Department of Surgery, University of Missouri, Kansas City School of Medicine, Kansas City, MO, USA.
HPB (Oxford). 2004;6(3):181-5. doi: 10.1080/13651820410030826.
Mortality and morbidity rates from major liver resections have decreased sharply over the past 25 years. This improvement is due to a better understanding of liver anatomy and the introduction of new operative techniques, but also to improved anesthetic perioperative support. Certain cases are still associated with voluminous blood loss. These patients may be at higher risk for postoperative problems and increased length of stay (LOS) in hospital.
We have retrospectively reviewed 115 patients undergoing major hepatic resections (three or more anatomic segments) with respect to operative blood loss (EBL). Those with an EBL >or=5000 ml (group 1; n = 39) were compared to those with an EBL <or=2000 ml (group 2; n=42). Type of resection, age (>or=70 years), tumor size, mortality, morbidity, and hospital LOS were examined. Operative reports were examined for any explanation for excessive blood loss. Anesthetic support often entailed the use of a rapid infusion system.
The EBL was 7692+/-3848 ml for group 1 and 1359+/-514 ml for group 2. Primary liver tumors were resected in 20 patients in group 1 and in 18 patients in group 2. The remaining resections were for metastatic tumors, primarily colorectal in origin. In group 1, 13/39 patients had a left hepatectomy compared to 10/42 patients in group 2 (p=0.34). The overall mortality was 5/1 15. Four deaths occurred in group 1 and one in group 2 (p=0.16). Two deaths in group 1 were intra-operative (hemorrhage, air embolism). There was no difference in the number of patients with complications, 12/ 39 in group 1 and 8/42 in group 2 (p=0.22). Two patients in group 1 required re-operation for bleeding; there were none in group 2. Largest tumor size did not differ between the two groups (p=0.08), nor did the proportion of patients aged 70 years or older (p=0.06). There was no difference in hospital LOS (10.54+/-6.1 vs 8.90+/-4.7 days, p=0.2l). Review of operative notes in group 1 indicated no unusual problems in 13/39, large tumors or proximity to the inferior vena cava in 10/39, and bleeding from the middle hepatic vein in 7/39. Three patients in group 1 required total vascular exclusion for tumor removal; there were none in group 2.
Massive EBL during major liver resection seems to be provoked by tumors near the inferior vena cava or major hepatic veins, or injury to the middle hepatic vein during operation, and not by patient age, tumor size alone, or type of hepatectomy. However, by avoiding prolonged hypotension and hypothermia with the use of rapid infusion devices, the perioperative course of these patients does not differ from those with much less EBL.
在过去的 25 年中，主要肝切除术的死亡率和发病率急剧下降。这种改善归因于对肝脏解剖结构的更好理解和新手术技术的引入，但也归因于围手术期麻醉支持的改善。某些情况下仍与大量失血有关。这些患者术后可能出现更多问题，住院时间（ LOS ）延长。
我们回顾性分析了 115 例接受大肝切除术（三个或更多解剖段）的患者的手术出血量（ EBL ）。 EBL ＞ 5000ml 的患者（组 1 ； n = 39 ）与 EBL ＜ 2000ml 的患者（组 2 ； n = 42 ）进行比较。检查了手术类型、年龄（≥ 70 岁）、肿瘤大小、死亡率、发病率和住院 LOS 。检查手术报告是否有任何关于过度失血的解释。麻醉支持通常需要使用快速输液系统。
组 1 的 EBL 为 7692±3848ml ，组 2 为 1359±514ml 。组 1 中有 20 例原发性肝癌患者接受了切除术，组 2 中有 18 例患者接受了切除术。其余的切除术是为转移性肿瘤，主要是结直肠来源的。在组 1 中，有 13/39 例患者行左肝切除术，而组 2 中有 10/42 例患者行左肝切除术（ p = 0.34 ）。总死亡率为 5/115 。组 1 中有 4 例死亡，组 2 中有 1 例死亡（ p = 0.16 ）。组 1 中有 2 例死亡是术中出血、空气栓塞引起的。组 1 和组 2 中并发症患者的数量没有差异，分别为 12/39 和 8/42 （ p = 0.22 ）。组 1 中有 2 例患者因出血需要再次手术，组 2 中没有。两组肿瘤最大直径无差异（ p = 0.08 ），年龄≥ 70 岁患者比例无差异（ p = 0.06 ）。住院 LOS 无差异（ 10.54±6.1 与 8.90±4.7 天， p = 0.21 ）。组 1 手术记录显示， 13/39 例无异常， 10/39 例肿瘤较大或靠近下腔静脉， 7/39 例肝中静脉出血。组 1 中有 3 例患者因肿瘤切除需要完全血管阻断，组 2 中没有。
大肝切除术期间大量出血似乎是由靠近下腔静脉或主要肝静脉的肿瘤、术中肝中静脉损伤引起的，而不是由患者年龄、肿瘤大小或肝切除术类型引起的。然而，通过使用快速输液装置避免长时间低血压和低体温，这些患者的围手术期过程与出血量较少的患者没有区别。
