巨大肝癌并肝硬化患者的围手术期处理

PERIOPERATIVE MANAGEMENT OF THE PATIENT WITH HUGE HEPATIC CANCER WITH CIRRHOSIS

74例巨大肝癌合并肝硬化患者实施半肝或肝左三叶切除,围手术期处理包括①纠正贫血和低蛋白血症及低氧血症,纠正水与电解质平衡失调;②手术前后肠外营养支持;③术前按结肠手术的要求准备肠道;④术中不阻断肝门血流;⑤术后适当限制水盐摄入量及利尿治疗。结果:71例半肝切除患者中,术前肝功A级58例,B级13例,术后1～2周评定肝功A级22例,B级30例,C级12例(其中1例于术后17天死于消化道出血);术后3～4周评定肝功A级43例,B级23例,C级4例,3例肝左三叶切除的术前肝功均为A级,但3例均于术后1个月内死于肝衰竭。表明在充分的围手术期处理下,绝大多数肝功能处于代偿期的肝癌合并肝硬化患者可以安全耐受半肝切除术,但不能耐受肝三叶切除手术。

The program of perioperative managements of the patient with hepatic cancr with cirrhosis included; (1) correction of anemia, hypoproteinemia, hypoxemia, and the disorders in fluid and electrolyte balance. (2) parenteral nutrition support. (3) preparing gut as the same as the operation on the colon. (4) blocking hepatic portal in the operative period not be used. (5) the mild dehydration was made by diuretic therapy or controlling the intake of fluid and sodium in the early postoperative period. All of 3 patients who received left trilobectomy, aelhough the preoperative liver function was in child's class A, died of hepatic failure within 30 dayes postoperatively. The preopecatine liver function of the remaining 71 patients who received hemihepatectomy was in child's class A in 55 and in B 13 cases respectively. But the liver function in class A, B and C was in 29, 30 and 12 cases (one of them died of gastreintinal heorrhage on the 17 day postoperatively) respectively 1 - 2 week after surgery, and in class A, B and C was in 43, 23 and 4 cases respectively 3-4 week after operation. These results indicated that if the patient who had a good peri-operative treatment aned compensatory liver function, who could undergo hemihepatectomy safely, but trilobectomy was very dangerous in the majority of the patients with liver cancer with cir- rhosis.