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  • 隋承军,张敏峰,戴炳华,沈伟峰,陆炯炯,杨甲梅.半肝血流完全阻断法在肝细胞癌肝切除术中的应用:前瞻性随机对照研究[J].第二军医大学学报,2016,37(10):1230-1238    [点击复制]
  • SUI Cheng-jun,ZHANG Min-feng,DAI Bing-hua,SHEN Wei-feng,LU Jiong-jiong,YANG Jia-mei.Total hemihepatic vascular exclusion versus Pringle maneuver in liver resection for hepatocellular carcinoma: a randomized controlled trial[J].Acad J Sec Mil Med Univ,2016,37(10):1230-1238   [点击复制]
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半肝血流完全阻断法在肝细胞癌肝切除术中的应用:前瞻性随机对照研究
隋承军,张敏峰,戴炳华,沈伟峰,陆炯炯,杨甲梅*
0
(第二军医大学东方肝胆外科医院特需治疗一科、肝移植科, 上海 200438
*通信作者)
摘要:
目的 评估半肝血流完全阻断法(THHVE)在肝细胞癌肝切除术中的应用价值及其对肿瘤复发、转移和患者生存期的影响。方法 2011年8月至2013年8月期间在我科住院拟行手术切除的肝癌患者中,选择符合标准的患者纳入本研究。将所有入选患者随机分为两组,THHVE组患者在肝切除术中采用THHVE法控制血流,Pringle组采用Pringle法控制血流。对两组患者的术中总出血量、断肝过程中出血量、输血率、手术时间、血流阻断时间、并发症发生率、死亡率、术后住院时间、术后肝功能指标、无瘤生存期和总生存期等进行比较。结果 剔除不符合纳入标准的患者,共有143例符合标准的患者纳入最终分析,THHVE组71例,Pringle组72例。与Pringle组相比较,THHVE组患者的术中总出血量[250.0(150.0~400.0)mL vs 350.0(200.0~637.5)mL,P<0.001]及断肝过程中出血量[100.0(50.0~200.0)mL vs 215.0(100.0~380.0)mL,P<0.001]均减少。THHVE组患者的血流阻断时间长于Pringle组[27.0(20.0~31.0)min vs 20.0(16.0~24.0)min,P<0.001],术后第1、第3、第7天的丙氨酸氨基转移酶水平低于Pringle组(P<0.05),术后第7天的总胆红素水平低于Pringle组(P=0.013)、血清前白蛋白高于Pringle组(P=0.038)。THHVE组并发症发生率低于Pringle组(21.1% vs 37.5%,P=0.032)。THHVE组患者的总生存期长于Pringle组(P=0.036),Cox比例风险回归模型多因素分析结果显示采用THHVE法是影响患者总生存期的独立因素之一,采用THHVE法的患者的死亡风险是采用Pringle法的47.6%。结论 THHVE法是肝癌肝切除术中一种安全、有效的血流控制方法,可减少术中出血、减轻术后肝功能损害、降低并发症发生率,较Pringle法明显延长了患者的总生存期。
关键词:  肝肿瘤  肝细胞癌  肝切除术  半肝血流阻断法  手术失血  存活率分析
DOI:10.16781/j.0258-879x.2016.10.1230
投稿时间:2016-05-23修订日期:2016-07-05
基金项目:上海市科委医学引导项目(134119a7000).
Total hemihepatic vascular exclusion versus Pringle maneuver in liver resection for hepatocellular carcinoma: a randomized controlled trial
SUI Cheng-jun,ZHANG Min-feng,DAI Bing-hua,SHEN Wei-feng,LU Jiong-jiong,YANG Jia-mei*
(Department of Special Medical Care Ⅰ and Liver Transplantation, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai 200438, China
*Corresponding author)
Abstract:
Objective To evaluate the clinical value of total hemihepatic vascular exclusion (THHVE) for liver resection in hepatocellular carcinoma (HCC) patients and its effect on tumor recurrence, metastasis and patient survival. Methods Consecutive patients who were scheduled for elective hepatic resection were screened and allocated randomly to THHVE and Pringle maneuver groups. The total intraoperative blood loss, blood loss during transection, blood transfusion rate, operation time, vascular clamping time, complication, mortality, postoperative hospital stay, postoperative liver function index, overall survival time and disease-free survival time were analyzed and compared between the two groups. Results From Aug. 2011 to Aug. 2013, 143 patients were eligible and were analyzed, with 71 in THHVE group and 72 in Pringle group. Baseline data were similar between the two groups. Total blood loss (250.0[150.0-400.0] mL vs 350.0[200.0-637.5] mL,P<0.001) and blood loss during hepatic transection (100.0[50.0-200.0] mL vs 215.0[100.0-380.0] mL,P<0.001) in the THHVE group were significantly less than those in the Pringle group. The vascular clamping time in THHVE group was significantly longer than that in Pringle group (27.0[20.0-31.0] min vs 20.0[16.0-24.0] min, P<0.001); the serum ALT levels (P<0.05) on postoperative day 1, 3, 7 and the serum total bilirubin levels (P=0.013) on postoperative day 7 in the THHVE group were significantly lower than those in the Pringle group, and the serum pre-albumin level was significantly higher in the THHVE group than that in the Pringle group on postoperative day 7 (P=0.038). The incidence rate of postoperative complication in THHVE group was significantly lower than that in Pringle group (21.1% vs 37.5%,P=0.032). The overall survival time in THHVE group was significantly longer than that in Pringle group (P=0.036). Multivariate analysis by the Cox proportional hazard regression model showed that THHVE was one of the independent factors affecting overall survival, and the death risk of the patients in THHVE group was 47.6% that of the patients in Pringle group. Conclusion THHVE is a safe and effective method in liver resection for patients with HCC, and the method is associated with less intraoperative bleeding, better postoperative liver function recovery, lower incidence rate of complication and better overall survival compared with Pringle maneuver.
Key words:  liver neoplasms  hepatocellular carcinoma  hepatectomy  hemihepatic vascular exclusion  blood loss  survival analysis