远隔缺血预处理联合控制性低中心静脉压在肝切除术中的应用

Application of remote ischemic preconditioning combined with controlled low central venous pressure in hepatectomy

目的评价远隔缺血预处理(RIPC)联合控制性低中心静脉压(CLCVP)在肝切除术中的应用效果。方法选取2021年5月—2022年4月择期在重庆医科大学附属永川医院行部分肝切除术患者80例,采用随机数表法分成对照组(C组)、CLCVP组(L组)、RIPC组(R组)、RIPC联合CLCVP组(RL组),每组20例。L组接受CLCVP干预,R组接受RIPC干预,RL组同时接受CLCVP和RIPC干预。比较患者术前第1天(D0)、术后第1天(D1)、术后第3天(D3)、术后第5天(D5)、术后第7天(D7)TNFα、ALT、AST、TBil和患者围术期一般情况。正态分布的计量资料组间比较采用单因素方差分析或重复测量方差分析,偏态分布的计量资料组间比较采用Kruskal-Wallis H检验;计数资料组间比较采用χ^(2)检验。结果RL组患者手术持续时间(H=14.278,P=0.015)、总输液量(H=24.175,P=0.001)、出血估计量(H=45.625,P<0.001)均低于R组。分组和时间因素对四组患者TNFα、ALT、AST均具有显著交互作用(P值分别为<0.001、0.010、0.012)。RL组患者D1的TNFα均低于L组(P值均<0.001)。RL组患者D1(P=0.008)、D7(P<0.001)ALT水平均低于L组。结论RIPC联合CLCVP技术能够有效减少肝切除术患者术中出血量,提供清晰手术视野和缩短手术时间;同时还能通过降低患者TNFα,抑制机体炎症反应,但不能有效减轻CLCVP技术下肝切除术后的肝缺血-再灌注损伤。

Objective To investigate the application effect of remote ischemic preconditioning(RIPC)combined with controlled low central venous pressure(CLCVP)in hepatectomy.Methods A total of 80 patients who underwent elective partial hepatectomy in Yougchuan Hospital Affiliated to Chongqing Medical University from May 2021 to April 2022 were enrolled and divided into control group(group C),CLCVP group(group L),RIPC group(group R),and RIPC+CLCVP group(group RL)using a random number table,with 20 patients in each group.The patients in group L received CLCVP,those in group R received RIPC,and those in group RL received both CLCVP and RIPC.The patients were compared in terms of perioperative general status and the levels of tumor necrosis factor-α(TNFα),alanine aminotransferase(ALT),aspartate aminotransferase(AST),and total bilirubin on preoperative day 1(D0),postoperative day 1(D1),postoperative day 3(D3),postoperative day 5(D5),and postoperative day 7(D7).A one-way analysis of variance or a repeated measures analysis of variance was used for comparison of normally distributed continuous data between groups,and the Kruskal-Wallis H test was used for comparison of continuous data with skewed distribution between groups;the chi-square test was used for comparison of categorical data.Results Compared with group R,group RL had a significantly shorter time of operation(H=14.278,P=0.015),a significantly lower total infusion volume(H=24.175,P=0.001),and a significantly lower estimated blood loss(H=45.625,P<0.001).Group and time factors had significant interaction effects on TNFα,ALT,and AST in the four groups(P<0.001;P=0.010;P=0.012).Group RL had a significantly lower level of TNFαthan group L on D1(P<0.001)and D3(P<0.001).Group RL had a significantly lower level of ALT than group L on D1(P=0.008)and D7(P<0.001).Conclusion For patients undergoing hepatectomy,RIPC combined with CLCVP can effectively reduce intraoperative blood loss,provide a clear surgical field,and shorten the time of operation;meanwhile,it can also inhibit inflammatory response by reducing TNFα,but it cannot effectively alleviate hepatic ischemia-reperfusion injury after hepatectomy under the context of CLCVP.