压力控制容量保证通气模式在腹腔镜肝细胞癌切除术中的应用

Application of pressure-controlled ventilation volume-guaranteed mode in laparoscopic hepatectomy for hepatocellular carcinoma

目的探讨压力控制容量保证通气(PCV-VG)模式在腹腔镜肝细胞癌(肝癌)切除术中的应用价值。方法本前瞻性研究对象为2021年1月至2021年12月解放军联勤保障部队第九〇九医院收治的75例行腹腔镜肝癌切除术患者。其中男46例,女29例;年龄33~69岁,中位年龄50岁。患者均签署知情同意书,符合医学伦理学规定。采用随机数字表法将75例患者分为容量控制通气(VCV)组、压力控制通气(PCV)组、PCV-VG组,每组25例。比较3组切肝开始前(T_(1))、切肝开始后10 min(T_(2))、切肝结束后10 min(T3)的平均动脉压(MAP)、中心静脉压(CVP)、心率、气道平均压力(P_(mean))、气道峰值压力(P_(peak))、动态肺顺应性(Cdyn),以及术后并发症发生率等指标。多组间比较采用单因素方差分析,两两比较采用LSD-t检验。率的比较采用χ2检验或Fisher确切概率法。结果VCV组、PCV组、PCV-VG组T_(2)的平均CVP分别为(3.5±0.6)、(3.0±0.6)、(2.6±0.5)cmH2O(1 cmH2O=0.098 kPa),PCV-VG组明显低于VCV组和PCV组(LSD-t=-18.452,-8.945;P<0.05)。3组T_(2)时P_(mean)和P_(peak)分别为(10.7±1.9)、(9.5±1.7)、(8.4±1.7)cmH2O和(23.6±1.5)、(20.65±2.2)、(18.5±2.3)cmH2O,PCV-VG组明显低于VCV组和PCV组(LSD-t=-21.245,-13.180和-27.521,-11.088;P<0.05)。3组T_(2)时Cdyn分别为(25±7)、(26±5)、(29±6)ml/cmH2O,PCV-VG组明显高于VCV组和PCV组(LSD-t=28.646,13.038;P<0.05)。3组手术时间、术中出血量、肝门阻断时间、切肝用时分别为(196±37)、(190±46)、(170±40)min,(164±27)、(152±34)、(137±39)ml,(20±5)、(17±5)、(16±4)min,(40±13)、(37±15)、(31±10)min,PCV-VG组明显低于VCV组和PCV组(LSD-t=-21.452,-37.192,-13.452,-17.457和-15.614,-18.514,-6.087,-11.551;P<0.05)。3组术后并发症发生率比较差异无统计学意义(P>0.05)。结论腹腔镜肝癌切除术中采用PCV-VG通气模式可降低气道压和改善肺顺应性,将术中CVP控制在较低水平可减少术中出血量和手术时间,且不增加术后并发症发生率。

Objective To evaluate the application value of pressure-controlled ventilation volume-guaranteed(PCV-VG)mode in laparoscopic hepatectomy for hepatocellular carcinoma(HCC).Methods 75 HCC patients who underwent laparoscopic hepatectomy in the 909th Hospital of Joint Logistics Support Force of PLA from January 2021 to December 2021 were enrolled in this prospective study.Among them,46 patients were male and 29 female,aged from 33 to 69 years,with a median age of 50 years.The informed consents of all patients were obtained and the local ethical committee approval was received.75 patients were randomly divided into the volume-controlled ventilation(VCV)group,pressure-controlled ventilation(PCV)group and PCV-VG group,with 25 patients in each group.The mean arterial pressure(MAP),central venous pressure(CVP),heart rate,mean airway pressure(P_(mean)),peak airway pressure(P_(peak)),dynamic lung compliance(Cdyn)before liver resection(T_(1)),10 min after the beginning of liver resection(T_(2))and 10 min after liver resection(T3)and the incidence of postoperative complications were compared among three groups.Multi-group comparison was performed by one-way ANOVA.Two-group comparison was conducted by LSD-t test.The rate comparison was carried out by Chi-square test or Fisher's exact probability test.Results The mean CVP at T_(2) in the VCV,PCV and PCV-VG groups was(3.5±0.6),(3.0±0.6)and(2.6±0.5)cmH2O(1 cmH2O=0.098 kPa),respectively.The mean CVP in the PCV-VG group was significantly lower than those in the VCV and PCV groups(LSD-t=-18.452,-8.945;P<0.05).At T_(2),P_(mean)and P_(peak)in three groups were(10.7±1.9),(9.5±1.7)and(8.4±1.7)cmH2O,and(23.6±1.5),(20.65±2.2)and(18.5±2.3)cmH2O,respectively.The P_(mean)and P_(peak)in the PCV-VG group were significantly lower than those in the VCV and PCV groups(LSD-t=-21.245,-13.180 and-27.521,-11.088;P<0.05).The Cdyn at T_(2) in three groups were(25±7),(26±5)and(29±6)ml/cmH2O,respectively.The Cdyn in the PCV-VG group was significantly higher than those in the VCV and PCV groups(LSD-t=28.646,13.038;P<0.05).The operation time,intraoperative blood loss,hepatic portal occlusion time and liver resection time in three groups were(196±37),(190±46)and(170±40)min,(164±27),(152±34)and(137±39)ml,(20±5),(17±5)and(16±4)min,and(40±13),(37±15)and(31±10)min,respectively.The values in the PCV-VG group were significantly lower than those in the VCV and PCV groups(LSD-t=-21.452,-37.192,-13.452,-17.457 and-15.614,-18.514,-6.087,-11.551;P<0.05).No significant difference was observed in the incidence of postoperative complications among three groups(P>0.05).Conclusions PCV-VG mode can lower airway pressure and improve lung compliance during laparoscopic hepatectomy for HCC.Intraoperative controlling CVP at a low level can reduce intraoperative blood loss and shorten operation time without increasing the incidence of postoperative complications.