Department of Hepatogastroenterological Surgery, Aso Iizuka Hospital, Iizuka, 820-8505, Japan.
World J Surg. 2010 Jul;34(7):1555-62. doi: 10.1007/s00268-010-0495-3.
Massive bleeding during hepatectomy is a risk for mortality and morbidity. We examined the risk factors for massive bleeding and their correlations with outcomes.
The study was a retrospective case series. Among 353 consecutively hepatectomized patients, the mean estimated blood loss (EBL) was 825 ml. Ten patients (2.8%) experienced EBL of between 3000 and 5000 ml. Five patients (1.4%) experienced massive EBL defined as more than 5000 ml, and all five patients had undergone right major hepatectomy (RMH) for primary liver cancer (PLC). All the patients with PLC who underwent RMH were divided into two groups: group I with EBL < or = 5000 ml (n = 19) and group II with EBL > 5000 ml (n = 5). Perioperative factors regarding massive bleeding and operative mortality and morbidity were compared between the two groups.
Among the ten patients who experienced EBL of between 3000 and 5000 ml, three had partial hepatectomy of no more than subsegmentectomy of the paracaval portion of the caudate lobe and three had central bisegmentectomy. The mean tumor size was 7.9 +/- 4.7 cm in group I and 15.1 +/- 2.2 cm in group II (P = 0 .0034). Tumor compression of the inferior vena cava (IVC) on CT scans was observed in all patients in group II, but in no patients in group I (P < 0.0001). Four of five patients in group II received surgery through an anterior approach. The liver-hanging maneuver (LHM) was applied in 14 of 19 patients (74%) in group I but could not be applied in group II (P = 0.0059). No postoperative and in-hospital mortalities occurred in group II and there were no significant differences in the incidence of mortality and morbidity between the groups.
RMH for large PLCs, tumor compression of the IVC, and an anterior approach without the LHM are risks for massive bleeding during hepatectomy. Preparation of rapid infusion devices in these cases is necessary to avoid prolonged hypotension.
肝切除术中大出血是死亡和发病的风险因素。我们研究了大出血的危险因素及其与结果的相关性。
本研究为回顾性病例系列研究。在 353 例连续接受肝切除术的患者中，平均估计失血量（EBL）为 825ml。10 例（2.8%）EBL 为 3000-5000ml。5 例（1.4%）发生大量 EBL（定义为>5000ml），所有 5 例均因原发性肝癌（PLC）行右半肝切除术（RMH）。所有行 RMH 的 PLC 患者分为两组：EBL<或=5000ml 组（n=19）和 EBL>5000ml 组（n=5）。比较两组患者与大出血和手术死亡率及并发症相关的围手术期因素。
在 10 例 EBL 为 3000-5000ml 的患者中，3 例行不超过肝尾状叶旁叶段切除术的部分肝切除术，3 例行中央双段切除术。组 I 的平均肿瘤大小为 7.9+/-4.7cm，组 II 为 15.1+/-2.2cm（P=0.0034）。组 II 所有患者 CT 扫描均见肿瘤压迫下腔静脉（IVC），而组 I 无患者（P<0.0001）。组 II 中有 4 例患者采用前入路手术。19 例患者中有 14 例（74%）应用肝悬带术（LHM），但组 II 中无法应用（P=0.0059）。组 II 无术后和院内死亡，两组死亡率和并发症发生率无显著差异。
行 RMH 治疗大的 PLC、肿瘤压迫 IVC、不应用 LHM 的前入路是肝切除术中大出血的危险因素。这些情况下有必要准备快速输液设备，以避免长时间低血压。
