半肝阻断联合控制性低中心静脉压在肝切除中的应用

Application of Half Hepatic Block Combined with Low Central Venous Pressure Control in Liver Resection

目的探讨半肝阻断联合控制性低中心静脉压(LCVP)技术对肝切除术中的出血量及术后肝肾功能的影响。方法回顾性分析2013年6月至2015年12月西京医院肝胆外科行半肝阻断肝切除符合研究入组标准患者80例,并分为LCVP组[术中维持中心静脉压0~5 cm H_2O(1 cm H_2O=0.098 kPa)]40例和正常中心静脉压(NCVP)组(术中维持中心静脉压在6~12 cm H_2O)40例。比较两组手术时间、术中出血量、术中输血量、术后1、3、5 d肝功能及肾功能变化。结果两组手术时间比较差异无统计学意义(P>0.05);NCVP组出血量显著大于LCVP组[(1 225±674)mL比(304±181)mL,P<0.05];两组患者丙氨酸转氨酶(ALT)、天冬氨酸转氨酶(AST)及总胆红素(TBil)术后1 d升至最高,之后下降,到术后5 d(除ALT外),逐渐接近术前水平,ALT、AST及TBil组间、组间·时点间交互效应差异无统计学意义(P>0.05),两组时点间比较差异有统计学意义(P<0.05);而两组血清白蛋白(ALB)均从术后1 d明显下降,之后轻度降低,但LCVP组下降的幅度小于NCVP组,两组在组间、时点间比较差异有统计学意义(P<0.05),两组组间·时点间交互效应差异无统计学意义(P>0.05)。LCVP组术后各时间点BUN高于NCVP组,变化趋势为术后1 d轻度升高,然后逐步下降,两组在组间、时点间比较差异有统计学意义(P<0.05),两组在组间·时点间交互效应差异无统计学意义(P>0.05)。两组术后1、3、5 d血肌酐水平轻度下降,两组在时点间比较差异有统计学意义(P<0.05),两组在组间、组间·时点间交互效应差异无统计学意义(P>0.05)。结论两种切肝方法同样安全有效。LCVP组在控制术中出血和输血方面优于NCVP组,且对于术后肝功能恢复有积极作用。LCVP技术在肝切除术中有良好的应用价值,值得推广应用。

Objective To investigate the effects of half hepatic block combined with low central venous pressure（LCVP） control on blood loss in liver resection and evaluate its influence on hepatic and renal function. Methods Eighty patients undergoing hepatectomy from Jun. 2013 to Dec. 2015 in Xijing Hospital were divided into a LCVP group（40cases） and a normal central venous pressure group（NCVP group,40 cases）. The patients in the NCVP group maintained central venous pressure on 6-12 cm H2O,while LCVP group maintained 0-5 cm H2O of central venous pressure. The operation time,blood loss,blood transfusion and postoperative 1,3,5 d liver and renal function of the two groups were compared.Results The operative time had no significant difference between the two groups. The blood loss in the NCVP group was significantly more than that in the LCVP group[（1 225 ± 674） mL vs（304 ± 181） mL,P 〈 0. 05]. The values of alanine aminotransferase（ALT）,aspartate aminotransferase（AST） and tolal bilirubin（TBil） in the two groups were highest on the 1st day after operation,then decreased later and reached around the preoperative levels on the 5th day. There were no statistically significant differences between groups and groups·time point interaction effect（P 〉 0. 05）,while there were statistically significant differences between time points of the two groups（P 〈 0. 05）. ALB in the two groups had significantly decreased on the1 st day after operation,then slightly decreased later,while ALB in the LCVP group was less than that in the NCVP group.There were statistically significant differences between groups,time points（P 〈 0. 05）,no statistical significance on the interaction effect of groups·time point（P 〉 0. 05）. BUN in the LCVP group was higher than that in the NCVP group after operation,and increased slightly on the 1st day,then decline gradually. There were statistically significant differences between two groups,time points（P 〈 0. 05）,no statistical significance on the interaction effect of groups·time point（P 〉 0. 05）. Serum creatinine had slightly decreased on the 1st,3rd,5th day after operation in both groups,and there were statistically significant differences between time points of the two groups（P 〈 0. 05）,while there were no statistical significance between groups and groups·time point interaction effect（P 〉 0. 05）. Conclusion Both resection methods are safe and effective. LCVP group is superior to NCVP group in control of hemorrhage and blood transfusion during liver resection,and has positive effects on postoperative liver function recovery. LCVP has good application value in liver resection,therefore is worthy of popularization.