肝细胞癌半肝切除术后门静脉压力变化及其临床意义

Changes and clinical significance of portal vein pressure after hemihepatectomy for hepato⁃cellular carcinoma

目的探讨肝细胞癌(hepatocellular carcinoma,HCC)患者行半肝切除术后门静脉压力的变化情况及其影响因素,以及对肝再生和肝衰竭的影响。方法以2016—2020年于广西医科大学附属肿瘤医院行半肝切除术的125例HCC患者为研究对象,测算所有患者术前的残余肝脏体积(remnant liver volume,RLV)、脾脏体积(spleen volume,SV)及术后1周、5周、9周和13周增生后的RLV、SV等。采用多因素logistics回归分析影响患者术后1周肝静脉压力梯度(hepatic venous pressure gradient,HVPG)增高的因素,Pearson相关性分析术后1周HVPG增高值(ΔHVPG)与肝再生率的相关性,受试者工作特征(ROC)曲线分析ΔHVPG诊断术后肝功能衰竭(posthepatectomy liver failure,PHLF)的效能。结果125例HCC患者中PHLF 13例,死亡1例。术后1周、5周、9周、13周,HVPG较术前分别增加4.86 mmHg、2.30 mmHg、2.37 mmHg、2.35 mmHg(均P<0.05)。多因素分析显示切除的肝脏体积>820 cm^(3)(OR=4.424,95%CI:1.106-17.692,P=0.035),肝硬化(OR=84.843,95%CI:20.175-356.788,P<0.001)以及RLV<601 cm^(3)(OR=3.415,95%CI:1.183-14.271,P=0.029)是术后1周HVPG增高的危险因素。术后1周,ΔHVPG>4.86 mmHg组患者的肝再生率高于ΔHVPG≤4.86 mmHg组患者[(31.48±22.09)%vs(21.25±19.51)%,P=0.007],且肝再生率与ΔHVPG呈正相关(r=0.283,P=0.002)。术后1周,PHLF组的肝再生率高于无PHLF组[(42.6±21.1)%vs(22.3±18.5)%,P<0.001],ΔHVPG也高于无PHLF组[(7.02±1.44)mmHg vs(4.44±2.43)mmHg,P=0.001]。ROC曲线分析显示,当术后ΔHVPG截断值为5.83 mmHg时,其诊断PHLF的AUC为0.813(95%CI:0.729-0.892),敏感度为0.923,特异度为0.723。结论HCC患者行半肝切除术后1周HVPG增高明显,之后逐渐下降,其中切除的肝脏体积>820 cm^(3)、RLV<601 cm^(3)及肝硬化是术后1周HVPG增高的危险因素,且术后1周HVPG增高与肝再生和PHLF相关。

Objective To investigate the change of portal vein pressure in the patients with hepatocellular carcinoma(HCC)after hemihepatectomy and its influence on liver regeneration and liver failure.Methods A total of 125 patients with HCC who underwent hemihepatectomy in our hospital were enrolled.The preoperative residual liver volume(RLV),spleen volume(SV),and post⁃prolifera⁃tive RLV and SV at 1,5,9 and 13 weeks after surgery were calculated.The factors influencing the increase of postoperative hepatic ve⁃nous pressure gradient(HVPG)were analyzed by multivariable logistics regression analysis.The correlation between theΔHVPG and the rate of liver regeneration at 1 week after operation was analyzed by Pearson correlation analysis.The receiver operating characteristic(ROC)curve was used to analyze the efficacy ofΔHVPG in diagnosing posthepatectomy liver failure(PHLF).Results Among the 125 patients,PHLF occurred in 13 patients and 1 patients died.At 1,5,9 and 13 weeks after surgery,the HVPG increased by 4.86 mmHg,2.30 mmHg,2.37 mmHg,2.35 mmHg compared with preoperative(all P<0.05).Multivariable analysis showed that the volume of resected liver>820 cm^(3)(OR=4.424,95%CI:1.106-17.692,P=0.035),liver cirrhosis(OR=84.843,95%CI:20.175-356.788,P<0.001)andRLV<601cm^(3)(OR=3.415,95%CI:1.183-14.271,P=0.029)weretheriskfactorsfortheincrease of HVPG at the first week after surgery.The liver regeneration rate of the ΔHVPG>4.86 mmHg was higher than ΔHVPG≤4.86 mmHg group at the first week after surgery[(31.48±22.09)%vs(21.25±19.51)%,P=0.007],and the liver regeneration rate was positively correlated with ΔHVPG(r=0.283,P=0.002).At 1 week after surgery,the liver regeneration rate in the PHLF group was higher than that in the non⁃PHLF[(42.6±21.1)%vs(22.3±18.5)%,P<0.001],and ΔHVPG was also higher than that in the non⁃PHLF group[(7.02±1.44)mmHg vs(4.44±2.43)mmHg,P=0.001].The ROC curve analysis showed that when the cut⁃off value of postoperativeΔHVPG increase was 5.83 mmHg,the AUC for diagnosing postoperative PHLF was 0.813(95%CI:0.729-0.892),the sensitivity was 0.923,and the specificity was 0.723.Conclusions The HVPG increases significantly at 1 week after hemihepatectomy in HCC patients,and then gradually decreases.The resected liver volume>820 cm^(3),RLV<601 cm^(3) and liver cirrhosis are the risk factors for the increase of HVPG at 1 week after surgery,and the increase of HVPG at 1 week after surgery is associated with liver regeneration and PHLF.