Nuzzo Gennaro, Giuliante Felice, Vellone Maria, De Cosmo Germano, Ardito Francesco, Murazio Marino, D'Acapito Fabrizio, Giovannini Ivo
Department of Surgical Sciences, Hepato-Biliary Surgery Unit, Rome, Italy.
Liver Transpl. 2004 Feb;10(2 Suppl 1):S53-7. doi: 10.1002/lt.20045.
Hepatic pedicle clamping (HPC) is widely used to control intraoperative bleeding during hepatectomy; intermittent HPC is better tolerated but is associated with blood loss during each period of reperfusion. Recently, it has been shown that ischemic preconditioning (IP) reduces the ischemia-reperfusion damage for up to 30 minutes of continuous clamping in healthy liver. We evaluated the safety of IP for more prolonged periods of continuous clamping in 42 consecutive patients with healthy liver submitted to hepatectomy. IP was used in 21 patients (group A); mean +/- SD of liver ischemia was 54 +/- 19 minutes (range, 27-110; in 7 cases >60 minutes). In the other 21 patients, continuous clamping alone was used (Group B); liver ischemia lasted 36 +/- 14 minutes (range, 13-70; in 2 cases >60 minutes). Two patients in Group A (9.5%) and 3 in Group B (14.2%) received blood transfusions. In spite of the longer duration of ischemia (P=.001), patients with IP had lower aspartate aminotransferase (AST; P=.03) and alanine aminotransferase (ALT; P=not significant) at postoperative day 1, with a similar trend at postoperative day 3. This was reconfirmed by multiple regression analysis, which showed that although postoperative transaminases increased with increasing duration of ischemia and of the operation in both groups, the increases were significantly smaller (P<.001) with the use of preconditioning. In conclusion, the present study confirms that IP is safe and effective for liver resection in healthy liver and is also better tolerated than continuous clamping alone for prolonged periods of ischemia. This technique should be preferred to continuous clamping alone in healthy liver. Additional studies are needed to assess the role of IP in cirrhotic liver and to compare IP with intermittent clamping.
肝蒂阻断（HPC）广泛应用于肝切除术时控制术中出血；间歇性肝蒂阻断耐受性较好，但在每次再灌注期间会导致失血。最近有研究表明，缺血预处理（IP）可减轻健康肝脏连续阻断长达30分钟时的缺血再灌注损伤。我们评估了42例接受肝切除术的健康肝脏患者在更长连续阻断时间下缺血预处理的安全性。21例患者采用缺血预处理（A组）；肝脏缺血的平均时间±标准差为54±19分钟（范围为27 - 110分钟；7例超过60分钟）。另外21例患者仅采用连续阻断（B组）；肝脏缺血持续36±14分钟（范围为13 - 70分钟；2例超过60分钟）。A组2例患者（9.5%）和B组3例患者（14.2%）接受了输血。尽管缺血时间更长（P = 0.001），但接受缺血预处理的患者在术后第1天的天冬氨酸转氨酶（AST；P = 0.03）和丙氨酸转氨酶（ALT；P无显著性差异）较低，术后第3天也有类似趋势。多元回归分析再次证实了这一点，该分析表明，尽管两组术后转氨酶均随缺血时间和手术时间的延长而升高，但使用预处理时升高幅度明显较小（P < 0.001）。总之，本研究证实缺血预处理在健康肝脏肝切除术中是安全有效的，并且在长时间缺血时比单纯连续阻断耐受性更好。在健康肝脏中，应优先选择该技术而非单纯连续阻断。需要进一步研究评估缺血预处理在肝硬化肝脏中的作用，并将其与间歇性阻断进行比较。
