老年肝癌合并肝硬化患者围手术期不同液体管理在腹腔镜肝切除术中的对比研究

目的探究围手术期不同液体管理在老年肝癌合并肝硬化患者行腹腔镜肝切除术中的应用效果及其对血流动力学和免疫应激的影响。 方法前瞻性选取2019年6月至2021年5月上海市宝山区中西医结合医院收治的86例行腹腔镜肝切除术的老年肝癌合并肝硬化患者，采用随机数字表法分为控制性低中心静脉压（CLCVP）组和目标导向液体治疗（GDFT组），每组43例；CLCVP组术中以CLCVP为指导进行液体输注，GDFT组术中以每搏量变异度（SVV）为指导进行GDFT。观察两组围手术期指标及术后并发症；检测麻醉诱导前（T1）、肝切除前5 min（T2）、肝切除后5 min（T3）及手术结束时（T4）两组血流动力学及血气指标；观察两组手术前后应激指标和细胞免疫指标变化。 结果GDFT组术中出血量、肝血流阻断时间、胃肠功能恢复时间及住院时间优于CLCVP组（t=2.044、2.229、3.637、2.410，均P<0.05）。两组术后并发症发生率差异无统计学意义（30.2% vs 20.9%，χ²=0.943，P=0.331）。GDFT组心脏指数（CI）在T3、T4时均明显高于CLCVP组（P<0.05）；T3时中心静脉压（CVP）高于CLCVP组，T4时低于CLCVP组（均P<0.05）；中心静脉血氧饱和度（ScvO₂）在T3、T4时均高于CLCVP组（均P<0.05）；乳酸在T4时低于CLCVP组（P<0.05）。术后3、7 d时，GDFT组应激指标Cor、IL-6、TNF-α水平均低于CLCVP组，差异有统计学意义（P<0.05）。术后7 d时，GDFT组免疫指标CD4+、CD8+、CD4+/CD8+水平均高于CLCVP组（P<0.05）。 结论老年肝癌合并肝硬化患者腹腔镜肝切除围手术期采用以SVV为指导的GDFT管理，能够稳定术中血流动力学，改善机体免疫应激，减少术中出血和肝血流阻断时间。

Comparative study of perioperative fluid management in elderly patients with hepatocellular carcinoma complicated with cirrhosis in laparoscopic hepatectomy

ObjectiveTo investigate the effect of different perioperative fluid management in laparoscopic hepatectomy in elderly patients with hepatocellular carcinoma complicated with cirrhosis and its effect on hemodynamics and immune stress. MethodsA total of 86 elderly patients with hepatocellular carcinoma complicated with cirrhosis who underwent hepatectomy were prospectively selected from Shanghai Baoshan District Hospital of Integrated Traditional Chinese Medicine and Western Medicine from June 2019 to May 2021. The patients were divided into controlled lower central venous pressure (CLCVP) group and goal-directed fluid therapy (GDFT) group by random number table method, with 43 cases in each group. Intraoperative fluid infusion was performed in the CLCVP group guided by CLCVP, and GDFT guided by SVV was performed in the GDFT group . The perioperative indexes and postoperative complications were observed. Hemodynamics and blood gas indexes of the two groups were detected before anesthesia induction (T1), 5 min before hepatectomy (T2), 5 min after hepatectomy (T3) and at the end of surgery (T4). The changes of stress index and cellular immunity index before and after operation were observed. ResultsIntraoperative blood loss, hepatic blood flow occlusion time, gastrointestinal function recovery time and hospital stay in GDFT group were significantly better than CLCVP group (t=2.044, 2.229, 3.637, 2.410, all P<0.05). There was no significant difference in the incidence of postoperative complications between the two groups (30.2% vs 20.9%, χ²=0.943, P=0.331). The cardiac index (CI) in GDFT group was significantly higher than that in CLCVP group at T3 and T4 (P<0.05). The central venous pressure (CVP) at T3 was higher than that in CLCVP group (P<0.05), and at T4 was lower than that in CLCVP group (P<0.05). Central venous oxygen saturation (ScvO₂) at T3 and T4 was higher than that in CLCVP group (P<0.05). Lactic acid at T4 was lower than that in CLCVP group (P<0.05). The levels of Cor, IL-6 and TNF-α in GDFT group were lower than those in CLCVP group at 3 d and 7 d after surgery (P<0.05). The levels of CD4+, CD8+ and CD4+/CD8+ in GDFT group were higher than those in CLCVP group at 7 d after surgery (P<0.05). ConclusionGDFT guided by SVV can stabilize intraoperative hemodynamics, improve immune stress, reduce intraoperative bleeding and hepatic blood flow blocking time, and is more conducive to postoperative recovery of elderly patients with liver carcinoma complicated with cirrhosis during hepatectomy.