脂肪变性肝切除术后肝功能变化的研究

发布时间：2018-11-02 06:48

【摘要】：目的我国是肝癌的高发区,肝切除术(partial hepatectomy,PH)仍然是其目前唯一的根治性治疗手段。PH术后肝脏能否恢复功能,直接影响了手术治疗的效果。随着生活水平的提高,糖尿病、高血压、高血脂等代谢相关疾病的发病率逐渐增高,脂肪肝已成为肝脏最常见的实质性病变之一。其对肝切除术围术期的影响报道甚多,但多为基础研究,目前尚缺乏可靠的临床数据。因此,本文就肝脏脂肪变性对肝切除术术中及术后并发症发生率、术后肝再生(liver regeneration,LR)等方面作一探讨。方法选取南京鼓楼医院2010年10月一2014年10月238例因肝癌行PH的患者的临床资料。回顾性收集入组病人的术前血清学、影像学数据,术中手术情况,术后恢复状况及病理相关资料,测量术前及术后肝脏体积,探讨肝脏脂肪变性对PH围手术期并发症发生率及术后肝再生的影响。结果238例患者中正常组176例,包括左半肝组92例,右半肝组84例,轻度脂肪变性组40例,包括左半肝组22例,右半肝组18例,中重度脂肪变性组22例,包括左半肝组12例,右半肝组10例。正常组、轻度脂肪变性组、中重度脂肪变性组在性别、年龄、肝硬化程度、有无肝炎等术前资料上无差异。轻度脂肪变性组、中重度脂肪变性组的体质指数(Body Mass Index,BMI)均高于对照组(P0.05)。术前血清学检查中甘油三酯(Triglyceride,TG)、总胆固醇(total cholesterol,TCHO)、低密度脂蛋白(low densith lipoprotein, LDL)、谷丙转氨酶(Alanine transaminase, ALT)、谷草转氨酶(Aspartate transaminase,AST)、尿酸(Uric acid,UA)在脂肪肝组中的水平均明显高于对照组(P0.05),且随着脂肪肝的严重程度而逐渐升高。高密度脂蛋白(high densith lipoprotein,HDL)、AST/ALT值在脂肪肝组中低于正常组,且随着脂肪肝程度的加重而逐渐降低(P0.05)。中重度脂肪肝组血小板(blood platelet, PLT)计数低于正常组(P0.05),轻度脂肪肝组与正常组PLT计数无差异(P0.05)。正常组、轻度脂肪变性组、中重度脂肪变性组之间胆红素水平无明显差异(P0.05)。术前用肝脾电子计算机断层值(Computed Tomography,CT)比值标准诊断脂肪肝正确率为74.4%。用肝血管相对密度标准判断,准确率为84.1%。相对于轻度脂肪变性组、正常组,中重度脂肪变性组的手术时间、肝血流阻断时间、出血量、输血率、ICU入住率、术后恢复时间、总住院时间,术后并发症发生率及需要治疗的并发症发生率均明显提高(P0.05),而正常组与轻度脂肪变性组间无差异。采用Logisitic多因素模型分析提示脂肪变性是影响PH术后并发症发生率增高的独立危险因素(P0.05)。正常组、轻度脂肪变性组、中重度脂肪变性组术后ALT、AST、总胆红素在各个时象点虽有差异,但无统计学意义。轻度脂肪变性对肝再生的影响较小(P0.05),中重度脂肪变性明显抑制肝再生(P0.05)。通过多重线性回归分析模型提示肝切除量和肝脂肪变性均是影响PH术后肝再生的危险因素。结论1.中重度脂肪变性可延长肝切除术的手术时间、肝血流阻断时间、术后恢复时间、总住院时间,增加出血量、术后并发症发生率及需要治疗的并发症发生率。轻度脂肪变性对肝切除术围术期未见明显影响。2.轻度脂肪变性对肝切除术后肝再生无明显影响,中重度脂肪变性明显抑制肝再生。
[Abstract]:Objective: Our country is the high incidence area of liver cancer, and liver resection (PH) is still the only radical therapy. The recovery of liver function after PH directly affects the effect of surgical treatment. With the improvement of living standard, the incidence of metabolic related diseases such as diabetes, hypertension and hyperlipemia is increasing, fatty liver has become one of the most common pathological changes in liver. There are many reports on the perioperative period of hepatectomy, but there are no reliable clinical data at present. Therefore, the incidence of hepatic steatosis in liver resection and postoperative complications, liver regeneration (LR) and so on are discussed in this paper. Methods The clinical data of 238 patients with liver cancer underwent PH were selected from October, 2010 to October, 2014 in Nanjing Drum Tower Hospital. To retrospectively collect pre-operation serology, imaging data, intraoperative operative condition, postoperative recovery status and postoperative liver volume of patients in group, to investigate the influence of hepatic steatosis on the incidence of postoperative complications and post-operative liver regeneration in PH peri-operative period. Results Among 238 patients, 176 cases were normal group, including 92 cases of left half liver group, 84 cases of right half liver group and 40 cases of mild fatty degeneration group, including 22 cases of left half liver group, 18 cases of right half liver group and 22 cases of moderate to severe fat degeneration group, including 12 cases of left half liver group and 10 cases of right half liver group. There was no difference in sex, age, degree of liver cirrhosis, presence or absence of hepatitis, etc. in normal group, mild fatty degeneration group and moderate to severe fatty degeneration group. Body Mass Index (BMI) was higher in mild fatty degeneration group than in control group (P0.05). Triglycerides (TG), total cholesterol (TCHO), low density lipoprotein (LDL), glutamic pyruvic transaminase (ALT), glutamic oxaloacetic transaminase (AST), uric acid (Uric acid, The level of UA in the fatty liver was significantly higher than that in the control group (P0.05), and the level of fatty liver gradually increased with the severity of fatty liver. The values of high density lipoprotein (HDL) and AST/ ALT were lower in the fatty liver group than in the control group (P0.05). There was no difference in platelet count in patients with moderate and severe fatty liver (P0.05), and there was no difference between mild fatty liver and normal group (P0.05). There was no significant difference in bilirubin level between normal group and mild fatty degeneration group (P0.05). The accuracy of diagnosis of fatty liver was 74. 4% with computed tomography (CT) ratio standard before operation. The accuracy rate was 84.1%. Relative to mild fatty degeneration group, normal group, operation time of moderate to severe fatty degeneration group, hepatic blood flow occlusion time, blood loss, transfusion rate, ICU admission rate, postoperative recovery time, total hospital stay time, The incidence of postoperative complications and the incidence of complications requiring treatment were significantly increased (P0.05), and there was no difference between the normal group and the mild fatty degeneration group. Logistic multi-factor model analysis suggested that fat denaturation was an independent risk factor affecting the incidence of postoperative complications (P0.05). ALT, AST and total bilirubin were different in normal group, mild fatty degeneration group and moderate to severe fatty degeneration group, but there was no statistical significance. The effect of mild fatty degeneration on liver regeneration was small (P0.05). Through multiple linear regression analysis model, it is suggested that liver resection and liver fat degeneration are the risk factors affecting liver regeneration after PH. Conclusion 1. Moderate and severe fat degeneration can prolong the operation time of hepatectomy, hepatic blood flow blocking time, postoperative recovery time, total hospital stay time, increase blood loss, postoperative complication rate and complication rate needing treatment. Mild fatty degeneration did not significantly affect the peri-operative period of hepatectomy. Mild fatty degeneration has no obvious effect on liver regeneration after hepatectomy, and moderate to severe fat degeneration significantly inhibits liver regeneration.
【学位授予单位】：东南大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R657.3

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