肝细胞癌肝切除术后出血的防治

Prevention and treatment of hemorrhage after hepatectomy for hepatocellular carcinoma

目的探讨肝细胞癌(肝癌)患者肝切除术后出血的防治方法。方法回顾性分析2010年12月至2016年12月在佛山市第一人民医院接受肝切除术且术后出血的10例肝癌患者临床资料。其中男8例,女2例;年龄42~68岁,中位年龄48岁。接受腹腔镜肝中叶部分肝段切除术5例,开腹右半肝切除术2例,腹腔镜肝Ⅴ、Ⅷ段及部分Ⅳ段切除术1例,腹腔镜左半肝切除术2例。患者均签署知情同意书,符合医学伦理学规定。分析术后出血的原因及其治疗方法。结果术后48 h内出血9例。其中5例为肝创面出血,1例肝短静脉出血,1例肝右静脉出血,1例肝静脉出血,1例胆囊动脉出血,患者均经手术探查后找到出血点,予以确切缝扎止血。1例术后10余天突发出血,该患者为胃右动脉根部出血,无法行栓塞止血,经手术探查,修补肝总动脉出血点及肝创面胆漏处。所有患者随访两个月无再次出血或其他并发症发生。结论肝癌肝切除术后出血重在预防,术前行严格评估、术中精细且规范操作、术后严密观察和及时的外科干预可降低术后死亡率。

Objective To investigate the prevention and treatment of hemorrhage after hepatectomy for patients with hepatocellular carcinoma （HCC）. Methods Clinical data of 10 HCC patients with hemorrhage after hepatectomy in the First People＇s Hospital of Foshan between December 2010 and December 2016 were retrospectively analyzed. Among them, 8 cases were males and 2 were females, aged 42-68 years old with a median age of 48 years old. Laparoscopic resection of patial segment of the middle lobe was performed on 5 cases, open right hemihepatectomy on 2, laparoscopic resection of segments V, and patial segments 1V on 1, and laparoscopic left hemihepatectomy on 2. The informed consents of all patients were obtained and the local ethical committee approval was received. The causes and treatment of postoperative hemorrhage were analyzed. Results Hemorrhage within postoperative 48 h was observed in 9 cases, including 5 cases with the liver wound surface hemorrhage, 1 with short hepatic vein hemorrhage, 1 with right hepatic vein hemorrhage, 1 with hepatic vein hemorrhage and 1 with gallbladder artery hemorrhage. The hemorrhagic spots were all found after exploratory surgery and were definitely sutured for hemostasis. One case suddenly suffered from hemorrhage over 10 d after surgery. The patients could not undergo embolization due to hemorrhage at the root of right gastric artery, thus surgical exploration was performed and the hemorrhagic spots at the common hepatic artery and bile leakage on the liver wound surface were repaired. No rebleeding or other complications were observed during 2 months follow-up.Conclusions Prevention is the emphasis for hemorrhage after hepatectomy for HCC. Strict preoperative evaluation, precise and standard intraoperative operation, intimate postoperative observation and timely surgical intervention can decrease postoperative mortality.