Cunningham J D, Fong Y, Shriver C, Melendez J, Marx W L, Blumgart L H
Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY.
Arch Surg. 1994 Oct;129(10):1050-6. doi: 10.1001/archsurg.1994.01420340064011.
Hepatic resection is prone to significant blood loss. Adverse effects of blood loss and transfusion mandate improvements in surgical techniques to reduce blood loss and transfusion requirements.
One hundred hepatic resections were carried out using a standard surgical technique that includes control of the hilar structures, extrahepatic control of the hepatic veins, and use of the Pringle maneuver. Low central venous pressure and Trendelenburg positioning were used during parenchymal transection. Data were collected retrospectively in the first 36 patients, whereas data were collected prospectively in the remaining 64 patients.
Hospital mortality was 3%. Median blood loss was 450, 700, 1000, 1100, and 1500 mL for segmental, nonanatomic, lobar, extended right, and extended left resections, respectively. Major resections were more likely than minor resections to be transfused with albumin (P = .008), fresh frozen plasma (P = .009), and packed red blood cells or whole blood (P = .04). Overall transfusion of packed red blood cells or whole blood occurred in 59 of 100 patients. In the 64 patients who were followed up prospectively, the predeposit of autologous blood decreased the need for homologous transfusions from 56% to 38%. A further reduction in the transfusion rate of 25% could have been possible if all patients in the prospective group had donated 2 U of autologous blood. Patients who predeposited blood were more likely to receive transfusions and to have had a transfusion more than 24 hours after surgery than were patients who did not donate blood.
The surgical techniques used results in acceptable blood loss and transfusion requirements for hepatic resection. This approach is safe, cost-effective, reproducible, and applicable for widespread use.
肝切除手术容易导致大量失血。失血和输血的不良反应促使手术技术不断改进，以减少失血和输血需求。
采用标准手术技术进行了100例肝切除手术，该技术包括控制肝门结构、肝静脉的肝外控制以及使用Pringle手法。在实质切开过程中采用低中心静脉压和头低脚高位。对前36例患者的数据进行回顾性收集，而对其余64例患者的数据进行前瞻性收集。
医院死亡率为3%。节段性、非解剖性、叶切除、扩大右半肝切除和扩大左半肝切除的中位失血量分别为450、700、1000、1100和1500 mL。大手术比小手术更有可能输注白蛋白（P = .008）、新鲜冰冻血浆（P = .009）以及浓缩红细胞或全血（P = .04）。100例患者中有59例接受了浓缩红细胞或全血的总体输血。在进行前瞻性随访的64例患者中，自体血预存使同源输血需求从56%降至38%。如果前瞻性组的所有患者都捐献2单位自体血，输血率可能会进一步降低25%。预存血液的患者比未献血的患者更有可能接受输血，并且在术后24小时以上进行输血。
所采用的手术技术导致肝切除手术的失血量和输血需求在可接受范围内。这种方法安全、具有成本效益、可重复且适用于广泛应用。
