测量与估计总肝体积以术前评估剩余肝体积的充足性：我们应该使用哪种方法？

Measured versus estimated total liver volume to preoperatively assess the adequacy of the future liver remnant: which method should we use?

机构信息

*Department of General Surgery and Surgical Oncology, Ospedale Mauriziano "Umberto I" †Department of Radiology, Istituto per la Ricerca e la Cura del Cancro, Candiolo, Turin, Italy.

出版信息

Ann Surg. 2013 Nov;258(5):801-6; discussion 806-7. doi: 10.1097/SLA.0000000000000213.

DOI:10.1097/SLA.0000000000000213

PMID:24045451

Abstract

OBJECTIVES

To determine which method of liver volumetry is more accurate in predicting a safe resection.

BACKGROUND

Before major or extended hepatectomy, assessment of the future liver remnant (FLR) is crucial to reduce the risk of postoperative hepatic insufficiency. The FLR volume is usually expressed as the ratio of FLR to nontumorous total liver volume (TLV), which can be measured directly by computed tomography (mTLV) or estimated (eTLV) on the basis of correlation existing with the body surface area. To date, these 2 methods have never been compared.

METHODS

All consecutive, noncirrhotic patients who underwent resection of 3 or more liver segments between April 2000 and April 2012 and for whom (i) preoperative computed tomographic scans and (ii) body surface area were available entered the study. The mTLV (calculated as TLV - tumor volume) was compared with the eTLV (calculated as -794.41 + 1267.28 × body surface area) using volumetric data (cm) and clinical outcome measures (specifically, hepatic insufficiency and 90-day mortality). Definition of hepatic insufficiency was peak postoperative serum total bilirubin level of more than 7 mg/dL or, in jaundiced patients, an increasing bilirubin level on day 5 or thereafter.

RESULTS

Two-hundred forty-three patients who had undergone major (n = 135) or extended (n = 108) hepatectomies met the inclusion criteria. Twenty-eight patients (11.5%) developed hepatic insufficiency, whereas 7 patients (2.9%) died postoperatively. Compared with the eTLV, the mTLV underestimated the liver volume in 60.1% of the patients (P < 0.01). Forty-seven and 73 patients had an inadequate FLR based on mTLV and eTLV, respectively. Portal vein occlusion (PVO) was used in 44 patients. In patients (n = 162) in whom both methods did not evidence the need for PVO, postoperative hepatic insufficiency and mortality were 4.9% and 0.6%, respectively. Conversely, in patients (n = 27) in whom the eTLV but not the mTLV evidenced the need for PVO, and thus PVO was not performed, hepatic insufficiency (22.2%; P = 0.001) and mortality (3.7%; P = ns) were higher.

CONCLUSIONS

The use of eTLV identifies a subset of patients (∼11%) in whom liver volumetry with the mTLV underestimates the risk of hepatic insufficiency.

摘要

目的

确定哪种肝体积测量方法更能准确预测安全切除。

背景

在进行大或扩大肝切除术之前，评估剩余肝（FLR）对于降低术后肝功能不全的风险至关重要。FLR 体积通常表示为 FLR 与非肿瘤总肝体积（TLV）的比值，可通过计算机断层扫描（mTLV）直接测量，或根据与体表面积的相关性进行估计（eTLV）。迄今为止，这两种方法从未进行过比较。

方法

所有连续非肝硬化患者于 2000 年 4 月至 2012 年 4 月期间接受 3 个或更多肝段切除术，且术前均有（i）计算机断层扫描和（ii）体表面积，纳入本研究。mTLV（计算为 TLV - 肿瘤体积）与 eTLV（计算为 -794.41 + 1267.28 × 体表面积）进行比较，使用体积数据（cm）和临床结果测量值（特别是肝功能不全和 90 天死亡率）。肝功能不全的定义为术后血清总胆红素峰值超过 7mg/dL，或黄疸患者第 5 天或之后胆红素水平升高。

结果

符合纳入标准的 243 例患者中，135 例接受了大肝切除术，108 例接受了扩大肝切除术。28 例（11.5%）患者发生肝功能不全，7 例（2.9%）患者术后死亡。与 eTLV 相比，mTLV 低估了 60.1%患者的肝脏体积（P < 0.01）。根据 mTLV 和 eTLV，分别有 47 例和 73 例患者 FLR 不足。44 例患者采用门静脉阻断（PVO）。在未行 PVO 的 162 例患者（n = 162）中，术后肝功能不全和死亡率分别为 4.9%和 0.6%。相反，在仅 eTLV 而不是 mTLV 提示需要 PVO 且未行 PVO 的 27 例患者（n = 27）中，肝功能不全（22.2%；P = 0.001）和死亡率（3.7%；P = ns）更高。