不同肝门阻断方法在肝部分切除术中的应用

发布时间：2018-05-24 13:00

本文选题：肝脏肿物 + 持续性第一肝门阻断法　；参考：《河北医科大学》2016年硕士论文

【摘要】：目的:探讨四种不同入肝血流阻断法在肝部分切除术中对术中出血量及术后肝功能的影响,进而合理选择肝门阻断方法。方法:回顾性分析河北医科大学第四医院肝胆外科2014年1月至2016年1月收治的80例肝脏肿物患者的临床资料。根据不同的入肝血流肝门阻断方法将患者分为四组。持续性第一肝门血流阻断组为A组(n=30):完全阻断第一肝门,直至将肝脏肿瘤完整切除,但不超过20min。间歇性第一肝门血流阻断组为B组(n=30):将第一肝门血流阻断10min后恢复入肝血流5min,循环往复至肿瘤完整切除。半肝入肝血流阻断组为C组(n=10):术中解剖肝十二指肠韧带及肝门部,分离出肝固有动脉、左右肝动脉、门静脉主干及其左右枝,采用病变所在半肝入肝血流持续性阻断,健侧半肝血流通畅的方法直至肝部分切除术顺利完成。缺血预处理组为D组(n=10):肝部分切除手术前先阻断入肝血流1-5min,恢复入肝血流5min,然后持续性阻断第一肝门15min,间隔5min,循环往复直至肝部分切除术完成。比较四种不同肝门血流阻断法患者的性别、年龄、肿瘤大小、手术前后肝功能(谷丙转氨酶ALT,谷草转氨酶AST,总胆红素TB及白蛋白ALB)变化、术中出血量(ml)、平均阻断时间(min)等。结果:四组患者在性别、年龄、术前肝功能(ALT、AST、TB、ALB)、肿瘤大小、是否存在乙肝病史、平均阻断时间等方面均无统计学差异(P0.05)。C组出血量最少,B组出血量最多,B组与其他三组相比出血量明显增多(P0.05)。四组患者术后ALT、AST、TB数值的比较:ALT:A组与B组比较,第1、3天A组比B组明显增高(P0.05);A组与C组比较,第1、3、5、7天A组比C组明显增高(P0.05);A组与D组比较,第1、3、5、7天均无统计学差异(P0.05);B组与C组比较,第3天B组比C组明显增高(P0.05);B组与D组比较,第1天B组较D组明显降低(P0.05);C组与D组比较,第1、3天C组较D组明显降低(P0.05)。AST的变化与ALT相同。TB:A组与B、C组比较,第1、3天A组比B组、C组明显增高(P0.05);A组与D组比较,第1、3、5天A组比D组明显增高(P0.05);B组与C组比较,第3、5天B组比C组明显增高(P0.05);B组与D组比较,第1天B组较D组明显降低(P0.05),第5、7天B组比D组明显增高(P0.05);C与D组比较,第1、3天C组较D组明显降低(P0.05)。结论:1、肝部分切除术的患者术后肝功能的恢复与肝门阻断方法的选择有密切的关系。2、不同的肝门阻断方法中,半肝入肝血流阻断法对患者术后肝功能的影响最小,持续性肝门阻断法对患者术后肝功能的影响最大。3、间歇性第一肝门阻断法要优于预处理组,但预处理组后期的肝功能恢复较间歇性第一肝门阻断法快。4、间歇性第一肝门阻断组出血量明显多于其他组出血量。
[Abstract]:Objective: to investigate the effects of four different hepatic flow occlusion methods on intraoperative blood loss and liver function during partial hepatectomy, and to select a reasonable method of hepatic portal occlusion. Methods: the clinical data of 80 patients with hepatic tumor admitted from January 2014 to January 2016 in the fourth Hospital of Hebei Medical University were retrospectively analyzed. Patients were divided into four groups according to different hepatic portal occlusion methods. In group A, the first hepatic hilus was completely blocked until the tumor was removed completely, but not more than 20 min. The first hepatic portal blood flow occlusion group was group B: the first hepatic portal blood flow was blocked by 10min for 5 mins, and the circulatory flow returned to complete resection of the tumor. In group C, the ligaments and hilum of liver were dissected, and the proper hepatic artery, left and right hepatic artery, main portal vein and its branches were separated. The method of unobstructed hemihepatic blood flow was successfully completed until partial hepatectomy was performed. In the ischemic preconditioning group, the hepatic blood flow was blocked for 1 to 5 minutes before partial hepatectomy, and then continued to block the first hepatic hilum for 15 minutes, with an interval of 5 minutes, and circulatory reciprocating until partial hepatectomy was completed. Sex, age, tumor size, liver function (alt, AST, total bilirubin TB and Alb) before and after operation, intraoperative bleeding volume and mean blocking time were compared among the four different hepatic portal blood flow occlusion methods. Results: the patients in the four groups had the following characteristics: sex, age, liver function before operation, tumor size, liver function, and history of hepatitis B. There was no significant difference in the mean blocking time between group A and group B (P 0.05). Group C had the lowest amount of bleeding and group B had more blood loss than group B than the other three groups (P 0.05). Comparison of alt and ASTT TB levels in four groups after operation, the levels of TB in group A were significantly higher than those in group B on the first day of 3 days compared with those in group B, and significantly higher in group A than in group C on day 1, and in group A and group D on day 1, and in group A, group A and group D significantly higher than that in group C on the 7th day after operation. There was no statistical difference between group B and group C on the 7th day. On day 3, group B was significantly higher than group C, group B was significantly higher than group C and group D, and group B was significantly lower than group D on day 1. On the 1st day of the 3rd day, the changes of P0.05N. AST in group C were significantly lower than those in group D, and the changes in group A were significantly higher than those in group B and group C, and in group A and group C significantly higher than those in group A and group C on day 1 and day 3, respectively, and the changes in group A were significantly higher than those in group D on day 1, and in group B were significantly higher than those in group B and group C. On the 3rd day, group B was significantly higher than group C, group B was significantly lower than group D, group B was significantly lower than group D on day 1, group B was significantly higher than group D on day 5, group B was significantly higher than group D, and group C was significantly lower than group D on day 1 and day 3. Conclusion the recovery of liver function in patients with partial hepatectomy is closely related to the choice of hepatic portal occlusion methods. Among the different hepatic portal occlusion methods, hemihepatic flow occlusion has the least effect on postoperative liver function. Continuous hepatic portal occlusion had the greatest effect on liver function after operation. Intermittent first hepatic portal occlusion was better than pretreatment group. However, the recovery of liver function in the latter stage of pretreatment group was faster than that in the intermittent first hepatic portal occlusion method, and the amount of blood loss in the intermittent first hepatic portal occlusion group was significantly higher than that in the other groups.
【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2016
【分类号】：R657.3

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