肝下下腔静脉部分阻断在肝切除术中的应用价值

Application value of partial occlusion of the inferior vena cava in hepatectomy

目的探讨肝下下腔静脉部分阻断在肝切除术中的应用价值。方法回顾性研究2012年9月至2014年9月在华中科技大学同济医学院附属同济医院接受肝切除术的100例患者临床资料。患者均签署知情同意书,符合医学伦理学规定。根据出血控制方式不同将患者分为肝下下腔静脉全阻断组(全阻断组)、肝下下腔静脉部分阻断组(部分阻断组)和肝下下腔静脉未阻断组(未阻断组)。全阻断组28例,男24例,女4例;平均年龄(68±9)岁;行第一肝门联合肝下下腔静脉全阻断。部分阻断组24例,男21例,女3例;年龄(70±10)岁;行第一肝门联合肝下下腔静脉2/3阻断。未阻断组48例,男41例,女7例;年龄(67±11)岁;仅行第一肝门阻断。观察3组患者围手术期情况,包括术中出血量及输血情况、术中及术后并发症等。患者围手术期情况比较采用单因素方差分析和LSD-t检验或t检验,率的比较采用χ~2检验或Fisher确切概率法。结果全阻断组、部分阻断组术中出血量分别为(388±183)、(406±178)ml,明显低于未阻断组的(797±378)ml(LSD-t=-2.648,-2.109;P<0.05)。全阻断组、部分阻断组中输血患者分别为2、1例,明显少于未阻断组的12例(χ~2=3.752,7.328;P<0.05)。全阻断组和部分阻断组肝下下腔静脉阻断后中心静脉压分别为(3.2±1.8)、(3.6±1.4)cm H_2O(1 cm H_2O=0.098 k Pa),明显低于阻断前的(11.2±2.3)、(11.3±2.1)cm H_2O(LSD-t=-2.341,-1.927;P<0.05)。全阻断组肝下下腔静脉阻断后出现低血压2例,另外两组均未见术中血压明显波动,差异有统计学意义(P<0.05)。全阻断组、部分阻断组、未阻断组术后并发症发生率分别为29%(8/28)、29%(7/24)、31%(15/48),差异无统计学意义(χ~2=0.720,P>0.05)。3组患者术中、术后均无发生死亡及严重并发症。结论肝切除术中采用肝下下腔静脉部分阻断控制出血可以达到与全阻断相同的效果,且具有维持血流动力学稳定优势,是一种安全有效的出血控制方法。

Objective To investigate the application value of partial occlusion of the inferior vena cava in hepatectomy. Methods Clinical data of 100 patients who underwent hepatectomy in Tongji Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology from September 2012 to September 2014 were retrospectively analyzed. The informed consents of all patients were obtained and the local ethical committee approval was received. According to the different control method of blood loss, the patients were divided into three groups： the total occlusion of the inferior vena cava group （total occlusion group, n=28）, the partial occlusion of the inferior vena cava group （partial occlusion group, n=24） and the non-occlusion of the inferior vena cava group （non-occlusion group, n=48）. In the total occlusion group, 24 cases were males and 4 were females, aged （68±9） years old on average, and total occlusion of porta hepatis combined with inferior vena cava was performed. In the partial occlusion group, 21 were males and 3 were females, aged （70±10） years old, and partial occlusion of porta hepatis combined with 2/3 of the inferior vena cava was performed. In the non-occlusion group, 41 were males and 7 were females, aged （67±11） years old, and only porta hepatis occlusion was performed. The perioperative conditions including intraoperative blood loss, blood transfusion, intra- and post-operative complications were observed. The perioperative conditions were compared by one-way analysis of variance and LSD-t test or t test. The rates were compared by Chi-square test or Fisher＇s exact probability test. Results The intraoperative blood loss in the total and partial occlusion groups was respectively （388±183） and （406±178） ml, signifcantly less than （797±378） ml in the non-occlusion group （LSD-t=-2.648, -2.109; P〈0.05）. The number of blood transfusion in the total and partial occlusion group was respectively 2 and 1, significantly less than 12 in the non-occlusion group （χ2=3.752, 7.328; P〈0.05）. The central venous pressure after occlusion of inferior vena cava in the total and partial occlusion group was respectively （3.2±1.8） and （3.6±1.4） cmH2O （1 cmH2O=0.098 kPa）, signifcantly lower than （11.2±2.3） and （11.3±2.1） cmH2O before surgery （LSD-t=-2.341, -1.927; P〈0.05）. Two cases of hypotension were observed in the total occlusion group after occlusion of inferior vena cava, whereas no evident pressure fuctuation was observed in the partial- and non-occlusion group, and signifcant differences were observed （P〈0.05）. The incidence of postoperative complications in the total-, partial- and non-occlusion group was respectively 29% （8/28）, 29% （7/24） and 31% （15/48）, and no signifcant difference was observed （χ^2=0.720, P〉0.05）. No death or severe complications were observed in three groups during and after surgery. Conclusions Partial occlusion of the inferior vena cava can not only achieve similar clinical effcacy as the total occlusion, but also has the advantage of maintaining the hemodynamic stability. It is a safe and effcacious method for blood loss control.