肝细胞癌切除术中区域血流预阻断与区域血流阻断的疗效对比初探

Initial comparison of regional ischemic preconditioning and hemi-hepatic vascular inflow occlusion in resection of hepatocellular carcinoma

目的：初步比较区域血流预阻断法（ RIP）与区域血流阻断法（ HHV）应用于肝细胞癌切除术的疗效。方法将行开腹手术的54例肝右叶肝细胞癌患者分为RIP组（15例）和HHV组（39例）。 RIP组患者切肝前预先阻断右肝动脉及门静脉右支5 min，继之恢复血流5 min，再一次性持续阻断右侧入肝血流后切肝，保留健侧血供。 HHV组仅缺少预先阻断5 min和恢复血流5 min步骤。比较两组患者的临床疗效。结果 RIP组患者的中位术中出血量为300 ml，明显少于HHV组（400 ml，P＝0．039）。 RIP组术后仅有1例（6．7％）患者输血，明显少于HHV组[17例（43．6％），P＝0．010]。两组术后30 d内均无死亡病例。两组患者术后住院时间、术后肝功能不全、术后大量腹水、术后感染、胸腔积液、心肺并发症、术后肠道通气时间的差异均无统计学意义（均P＞0．05）。术后第3天和第5天，RIP组患者的凝血酶原时间活动度均高于HHV组（均P＜0．05），但两组患者术后丙氨酸氨基转移酶、天冬氨酸氨基转移酶、总胆红素、白蛋白、前白蛋白的差异均无统计学意义（均P＞0．05）。术后1周内，RIP组有5例（33．3％）患者丙氨酸氨基转移酶恢复正常，明显高于HHV组[1例（2．7％），P＝0．006]。结论 RIP在控制肝癌术中出血、减少术后输血及加快肝功能早期恢复方面较HHV可能更优。

Objective To evaluate preliminarily the clinical efficacy of two types of hepatic inflow occlusion in hepatectomy for hepatocellular carcinoma （ HCC） .Methods A total of 54 patients with HCC who underwent hepatectomy were divided into two groups：RIP group （ regional ischemic preconditioning with continuous clamping,n=15） and HHV group（hemi-hepatic vascular inflow occlusion, n=39）.HHV was performed by placing a clamp on the right hepatic artery and right portal vein, and was maintained until the liver resection was completed.In the RIP group, HHV was preceded by a 5-min period of ischemia followed by 5 min of reperfusion.The clinical indicators of the two groups were compared.Results The volume of intraoperative blood loss had significant difference between the two groups （P=0.039）.One case （6.7%） in the RIP group and 17 cases （ 43.6%） in the HHV group received postoperative blood transfusion, showing a significant difference （P=0.010）.No postoperative 30-day mortality happened in all patients. No significant differences were found between the two groups in hospital stay or postoperative morbidity, including hepatic insufficiency, infection, ascites, pleural effusion, cardiopulmonary complications and intestinal ventilation time （ P 〉0.05 for all）.The RIP group had a significantly higher PTA level at postoperative days 3 and 5 （P〈0.001）.Although no significant differences were found between the two groups regarding total bilirubin, albumin, prealbumin and aminotransferase （ P 〉0.05 ） during any postoperative stage, the ALT recovered to normal level in 5 patients （33.3%） of the RIP group and only in one case （2.7%） of the HHV group, with a significant difference between the two groups （P=0.006）. Conclusion The results of this study indicate that regional ischemic preconditioning may have better hemostatic effect on hepatectomy, can reduce postoperative blood transfusion and promote early recovery of liver function than hemi-hepatic vascular inflow occlusion.