选择性出入肝血流阻断在肝脏巨大肿瘤切除术中的应用

目的 探讨选择性出入肝血流阻断(SHVE)在肝脏巨大肿瘤切除术中应用的优势.方法 回顾性分析29例施行肝脏巨大肿瘤切除术患者的临床资料,随机分为SHVE组(15例)和第一肝门阻断组[(Pringle组),14例],比较两组患者的术中肝血流阻断时间、肝切除范围、出血量、术后肝功能恢复情况、术后2 d平均腹腔引流量以及并发症发生率等指标.结果 两组患者的性别、年龄、肿瘤大小、术中肝血流阻断时间以及肝切除范围的差异均无统计学意义(P＞0.05).SHVE组患者的术中出血量为(282.1±286.5)ml,明显少于Pringle组[(721.5±512.1)ml,P＜0.05].SHVE组患者术后第1、3、7天血清前白蛋白含量明显高于Pringle组(P＜0.05),血清谷丙转氨酶和总胆红素含量明显低于Pringle组(P＜0.05).SHVE组患者术后2 d平均引流量为(189.4±103.5)ml,明显少于Pringle组[(249.5±108.7)ml,P＜0.05].Pringle组有1例发生肝功能衰竭,SHVE组无一例发生肝功能衰竭.Pringle组有4例发生肝静脉损伤,3例发生肝静脉破裂大出血,1例发生空气栓塞;SHVE组虽有5例发生肝静脉损伤,但无一例发生肝静脉破裂大出血或空气栓塞.结论 SHVE术可以提高肝脏巨大肿瘤切除患者对手术的耐受性,是合理安全的肝脏手术术式.     

不同肝血流阻断方法对可手术小肝癌预后的影响

目的 比较可手术小肝癌选择性适时半肝血流阻断法与肝十二指肠韧带阻断法（Pringle法）对患者中长期生存的影响。方法 根据肝血流阻断不同方式,将我院腹部外科222例小肝癌手术患者分为无肝门阻断、选择性适时半肝血流阻断与Pringle法3组,对以上患者进行随访,收集生存资料进行分析比较。结果 选择性适时半肝血流阻断组与无肝门阻断和Pringle法组患者之间中位生存时间差异有统计学意义（P值分别为0.02、0.04）。无肝门阻断、选择性适时半肝血流阻断和Pringle法组患者3年生存率分别为81.3%、93.3%和76.0%,三者间差异有统计学意义（P=0.008）;5年生存率分别为70.6%、90.8%和50.7%,三者间差异有统计学意义（P<0.001）。选择性适时半肝血流阻断组3年生存率与5年生存率均优于其他两组。结论 在小肝癌可手术患者中应用选择性适时半肝血流阻断较Pringle法能显著延长患者的生存时间,提高患者生存率。     

控制性低中心静脉压联合肝血流阻断在肝癌切除术中的应用

目的:观察控制性低中心静脉压（controlled low central venous pressure,CLCVP ）联合肝血流阻断对肝切除术中出血及血流动力学变化的影响。方法:选取天津医科大学肿瘤医院2014年6 月至2014年12月60例肝叶/ 段切除术患者,随机分成肝血流阻断组（Ⅰ组）和肝血流阻断联合CLCVP 组（Ⅱ组）。 Ⅰ组在肝切除过程中只应用肝血流阻断技术,采用常规液体管理,维持中心静脉压（central venous pressure,CVP ）为6～12cmH2O;Ⅱ组在肝切除过程中联合应用肝血流阻断和CLCVP 技术。CLCVP 包括:限制液体输入和输注硝酸甘油,即从手术开始到肝实质分离完成时,液体输注速度控制在1～3 mL/（kg · h）左右,并以输注晶体液为主,必要时输注硝酸甘油,维持CVP ≤ 5 cmH2O;在肝切除后,快速输入乳酸钠林格氏液和羟乙基淀粉130/ 0.4 氯化钠注射液,恢复正常 CVP 。记录两组患者基本情况和手术信息,记录术前、气管插管后 5 min、肝切除开始、肝切除 20min、肝切除后 5 min、手术结束时的平均动脉压（mean arterial pressure ,MAP ）、心率（heartrate ,HR）、CVP 、脑电双频谱指数（bispectral index,BIS）等。结果:与Ⅰ组相比,Ⅱ组手术时间、出血量、输血量均明显减少（P < 0.05）,两组尿量无显著性差异（P > 0.05）。 两组患者术前各项指标比较无显著性差异（P > 0.05）。 术中不同时点,两组患者MAP 、HR也无显著性差异（P > 0.05）。 与Ⅰ组相比,Ⅱ组CVP 在肝切除开始及肝切除20min时显著下降（P < 0.05）,BIS值在肝切除开始、肝切除20min及肝切除后5 min显著降低（P < 0.05）。 结论:肝血流阻断联合应用CLCVP 技术能够有效降低肝切除术的术中出血量和减少输血。      

半肝缺血预处理在肝硬化肝癌手术中的临床应用价值

目的 探讨半肝缺血预处理（HIP）对肝硬化肝癌患者肝切除的保护作用及临床价值.方法 将60例行开腹手术的肝癌患者按入肝血流阻断方式的不同分为两组,即HIP组（20例）和半肝血流阻断法（HHV）组（40例）,比较两组的临床效果.结果 HIP组术中出血量（自然对数）、术后输血病例数、术后输血量分别为5.7±0.7、3例和（333.3±115.5）ml,均明显少于HHV组的6.1±0.6、18例及（1 433.3±918.4）ml,差异均有统计学意义（t=2.25,P=0.028;x2=5.27,P=0.022;t=4.86,P＜0.001）.两组手术时间、术后住院时间、并发症及肠道通气时间差异均无统计学意义（均P＞0.05）.术后第1、3、5、7天凝血酶原时间活动度HIP组均高于HHV组（均P＜0.05）.HIP组术后一周内有7例丙氨酸氨基转移酶恢复正常,HHV组仅1例（P=0.001）.结论 半肝缺血预处理法可能提高肝硬化肝癌患者手术的安全性,并有助于术后肝功能及早恢复.     

常温下半肝血流阻断后肝叶切除术的临床应用

目的：通过对79例肝癌的回顾性分析研究，讨论选择性半肝血流阻断与全肝血流阻断肝切除术对患者术后肝功能的影响。方法：37例行选择性半肝血流阻断肝切除术、42例行全肝血流阻断肝切除术。术后对两组病例的各项肝功能指标进行比较。结果：79例无手术死亡。94．6％行选择性半肝血流阻断肝切除术的患者和40．4％行全肝血流阻断肝切除术的患者于术后两周肝功能恢复正常或术前水平。两者比较有统计学差异（P＜0．05）。结论：对肝癌伴肝硬变的患者行选择性半肝血流阻断肝切除术可以减轻肝血流阻断对肝功能的损害、术后肝功能恢复较快，是目前较为恰当的入肝血流阻断方法之一。     

第Ⅷ肝段切除15例临床体会

目的 总结15例第Ⅷ肝段切除术的临床经验.方法 使用彭氏多功能手术解剖器(PMOD),采取选择性肝血流阻断,对15例第Ⅷ段肝癌进行肝段或联合肝段切除.结果 15例手术均顺利完成,无一例手术死亡.其中13例行第Ⅷ肝段切除,2例行联合第Ⅶ、第Ⅷ肝段切除.术中肝血流阻断1-2次,时间12～25 min,平均(17.3±5.2)min,切肝时间(阻断肝血流至肝脏肿块切除时间)10-23 min,平均(18.3±4.7)min.出血量约(50-700)ml,平均(186±78)ml,2例患者需输血.术后有2例合并胸腔积液,1例胆漏并发膈下感染.结论 使用PMOD在选择性肝血流阻断下,安全快捷地行第Ⅷ肝段的切除是完全可行的.     

入肝血流不同处理方式对肝癌手术患者的疗效及对其不良反应的影响分析

目的 研究入肝血流不同处理方式对肝癌手术患者的疗效及对其不良反应等的影响。方法 104例肝癌患者需要行手术,根据入肝血流不同处理方式进行分组,其中53例患者采用Glisson鞘外血流阻断为观察组,51例患者采用Pringle全入肝血流阻断为对照组。观察两组患者手术临床指标,术前及术后1 d、3 d、7 d肝功能指标,术后不良反应情况,术后情况,术前及术后生活质量评分。结果 两组患者肝血流阻断时间差异无统计学意义(P>0.05),但观察组手术时间、术中出血量、术中输血量、住院天数优于对照组(P<0.05)。术前两组患者肝功能指标对比差异无统计学意义(P>0.05),术后1 d、3 d、7 d观察组谷草转氨酶(aspartate transaminase, AST)、谷丙转氨酶(alanine aminotransferase, ALT)、总胆红素(total bilirubin, TBIL)水平低于对照组(P<0.05),血清白蛋白(albumin, ALB)高于对照组(P<0.05)。观察组不良反应发生率为11.32%,低于对照组(29.41%)(P<...     

美蓝染色标记法联合Glisson蒂横断式肝切除与非规则性肝切除治疗肝癌的临床疗效

目的 探讨美蓝染色标记法联合Glisson蒂横断式肝切除与非规则性肝切除治疗肝癌的临床疗效。方法 对美蓝染色标记法联合Glisson蒂横断式肝切除25例（联合组）与非规则性肝切除23例（非规则组）治疗肝癌作前瞻性研究,比较两组患者围手术期情况,包括平均手术时间、术中出血量、术后1 d和4 d AST的水平、肿瘤标本切缘阳性率、并发症发生率、术后1年复发率和1年生存率等,并分析其临床疗效。结果 两组患者均无围手术期死亡病例。联合组平均手术时间较非规则组少［（120.16±15.45） min vs（130.26±8.48） min,t=2.77,P<0.05］;联合组术中出血量较非规则组少［（252.40±81.25） ml vs （493.44±100.96） ml,t=8.42,P<0.05］;联合组术后1 d、4 d AST水平上升幅度较非规则组小［（1 d AST：（143.76±49.48）U/L vs （253.82±77.79） U/L,t=5.90,P<0.05;4 d AST：（79.36±24.51） U/L vs（129.57±45.66） U/L,t=4.80,P<0.05］;肿瘤标本切缘阳性率分别为4.0%和8.7%（P>0.05）;围手术期并发症发生率联合组较非规则组低（12.00% vs 39.13%,P<0.05）;术后1年复发率联合组较非规则组低（20.00% vs 47.83%,P<0.05）;术后1年生存率两组差异无统计学意义（80.00% vs 78.26%,P>0.05）。结论 美蓝染色标记法联合Glisson蒂横断式肝切除较非规则性肝切除治疗肝癌的术中出血量和术后并发症少,患者术后恢复快,复发率低,值得临床推广应用。     

常温下全肝血流分步阻断行第Ⅷ肝段肝癌切除5例报告

作者对传统的常温无血切肝术进行改良,利用微波切肝技术将全肝血流阻断步骤分解成三步,分步阻断全肝血流行肝切除术.临床应用于第Ⅷ肝段肝癌切除5例,肿瘤平均最大直径8.2cm.结果平均总切肝时间27分钟.全肝血流阻断时间13分钟,术后恢复顺利,无手术期死亡.本文介绍了手术的具体操作方法,认为该术式选择性缩短全肝血流的阻断时间.     

肝癌腹腔镜及开腹治疗的临床疗效比较

目的:比较腹腔镜及开腹肝癌切除术的治疗效果.方法:选取2012年4月至2014年12月的22例腹腔镜肝癌切除术(腔镜组)与57例开腹肝癌切除术(开腹组)患者,对比两者的相关临床资料.结果:两组均顺利完成肝癌切除术.腔镜组术中出血量、拔管时间、术后引流量、术后住院时间均明显少于开腹组(P＜0.05),而手术时间两组无明显差异(P＞0.05),治疗后腔镜组并发症发生率、复发率、生存率依次为4.5％、0％、100％,开腹组依次为10.5％、5.3％、94.7％,两组并发症发生率差别无意义(P＞0.05),腔镜组较开腹组生存率高、复发率低(P＜0.05).术后腹腔镜组AST、ALT、ALB以及TBIL水平均明显优于开腹组(P＜0.05).结论:腹腔镜肝癌切除术安全可靠,与开腹手术比较,具有手术创伤小,术后恢复快,住院时间短的优点.     

不同入肝血流阻断法在肝癌切除术中的应用

目的 探讨选择性Glisson鞘外阻断法和第一肝门阻断(Pringle)法在肝癌切除术中的价值.方法 回顾性分析2012年5月至2021年5月在河池市第三人民医院普通外科收治的93例原发性肝癌患者的临床资料,按照术中入肝血流阻断方式分组,对照组行Pringle法(n=46),观察组行选择性Glisson鞘外阻断法(n=...     

Selective hepatic vascular exclusion and Pringle maneuver: A comparative study in liver resection

Objective

Most liver resections require champing of the hepatic pedicle (Pringle maneuver) to avoid excessive blood loss. But Pringle maneuver cannot control backflow bleeding of the hepatic vein. Resection of liver tumors involving hepatic veins may cause massive hemorrhage or air embolism from injuries of the hepatic vein. Although total hepatic vascular exclusion (THVE) can prevent bleeding of the hepatic vein effectively, it also may result in systemic hemodynamic disturbance because of the clamped inferior vena cava (IVC). SHVE, a new technique, can control the inflow and outflow of the liver without clamping the vena cava. We compared the effects of selective hepatic vascular exclusion (SHVE) and Pringle maneuver in resection of liver tumors involving the junction of the hepatic vein.

Methods

From January 2000 to October 2005, 2100 patients with liver tumors had undergone liver resections in our department. Among them, tumors of 235 cases adhered to or were close to the junction of one or more hepatic veins. Both SHVE and Pringle maneuver were used to control blood loss during hepatectomy. These 235 cases were divided into two groups: Pringle maneuver group (110) from January 2000 to December 2002 and SHVE group (125) from January 2003 to October 2005. Data were analyzed regarding the intraoperative and postoperative courses of the patients. In the SHVE group, total SHVE (clamping the porta hepatis and all major hepatic veins) was used in 69 cases and partial SHVE (clamping the porta hepatic and one or two hepatic veins) in 56 cases. There were three methods in hepatic veins occlusion: ligating with suture, encircling and occluding with tourniquets and clamping with Satinsky clamps.

Results

There was no difference between the two groups regarding the age, gender, tumor size, cirrhosis and HBsAg rate, ischemia time and operating time. Intraoperative blood loss and transfusion requirements were significantly decreased in the SHVE group. Hepatic veins rupture with massive blood loss occurred in 14 and air embolism in three during the tumor resection, but there was no massive blood loss and air embolism in the SHVE group due to hepatic vein occlusion. Postoperative bleeding, reoperation, liver failure and mortality rate were higher, and ICU stay and hospital stay were longer in the Pringle group than those in the SHVE group.

Conclusion

SHVE is much more effective than Pringle maneuver in controlling intraoperative bleeding. It can prevent massive blood loss and air embolism from hepatic veins rupture and can reduce the postoperative complication rate and mortality rate. Clamping the hepatic veins with Satinsky clamps is much safer and easier than ligating with suture and occluding with tourniquets.     

老年肝癌根治性切除术后肝癌复发的高危因素分析

目的:探讨老年肝癌根治性切除术后肝癌复发的高危因素。方法:选择我院于2015年1月至2017年1月期间收治的行肝癌根治性切除术的老年肝癌患者300例作为研究对象。所有研究对象均完成术后12个月随访,观察患者复发情况,其中肝癌术后复发时间以影像学检查有明确的肿块存在为确诊依据。运用多因素分析术后复发危险因素。结果:老年肝癌根治性切除术患者300例,术后随访12个月肝癌复发58例,复发率为19.33%。经单因素分析显示,两组性别、合并基础疾病、术前ALT、术前AST和手术时间比较无统计学差异（P>0.05）;两组肿瘤直径、血管侵犯、肿瘤包膜和术中失血比较具有统计学差异（P<0.05）。将上述单因素分析具有统计学意义的纳入多因素分析显示,肿瘤直径、血管侵犯、肿瘤包膜和术中失血为影响老年肝癌根治性切除术后复发危险因素。结论:老年肝癌根治性切除术后肝癌复发影响因素较多,而肿瘤直径、血管侵犯、肿瘤包膜和术中失血为其危险因素。     

Selective continuous vascular occlusion and perioperative fluid restriction in partial hepatectomy. Outcomes in 101 consecutive patients.

BACKGROUND: This study documents patient outcomes with one department's approach to performing partial hepatectomy. METHODS: 101 consecutive patients underwent: preoperative dehydration; intraoperative CVP <5 cm H(2)O and selective continuous vascular occlusion. Outcome variables: pathology; type of hepatic resection; intraoperative blood loss and transfusion rate; 30 day morbidity and mortality; disease free and long term survival. Perioperative liver function was assessed by serial blood sampling. RESULTS: Of 101 resections: 90% malignant disease; 59% major resections and 35% synchronous procedures. Median estimated blood loss was 400 mL (mean 512 mL, range 50-3000 mL) with postoperative transfusions in 4%. Thirty day morbidity was 20% with no deaths. Median time to local recurrence after colorectal liver metastases resection was 17.1 months with 3 year survival of 51%. Distinct perioperative changes in hepatic function were seen. CONCLUSION: Selective continuous vascular occlusion and perioperative fluid restriction result in minimal blood loss, low morbidity and zero mortality in patients undergoing partial hepatectomy.     

The renal sequelae of a novel triphasic approach to blood loss reduction during hepatic resection.

AIMS: To report our novel triphasic approach to minimising blood loss during hepatic resection and the renal sequelae. METHODS: Fifty consecutive patients (median age 63.3 years, range 37-86) underwent hepatic resection. Triphasic approach consisted of: pre-operative bowel preparation with no supplementary fluids; intraoperative intravenous fluid restriction with low central venous pressure (<5 cmH2O) and continuous selective occlusion of the left or right portal structures and corresponding hepatic vein/s. The following variables were analysed: blood loss; transfusion requirements; perioperative renal function; perioperative morbidity and mortality. RESULTS: Median estimated blood loss was 330 mL (range 50-1200). No patient was transfused intraoperatively, with two patients transfused post-operatively. Median intraoperative urine output prior to hepatic re-perfusion was 28.4 mL/h (range 13.3-40.0) with no patient developing renal impairment. Morbidity occurred in 22% of patients with no documented hepatic failure. There was zero 30-day mortality. CONCLUSIONS: Pre-operative dehydration and intraoperative fluid restriction combined with continuous selective vascular occlusion minimizes blood loss during hepatic resection with no consequent detriment to renal function.     

Prognosis and postoperative lymphocyte count in patients with hepatocellular carcinoma who received intraoperative allogenic blood transfusion: A retrospective study

Aims

The effect of perioperative blood transfusion on the survival of hepatocellular carcinoma (HCC) has not been fully investigated. To clarify the prognostic value of intraoperative allogenic blood transfusion, we conducted a comparative retrospective analysis of 224 patients with HCC who underwent hepatic resection.

Methods

We compared clinicopathologic background and survival after hepatic resection between patients who received intraoperative blood transfusion (n = 101) and those who did not (n = 123).

Results

Patients with blood transfusion had a larger tumor and more frequent vascular invasion than those without blood transfusion. The 5-year cancer-related survival rate after hepatic resection, but not the disease-free survival rate, was significantly lower in patients who underwent blood transfusion than in those who did not (38.3% vs. 66.7%, P < 0.01). Multivariate analysis showed intraoperative blood transfusion (P = 0.02), microscopic portal invasion (P < 0.01), and preoperative serum alpha-fetoprotein elevation (P = 0.03) to be independent risk factors for poor outcome after hepatic resection. The negative effect of blood transfusion on postoperative survival was observed only in patients with a tumor larger than 50 mm in diameter. The absolute peripheral blood lymphocyte count on postoperative day 1 was significantly lower in patients who underwent blood transfusion (880/mm³) than in those who did not (1081/mm³) (P < 0.01).

Conclusions

Our data suggest that intraoperative blood transfusion results in immunosuppression in the early postoperative period, allowing for progression of residual HCC after resection. Therefore, intraoperative allogenic blood transfusion should be avoided in patients with resectable HCC, particularly in those with a large tumor.     

超选择性肾动脉栓塞联合经腹腹腔镜肾部分切除术在老年T1b期肾癌中的应用

目的:探讨DSA超选择性肾动脉栓塞联合经腹腹腔镜肾部分切除术治疗老年T1b期肾癌的安全性及可行性。方法:选择2016年1月至2018年1月于辽宁省肿瘤医院因罹患T1b期肾癌而行肾部分切除术的22例老年患者,进行回顾性研究。术前1~12 h先在介入手术室行DSA超选择性肾肿瘤靶动脉栓塞,然后再行经腹腹腔镜下零缺血肾部分切除术。对于术中手术时间、术中出血量、输血情况、术后胃肠道功能恢复所需时间、术后引流管拔除时间、术后并发症、术后住院时间、术后组织病理学指标等进行统计分析,并且术后进行随访统计肿瘤的复发和转移情况。结果:所有手术均成功完成,无中转改开放病例,无死亡病例,仅1例因肿瘤切除过程中出血较多,采用动脉夹暂时阻断肾动脉主干,阻断时间约为14 min。术中手术时间为（152.22±7.34） min,术中出血量为（102.27±66.82） ml,术后胃肠道功能恢复时间为（1.45±0.60） d,腹腔引流管拔除时间为（2.91±0.75） d,术后住院时间为（6.27±1.12） d,术后并发症发生率为9.09%,术中和术后输血率分别为4.54%和4.54%。所有患者均术后随访12~36个月,暂未发现肿瘤复发与转移。结论:超选择性肾动脉栓塞联合经腹腹腔镜肾部分切除术治疗老年T1b期肾癌安全、可行。     

骶骨肿瘤外科切除术中应用腹主动脉球囊导管低位阻断术的效果观察

目的:探讨骶骨肿瘤外科切除术中应用腹主动脉球囊导管低位阻断术的效果。方法:选取抚矿总医院骶骨肿瘤手术切除100例病例，随机等分为两组，术前分别给予A组球囊导管阻断术控制血流，B组动静脉置管麻醉，降低血压，观察术中出血量、输血量、手术时间，术中出血量与术后复发变化规律。结果:所选病例中A组术中出血量、术中输血量、手术时间均明显少于B组，有统计学意义（均P＜0.05）；术中出血量A组小于2 500 ml病例肿瘤复发率低于B组大于2 500 ml病例，两者比较有显著性差异(P＜0.05)。结论:腹主动脉球囊导管低位阻断术在骶骨肿瘤切除术中可以获得满意效果。     

Laparoscopic anatomic liver resection of segment 7 using a caudo-dorsal approach to the right hepatic vein

BackgroundLaparoscopic anatomic liver resection of segment 7 (S7) is technically challenging because of the posterosuperior location and the lack of clear anatomical landmarks [[1], [2], [3], [4]]. Here, we introduce a caudo-dorsal approach, which may offer a benefit for the difficult procedure.MethodsThe patient was a 53-year-old man with hepatocellular carcinoma located in S7 of the liver. After the transection of caudate process, the Glissonean pedicle of S7 (G7) extending from the right posterior Glissonean pedicle was identified on the liver dorsal side. The demarcation line was noted by isolating and clamping G7. The intraoperative ultrasound was then used to assess the extent of the tumor. The right hepatic vein was approached from the dorsal side and continuously exposed in a caudal-cranial direction along the anterior surface of inferior vena cava after isolating and cutting the venous branches draining S7. Following the dissection of G7, the liver parenchymal transection was proceeded along the ischemic line between segment 6 and 7 with the ventral cutting plane extended to join the dorsal one. The liver parenchyma of the ventral side of the exposed right hepatic vein (RHV) was further transected from the dorsal side toward the root side of RHV. The resection of S7 was completed with perihepatic ligaments dissection.ResultsThe intermittent Pringle maneuver (15 min occlusion and 5 min reperfusion) was applied when necessary with a total time of 45 min. The operation time was 200 min, the estimated blood loss was 300 ml, and no transfusion was required. Pathology confirmed moderately differentiated HCC with negative surgical margin. The patient was discharged on postoperative day 8 with no complications and has been followed up for 8 months without recurrence.ConclusionThis caudo-dorsal approach for laparoscopic anatomical S7 segmentectomy is easy and feasible when performed by experienced surgeons at experienced centers in well-selected patients