原发性肝癌合并门静脉高压症的围术期处理和联合手术治疗

Perioperative management and combined operation for primary hepatic carcinoma complicated with portal hypertension

目的探讨原发性肝癌合并门静脉高压症联合手术治疗的围术期处理、可行性、适应证和手术方式。方法回顾性分析我院1996年1月至2010年12月期间32例联合手术治疗原发性肝癌合并门静脉高压症患者的临床资料。围术期处理包括术前纠正贫血、低蛋白血症和凝血功能异常、加强营养支持治疗、护肝治疗、胃肠道准备、术后适当限水限盐及利尿治疗等。20例行肝癌切除加脾切除术，12例行肝癌切除加脾切除及门奇断流术。结果①术后脾功能亢进症状消失。术后1周，白细胞、血小板分别由术前的3．32×10^9／L、42．52×10^9／L上升到9．53×10^9／L、332．04×10^9／L。②总胆红素（TBil）、天门冬氨酸氨基转移酶（AST）、丙氨酸氨基转移酶（ALT）于术后第1天明显升高，然后呈逐渐下降趋势，至术后2周，恢复至术前水平或大致正常水平。③术后共出现并发症9例（28．1％），死亡1例（3．1％），死于消化道大出血。其余并发症包括中等量腹水5例、左侧胸腔积液2例、右侧胸腔积液1例，均经综合治疗后康复出院。术后1、3、5年生存率分别为78．1％、43．7％、21．9％。随访中死亡20例，死亡原因：肝癌复发11例，肝功能衰竭8例，上消化道大出血1例。结论重视围术期处理，有选择性地对原发性肝癌合并门静脉高压症患者施行联合手术治疗是安全可行的。肝癌切除联合行脾切除或（和）门奇断流术效果好，并不增加术后严重并发症，并有利于肝功能恢复，预防远期上消化道出血。

Objective To investigate the perioperative management, operative indications and operation types of liver resection in combination with devaseularization （ combined operation） in primary hepatic carcinoma （PHC） patients complicated with portal hypertension. Methods From Jan. 1996 to Jan. 2007, clinical datas of 32 PHC patients complicated with portal hypertension treated with combined operation were analyzed retrospectively. Perioperative management included ：①correction of anemia, hypoproteinemia and coagulation dysfunction ;② nutrition support ; ③liver function support ; ④gastrointestihal preparation; ⑤diuretic therapy or controlling intake of fluid and sodium in the early postoperative period. Hepatectomy, combined with splenectomy or with spleneetomy plus devascularizasion were performed in 20 and 12 patients respectively. Results ①One week after operation, the white blood cell count （WBC） and blood platelet count （BPC） increased significantly from 3.32 × 109/L to 9.53 × 109/L and from 42.52 × 109/L to 332.04 × 109/L respectively, suggesting the disappearance of hypersplenism; ②liver function, as indicated by total bilirubin （TBIL）, aspartate aminotransferase （AST） and alanine aminotransferase （ALT） . improved significantly from the second day after operation, and returned to normal 2 weeks after operation; ③Operative complications were found in 9 cases （28.1% ） , including aseites in 5 cases, left pleural effusion in 2 cases, right pleural effusion in 1 case and upper gastrointestinal hemorrhage in 1 case. One patient died of upper gastrointestinal bleeding during hospitol- ization （3.1%）. The survival rates of 1, 3 and 5 years were 78.1% , 43.7% and 21.9%, respectively. Twenty patients died during follow - up. Among them. 11 cases died of cancer recurrence, 8 cases died of liver function failure, and 1 case died of upper gastrointestinal hemorrhage. Conclusions Through careful perioperative managements and sutable selections of operation type, the combined operation is safe and feasible for treatment of PHC patients with portal hypertension. The combined operation does not increase severe postoperative complications, and is helpful for the recovery of liver function and for the prevention of esophageal variceal bleeding.