Hosein Shokouh-Amiri M, Osama Gaber A, Bagous W A, Grewal H P, Hathaway D K, Vera S R, Stratta R J, Bagous T N, Kizilisik T
Departments of Surgery (Division of Transplantation) and Anesthesia and the College of Nursing, University of Tennessee-Memphis, Memphis, Tennessee 38125, USA.
Ann Surg. 2000 Jun;231(6):814-23. doi: 10.1097/00000658-200006000-00005.
To examine how the choice of surgical technique influenced perioperative outcomes in liver transplantation.
The standard technique of orthotopic liver transplantation with venovenous bypass (VVB) is commonly used to facilitate hemodynamic stability. However, this traditional procedure is associated with unique complications that can be avoided by using the technique of liver resection without caval excision (the piggyback technique).
A prospective comparison of the two procedures was conducted in 90 patients (34 piggyback and 56 with VVB) during a 2.5-year period. Although both groups had similar donor and recipient demographic characteristics, posttransplant outcomes were significantly better for the patients undergoing the piggyback technique. The effect of surgical technique was examined using a stepwise approach that considered its impact on two levels of perioperative and postoperative events.
The analysis of the first level of perioperative events found that the piggyback procedure resulted in a 50% decrease in the duration of the anhepatic phase. The analysis of the second level of perioperative events found a significant relation between the anhepatic phase and the duration of surgery and between the anhepatic phase and the need for blood replacement. The analysis of the first level of postoperative events found that the intensive care unit stay was significantly related to both the duration of surgery and the need for blood replacement. The intensive care unit stay was in turn related to the second level of postoperative events, namely the length of hospital stay. Finally, total charges were directly related to length of hospital stay. The overall 1-year actuarial patient and graft survival rates were 94% in the piggyback and 96% in the VVB groups, respectively.
These data demonstrate that surgical choices in complex procedures such as orthotopic liver transplantation trigger a chain of events that can significantly affect resource utilization. In the current healthcare climate, examination of the sequence of events that follow a specific treatment may provide a more complete framework for choosing between treatment alternatives.
探讨手术技术的选择如何影响肝移植围手术期结局。
采用静脉-静脉转流（VVB）的原位肝移植标准技术常用于促进血流动力学稳定。然而，这种传统术式存在一些独特的并发症，而采用不切除腔静脉的肝切除技术（背驮式技术）可避免这些并发症。
在2.5年的时间里，对90例患者（34例行背驮式手术，56例行VVB手术）进行了这两种手术的前瞻性比较。尽管两组供体和受体的人口统计学特征相似，但接受背驮式技术的患者移植后结局明显更好。采用逐步分析方法研究手术技术的影响，该方法考虑了其对围手术期和术后事件两个层面的影响。
对围手术期事件的第一层面分析发现，背驮式手术使无肝期持续时间减少了50%。对围手术期事件的第二层面分析发现，无肝期与手术持续时间以及无肝期与输血需求之间存在显著关联。对术后事件的第一层面分析发现，重症监护病房停留时间与手术持续时间和输血需求均显著相关。重症监护病房停留时间又与术后事件的第二层面相关，即住院时间。最后，总费用与住院时间直接相关。背驮式组和VVB组的1年实际患者和移植物生存率分别为94%和96%。
这些数据表明，在原位肝移植等复杂手术中，手术选择会引发一系列事件，这些事件会显著影响资源利用。在当前的医疗环境下，检查特定治疗后的事件序列可能为在治疗方案之间进行选择提供一个更完整的框架。
