中心静脉压差值对腹腔镜肝细胞癌肝切除术中出血的影响

Effect of difference of central venous pressure on intraoperative blood loss in laparoscopic hepatectomy for hepatocellular carcinoma

目的:探讨腹腔镜肝细胞癌(肝癌)肝切除术中断肝前和断肝期间中心静脉压差值(ΔCVP)对术中出血量的影响。方法:回顾性分析2021年6月至2022年12月第九〇九医院行腹腔镜肝癌肝切除的57例患者临床资料。患者均签署知情同意书,符合医学伦理学规定。57例患者均采用控制性低中心静脉压技术(LCVP),计算断肝前和断肝期间ΔCVP。根据术中出血量中位数215 ml将57例患者分为A组(术中出血量≥215 ml,29例)和B组(术中出血量< 215 ml,28例),绘制ROC曲线分析ΔCVP对术中出血量的预测作用,Pearson线性分析ΔCVP与术中出血量的相关性,采用单因素和Logistic多因素分析术中出血量影响因素。结果:ROC曲线分析显示,ΔCVP对术中出血量预测的曲线下面积(AUC)0.867,约登指数最大值0.648,ΔCVP最佳界值5.5 cmH_(2)O(1 cmH_(2)O=0.098 kPa),敏感度0.786,特异度0.862,95%CI:0.765~0.969,P<0.05。Pearson相关性分析显示,ΔCVP与术中出血量成负相关(r=-0.781,P<0.05)。单因素分析显示,A组中ΔCVP<5.5 cmH_(2)O、肝硬化、脂肪肝、肿瘤直径≥10 cm、占位效应、困难部位肝癌的术中出血发生率明显高于B组(χ^(2)=24.097,6.908,5.179,5.695,5.221,8.211;P<0.05)。Logistic多因素分析显示,ΔCVP<5.5 cmH_(2)O、肝硬化、困难部位肝癌是腹腔镜肝切除术中出血的独立危险因素(OR=38.812,12.127,12.573;P<0.05)。结论:腹腔镜肝切除术中出血量与断肝前和断肝期间ΔCVP相关,通过评估切肝前CVP大小将切肝过程中CVP维持在合理水平,有助于降低术中出血量。

Objective To evaluate the effect of difference of central venous pressure(ΔCVP)before and during liver transection on intraoperative blood loss in laparoscopic hepatectomy for hepatocellular carcinoma(HCC).Methods Clinical data of 57 HCC patients who underwent laparoscopic hepatectomy in the No.909 Hospital from June 2021 to December 2022 were retrospectively analyzed.The informed consents of all patients were obtained and the local ethical committee approval was received.57 patients were treated with controlled low central venous pressure(LCVP),and theΔCVP before and during liver transection was calculated.According to the median intraoperative blood loss of 215 ml,57 patients were divided into group A(intraoperative blood loss of≥215 ml,n=29)and group B(intraoperative blood loss of<215 ml,n=28).The predictive effect ofΔCVP on intraoperative blood loss was assessed by the ROC curve.The correlation betweenΔCVP and intraoperative blood loss was determined by Pearson's linear analysis.The influencing factors of intraoperative blood loss were identified by univariate and multivariate Logistic regression analyses.Results ROC curve analysis showed that the area under the ROC curve(AUC)ofΔCVP for predicting intraoperative blood loss was 0.867.The maximum value of Youden's index was 0.648.The optimal threshold value ofΔCVP was 5.5 cmH_(2)O(1 cmH_(2)O=0.098 kPa).The sensitivity was 0.786 and the specificity was 0.862(95%CI:0.765-0.969,P<0.05).Pearson's correlation analysis indicated thatΔCVP was negatively correlated with intraoperative blood loss(r=-0.781,P<0.05).Univariate analysis showed that the incidence of intraoperative bleeding in patients withΔCVP<5.5 cmH_(2)O,liver cirrhosis,fatty liver,tumor diameter of≥10 cm,space-occupying effect and HCC at difficult sites in group A were significantly higher than those in group B(χ^(2)=24.097,6.908,5.179,5.695,5.221,8.211;P<0.05).Multivariate Logistic analysis showed thatΔCVP of<5.5 cmH_(2)O,liver cirrhosis and HCC at difficult sites were the independent risk factors for intraoperative bleeding of laparoscopic hepatectomy(OR=38.812,12.127,12.573;P<0.05).Conclusions The amount of blood loss during laparoscopic hepatectomy is correlated withΔCVP before and during liver transection.Maintaining CVP at a reasonable level during liver transection by evaluating the CVP before liver transection contributes to reducing the amount of blood loss during hepatectomy.