肝细胞癌肝切除术后大量腹水的危险因素分析

发布时间：2018-07-27 17:24

【摘要】：背景肝脏是人类体内最大的实质器官,在维持机体多项生理功能的过程中扮演着至关重要的角色。如果肝脏发生疾病,那么人体的健康将会受到巨大的影响。在面对多种肝脏疾病时,肝切除手术仍然是医生们能够解决问题所可以采取的最好办法。得益于手术疼痛、感染、止血、输血等问题的解决,现代外科学有了极大的发展,而肝脏外科发展至今也已有了百余年的历史。目前肝切除手术所针对的主要对象是肝脏肿瘤(恶性肿瘤如原发性肝癌、继发性肝癌;良性肿瘤如肝海绵状血管瘤、肝腺瘤、肝脂肪瘤、肝纤维瘤等),两者约占手术总比重的八成。其他的疾病包括肝内胆管结石、肝内胆道出血、外伤性肝破裂、肝脓肿、肝囊肿、肝包虫病等也都属于肝切除术的适应症。但在临床工作过程中,外科医生在对接受肝切除手术治疗的患者进行围手术期管理期间则面临着诸多问题,如何有效评价患者的肝储备功能,制定合理的手术方案,并尽最大努力减少肝切除术后并发症的发生率,提高患者术后的生活质量,缩短住院时间,从而使病患获得最大的受益则成为了重中之重。近年来,伴随着外科学技术的不断发展,尽管一些新材料、新技术(如射频消融技术)等的相继问世并投入临床应用,病人的围手术期管理亦得到日益改善,肝切除术后并发症的发生率及死亡率有了明显下降[1],然而,肝切除手术的风险仍然不容忽视。大量腹水、感染、胆漏、切口愈合不良、肝性脑病等术后并发症的出现,导致患者术后生活质量明显下降,住院时间也有所延长,这些状况一旦出现便会加大患者的经济压力,同时也将使其和家属背负上更为沉重的心理负担,甚至有可能引起危及患者生命的肝功能衰竭。为了尽可能地减少这种情况的发生,在对肝细胞癌等需要接受外科治疗的肝病患者进行手术前,完善的术前准备以及合理的手术规划是十分必要的。目的明确人口学特点、术前常规肝功能参数、肝病背景及手术情况等因素对肝切除术后大量腹水的影响;探究肝细胞癌肝切除手术后出现大量腹水的危险因素。资料和方法汇总2015年1月至2015年12月期间因肝细胞癌在郑州大学第一附属医院肝胆胰外科接受肝切除手术治疗的106例患者的临床资料,并进行回顾性分析。所有患者均需接受完善的术前检测及准备,依据CT、超声等影像学检查结果,明确肿瘤的大小、所处的位置以及其与周围血管之间的关系,从而合理选择手术切除方式。患者术后住院恢复期间,依据单日最大腹水引流量10m L/kg×术前体重(kg)[2]这一定义观察有无术后大量腹水的发生,并将所收集到的资料据此分为术后大量腹水组和非大量腹水组。对两组患者的人口学特点(如年龄、性别),术前肝功能参数(如血清谷丙转氨酶水平、血清前白蛋白水平、血清总胆红素水平、凝血酶原活动度、Child评分等指标),肝病背景(如病毒性肝炎、肝硬化等)以及手术情况(肝切除手术范围、肝门阻断情况、术中失血量和输血情况等)进行单因素和多因素logistic分析,以明确肝细胞癌肝切除手术后出现大量腹水的危险因素。结果纳入研究的106例患者中,共有26例患者出现了肝切除术后大量腹水,其发生率为24.5%。单因素分析结果表明,肝切除术后大量腹水组与非大量腹水组在Child分级、术中输血情况、术前门静脉高压、凝血酶原时间(PT)、凝血酶原活动度(PTA)、血清谷草转氨酶(AST)水平、谷氨酰转肽酶(GGT)水平、碱性磷酸酶(ALP)水平、前白蛋白(PA)水平、胆碱酯酶(CHE)水平、总胆红素(TBIL)水平、ICGR15、术中出血量以及手术时间这14个变量之间的差异具有显著的统计学意义(P0.05)。多因素Logistic分析结果显示:凝血酶原活动度(PTA)、血清碱性磷酸酶(ALP)水平、前白蛋白(PA)水平、手术时间和术前门静脉高压这5个因素为肝细胞癌肝切除术后大量腹水的独立危险因素。结论1.肝细胞癌肝切除术后大量腹水仍有着较高的发生率(24.5%)。2.术前凝血酶原活动度低、前白蛋白(PA)水平低、血清碱性磷酸酶(ALP)水平高、存在术前门静脉高压以及手术时间较长的肝细胞癌患者在接受肝切除术后更容易出现大量腹水。3.在对肝细胞癌患者施行肝切除手术前,全面、准确的肝功能评估是十分必要的。外科医生在对肝细胞癌手术患者进行筛选及制定临床治疗方案时应充分考虑手术治疗益处和风险之间的平衡。
[Abstract]:The liver is the largest substance in the human body and plays a vital role in maintaining a number of physiological functions. If the liver is a disease, the health of the body will be greatly affected. In the face of a variety of liver diseases, hepatectomy is still a problem that doctors can take to solve the problem. The best way. Thanks to the problem of surgical pain, infection, hemostasis, and blood transfusion, modern surgery has developed greatly, and liver surgery has been developed for more than 100 years. The main target of hepatectomy is liver tumor (malignant tumor such as primary liver cancer, secondary liver cancer, and benign tumor such as the liver sea). Cavernous hemangioma, hepatic adenoma, hepatic lipoma, hepatofibroma, etc., which account for about 80% of the total proportion of the operation. Other diseases including intrahepatic bile duct stones, intrahepatic biliary bleeding, traumatic liver rupture, liver abscess, hepatic cyst, hepatic echinococcosis, etc. are also indications of hepatectomy, but in clinical work, surgeons are butting the liver. The patients undergoing surgical treatment are faced with many problems during the period of perioperative management. How to effectively evaluate the patient's liver reserve function and make a reasonable operation plan, and make the best efforts to reduce the incidence of complications after hepatectomy, improve the quality of life and shorten the time of hospitalization, so that the patients can get the most. In recent years, with the continuous development of surgical techniques, although some new materials and new technologies, such as radiofrequency ablation technology, have been developed and put into clinical application, the perioperative management of patients has been improved, the incidence and mortality of complications after hepatectomy have been significantly reduced by [1], The risk of hepatectomy is still not to be ignored. A large number of ascites, infection, bile leakage, poor healing of the incision, hepatic encephalopathy and other postoperative complications, resulting in a significant decline in the quality of life and prolonged hospitalization of the patients. These conditions will add to the economic pressure of the patients as soon as they appear, and they will also bring them to their families. A heavier psychological burden may even cause liver failure that threatens the life of the patient. In order to reduce the occurrence of this situation as much as possible, it is necessary to complete pre operation preparation and reasonable hand planning before surgery for hepatopathy, such as hepatocellular carcinoma, which need to be treated with surgical treatment. The effects of preoperative routine liver function parameters, liver disease background and operation conditions on a large number of ascites after hepatectomy, and the risk factors of massive ascites after hepatectomy for hepatectomy. Data and methods were collected from January 2015 to December 2015, due to hepatocyte carcinoma at the First Affiliated Hospital of Zhengzhou University, hepatobiliary and pancreatic surgery. The clinical data of 106 patients treated with hepatectomy were analyzed retrospectively. All patients were required to undergo complete preoperative examination and preparation. According to the results of CT, ultrasound and other imaging examinations, the size of the tumor, the location and the relationship with the peripheral vessels were clearly defined, and the surgical resection was reasonably selected. During the post hospital recovery, a large number of ascites were observed on the basis of the definition of 10m L/kg (kg) [2] before operation, and the data collected were classified into a large number of ascites and non large ascites. The demographic characteristics of the two groups (such as age, sex), and preoperative liver function parameters (such as blood, such as blood) Single factor and multiple factor Logistic analysis of the level of propane aminotransferase, serum prealbumin, serum total bilirubin, prothrombin activity, Child score, and liver disease background (such as viral hepatitis, cirrhosis, etc.) and operation (hepatectomy, hepatic portal blockage, intraoperative blood loss and blood transfusion) To determine the risk factors for a large number of ascites after hepatectomy for hepatocellular carcinoma. Results of the 106 patients enrolled in the study, a total of 26 patients had a large number of ascites after hepatectomy, the incidence of which was 24.5%. single factor analysis showed that a large number of ascites and non large ascites after hepatectomy were classified by Child and intraoperative blood transfusion, Preoperation portal hypertension, prothrombin time (PT), prothrombin activity (PTA), serum glutamic aminotransferase (AST) level, glutamyl transaminopeptidase (GGT) level, alkaline phosphatase (ALP) level, prealbumin (PA) level, cholinesterase (CHE) level, total bilirubin (TBIL) level, ICGR15, intraoperative hemorrhage and operation time between the 14 variables The difference had significant statistical significance (P0.05). The results of multifactor Logistic analysis showed that the 5 factors, prothrombin activity (PTA), serum alkaline phosphatase (ALP) level, prealbumin (PA) level, operation time and anterior portal hypertension were independent risk factors for massive ascites after hepatectomy for hepatocarcinoma. Conclusion 1. liver cell carcinoma liver After excision, a large number of ascites still have a high incidence (24.5%) before.2., prothrombin activity is low, prealbumin (PA) is low, serum alkaline phosphatase (ALP) is high. There is a lot of ascites in the patients with hepatocellular carcinoma with high pressure of anterior portal vein and long operation time, and a large amount of ascites.3. is more likely to be in the liver cell carcinoma after hepatectomy. A comprehensive and accurate assessment of liver function is necessary before the resection of the hepatectomy. Surgeons should take full consideration of the balance between the benefits and risks of surgical treatment when screening and formulating a clinical treatment for patients with hepatocellular carcinoma.
【学位授予单位】：郑州大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R735.7

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