Zhou W, Li A, Pan Z, Fu S, Yang Y, Tang L, Hou Z, Wu M
The Third Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, 225 Changhai Road, Shanghai 200438, PR China.
Eur J Surg Oncol. 2008 Jan;34(1):49-54. doi: 10.1016/j.ejso.2007.07.001. Epub 2007 Aug 20.
Most liver resections require champing of the hepatic pedicle (Pringle maneuver) to avoid excessive blood loss. But Pringle maneuver cannot control backflow bleeding of the hepatic vein. Resection of liver tumors involving hepatic veins may cause massive hemorrhage or air embolism from injuries of the hepatic vein. Although total hepatic vascular exclusion (THVE) can prevent bleeding of the hepatic vein effectively, it also may result in systemic hemodynamic disturbance because of the clamped inferior vena cava (IVC). SHVE, a new technique, can control the inflow and outflow of the liver without clamping the vena cava. We compared the effects of selective hepatic vascular exclusion (SHVE) and Pringle maneuver in resection of liver tumors involving the junction of the hepatic vein.
From January 2000 to October 2005, 2100 patients with liver tumors had undergone liver resections in our department. Among them, tumors of 235 cases adhered to or were close to the junction of one or more hepatic veins. Both SHVE and Pringle maneuver were used to control blood loss during hepatectomy. These 235 cases were divided into two groups: Pringle maneuver group (110) from January 2000 to December 2002 and SHVE group (125) from January 2003 to October 2005. Data were analyzed regarding the intraoperative and postoperative courses of the patients. In the SHVE group, total SHVE (clamping the porta hepatis and all major hepatic veins) was used in 69 cases and partial SHVE (clamping the porta hepatic and one or two hepatic veins) in 56 cases. There were three methods in hepatic veins occlusion: ligating with suture, encircling and occluding with tourniquets and clamping with Satinsky clamps.
There was no difference between the two groups regarding the age, gender, tumor size, cirrhosis and HBsAg rate, ischemia time and operating time. Intraoperative blood loss and transfusion requirements were significantly decreased in the SHVE group. Hepatic veins rupture with massive blood loss occurred in 14 and air embolism in three during the tumor resection, but there was no massive blood loss and air embolism in the SHVE group due to hepatic vein occlusion. Postoperative bleeding, reoperation, liver failure and mortality rate were higher, and ICU stay and hospital stay were longer in the Pringle group than those in the SHVE group.
SHVE is much more effective than Pringle maneuver in controlling intraoperative bleeding. It can prevent massive blood loss and air embolism from hepatic veins rupture and can reduce the postoperative complication rate and mortality rate. Clamping the hepatic veins with Satinsky clamps is much safer and easier than ligating with suture and occluding with tourniquets.
大多数肝脏切除术需要阻断肝蒂（Pringle手法）以避免过多失血。但Pringle手法无法控制肝静脉的逆流出血。涉及肝静脉的肝肿瘤切除可能因肝静脉损伤导致大量出血或空气栓塞。虽然全肝血管阻断（THVE）能有效预防肝静脉出血，但由于下腔静脉（IVC）被阻断，也可能导致全身血流动力学紊乱。选择性肝血管阻断（SHVE）是一种新技术，可在不阻断腔静脉的情况下控制肝脏的流入和流出。我们比较了选择性肝血管阻断（SHVE）和Pringle手法在涉及肝静脉汇合处的肝肿瘤切除中的效果。
2000年1月至2005年10月，我科有2100例肝肿瘤患者接受了肝脏切除术。其中，235例患者的肿瘤与一条或多条肝静脉汇合处粘连或靠近该部位。在肝切除术中，SHVE和Pringle手法均用于控制失血。这235例患者分为两组：2000年1月至2002年12月的Pringle手法组（110例）和2003年1月至2005年10月的SHVE组（125例）。分析了患者术中及术后病程的数据。在SHVE组中，69例采用全SHVE（阻断肝门和所有主要肝静脉），56例采用部分SHVE（阻断肝门和一两条肝静脉）。肝静脉阻断有三种方法：缝扎、用止血带环绕阻断和用Satinsky钳夹闭。
两组在年龄、性别、肿瘤大小、肝硬化及HBsAg率、缺血时间和手术时间方面无差异。SHVE组术中失血量和输血量明显减少。肿瘤切除过程中，14例发生肝静脉破裂并大量失血，3例发生空气栓塞，但SHVE组未因肝静脉阻断发生大量失血和空气栓塞。Pringle组术后出血、再次手术、肝衰竭和死亡率较高，ICU停留时间和住院时间比SHVE组长。
SHVE在控制术中出血方面比Pringle手法更有效。它可预防肝静脉破裂导致的大量失血和空气栓塞，并可降低术后并发症发生率和死亡率。用Satinsky钳夹闭肝静脉比缝扎和用止血带阻断更安全、更容易。
