Emond J, Wachs M E, Renz J F, Kelley S, Harris H, Roberts J P, Ascher N L, Lim R C
Department of Surgery, University of California, San Francisco, USA.
Arch Surg. 1995 Aug;130(8):824-30; discussion 830-1. doi: 10.1001/archsurg.1995.01430080026003.
Total vascular exclusion (TVE) of the liver has been used to increase the safety of hepatectomy and the feasibility of difficult resections. Until recently, however, concern about the detrimental effect of warm ischemia has limited the use of this technique to patients with normal liver parenchyma.
To compare surgical outcomes of 12 patients with abnormal livers (group 1) with outcomes of 48 patients with normal parenchyma (group 2), based on the hypothesis that uncontrolled bleeding may be more detrimental than planned hepatic ischemia.
Retrospective analysis of 60 consecutive patients undergoing liver resection under TVE in a university medical center.
All 10 patients with cirrhosis had albumin levels of 30 g/L or higher and normal prothrombin times preoperatively; none had ascites. Two patients with cholestasis (one with cholangiocarcinoma and one with hepatocellular carcinoma) are included in group 1.
All 12 group 1 patients and 44 of 48 group 2 patients underwent total or extended lobectomy, with TVE induced by clamping the hilum and the vena cava above and below the liver during parenchyma division.
Hospital survival and selected surgical and laboratory parameters.
Operative times, ischemic times, and blood loss (1975 +/- 1601 vs 1255 +/- 1291 mL) (P = .10) were comparable in both groups. Sixty-day operative mortality was zero in both groups. There was an increased rate of complications in group 1 (44% vs 17% [P = 0.06]). Transient abnormal liver function was observed in both groups. However, significant delay in restoration of normal function was observed in group 1 with respect to bilirubin levels and prothrombin time.
Patients with cirrhosis can undergo successful resection using TVE. This conclusion must be limited to cirrhotic patients with good liver function. The trend toward increased blood loss may reflect greater difficulties in establishing hemostasis after reperfusion in group 1. While this group appears to have a higher risk for hepatic insufficiency, successful outcomes were achieved in all cases. Prospective study will be required to define the parameters for use of TVE in cirrhosis.
肝脏全血管阻断（TVE）已被用于提高肝切除术的安全性及困难切除术的可行性。然而，直到最近，由于担心热缺血的有害影响，该技术仅应用于肝实质正常的患者。
基于无控制的出血可能比计划性肝缺血更有害的假设，比较12例肝脏异常患者（第1组）与48例肝实质正常患者（第2组）的手术结果。
对一所大学医学中心60例连续接受TVE肝切除术的患者进行回顾性分析。
10例肝硬化患者术前白蛋白水平均≥30g/L，凝血酶原时间正常；均无腹水。第1组纳入2例胆汁淤积患者（1例胆管癌，1例肝细胞癌）。
第1组的12例患者和第2组的48例患者中的44例接受了全肝或扩大肝叶切除术，在肝实质离断期间通过钳夹肝门及肝脏上下的腔静脉诱导TVE。
住院生存率及选定的手术和实验室参数。
两组的手术时间、缺血时间和失血量（1975±1601 vs 1255±1291ml）（P = 0.10）相当。两组的60天手术死亡率均为零。第1组的并发症发生率更高（44% vs 17% [P = 0.06]）。两组均观察到短暂的肝功能异常。然而，第1组在胆红素水平和凝血酶原时间方面恢复正常功能有明显延迟。
肝硬化患者可通过TVE成功进行肝切除术。这一结论必须限于肝功能良好的肝硬化患者。失血量增加的趋势可能反映出第1组再灌注后止血更困难。虽然该组似乎发生肝衰竭的风险更高，但所有病例均取得了成功的结果。需要进行前瞻性研究以确定TVE在肝硬化中应用的参数。
