilar malignancy, approximately two thirds of hepatectomies can be performed in an experienced center without perioperative homologous blood transfusion using preoperative blood donation.