持久美蓝染色法辅助精准解剖性肝切除术的临床应用

Application of lasting methylene blue staining and three-dimensional reconstruction in precise anatomic hepatectomy for patients with liver cancer

目的探讨持久美蓝染色联合三维重建法精准解剖性肝切除术在肝癌患者中的应用价值。方法收集2015年1月至2017年12月解放军联勤保障部队第901医院收治的134例肝癌患者临床资料,术前均行三期增强CT或MRI检查,采用MeVis软件完成门静脉、肝动脉、肝静脉三维重建。其中54例行持久美蓝染色联合精准解剖性肝切除(联合组,穿刺肝蒂门静脉注入美蓝,每个肝段用量为4ml左右),80例仅行精准解剖性肝切除术(对照组)。比较两组患者的围手术期指标、肿瘤切缘以及术后1、3、5d肝功能恢复情况。Kaplan-Meier法计算术后1年累积生存率。结果联合组53例(98.15%)术中肝脏染色与肝血管成像一致。与对照组相比,联合组手术时间更长,术中出血量更少,差异有统计学意义(t=7.424、2.923,P=0.009、0.023);两组肝门阻断时间比较差异无统计学意义(t=0.317,P=0.261)。术后联合组并发症发生率为18.52%(10/54),对照组为17.50%(14/80),两组比较差异无统计学意义(χ^2=0.016,P=0.900)。两组患者肿瘤切缘均为阴性。联合组和对照组患者术后平均住院时间比较差异无统计学意义[(7.45±3.17)dvs(6.64±4.36)d,t=1.172,P=0.331]。联合组术后前2天腹腔引流量少于对照组,差异有统计学意义(t=5.382、4.944,P=0.015、0.033)。对照组术后第1、3天血清丙氨酸氨基转移酶、总胆红素值明显高于联合组,术后1、3、5d白蛋白明显低于联合组,差异均有统计学意义(P<0.05)。两组患者术后1年累积生存率比较,差异无统计学意义(90%vs89%,P=0.806)。结论持久美蓝染色联合三维重建精准解剖性肝切除术有助于降低术中出血量,最大限度保留正常肝实质,同时不会增加并发症发生率及肿瘤残留概率。

Objective To investigate the application value of lasting methylene blue staining and three-dimensional reconstruction in precise anatomic hepatectomy for patients with liver cancer.Methods From January 2015 to December 2017,one hundred and thirty-four patients with liver cancer in the 901st Hospital of the Joint Logistics Support Force of the Chinese People's Liberation Army were enrolled.Threephase enhanced CT or MRI were performed before operation,and three-dimensional reconstruction of portal vein,hepatic artery and hepatic vein was completed by MeVis software.Fifty-four patients underwent lasting methylene blue staining combined with precise anatomical hepatectomy (combined group,dosage of methylene blue was 4 ml per hepatic segment),and 80 patients underwent precise anatomical hepatectomy alone (control group).The perioperative indicators and 1-year cumulative survival rate were compared between the two groups after follow-up until December 2018.Results In the combined group,53 cases (98.15%) had the same intraoperative liver staining as hepatic angiography.Compared with the control group, patients of the combined group had longer operation time and less bleeding during operation (t=7.424,2.923;P=0.009,0.023).There were no significant differences in the time of hepatic hilar occlusion,incidence of complications between the two groups (t=0.317,P=0.261;18.52% vs 17.50%,χ^2=0.016,P=0.900).Tumor margins were negative in both groups.There was no significant difference in the average hospitalization time between the combined group and the control group [(7.45±3.17) d vs (6.64±4.36) d,t=1.172,P=0.331].The abdominal drainage volume in the combined group was less than that in the control group two days before operation,and the difference was significant (t=5.382,4.944;P=0.015,0.033).Compared with the combined group,the serum alanine aminotransferase and total bilirubin levels in the control group were significantly higher on the 1st,3rd day after operation,while the albumin levels were significantly lower on the 1st,3rd and 5th day after operation (all P<0.05).There was no significant difference in 1-year cumulative survival rate between the two groups (90% vs 89%,P=0.806).Conclusion The lasting methylene blue staining can improve the accuracy of anatomic hepatectomy and reduce the intraoperative blood loss,which is conductive to making clear the liver segmental boundaries and improving the accuracy of operative section selection.