Cherqui D, Alon R, Lauzet J Y, Salvat A, De Salles De Hys C, Rotman N, Duvoux C, Julien M, Fagniez P L
Service de Chirurgie Générale et Digestive, CHU Henri-Mondor, Créteil.
Gastroenterol Clin Biol. 1996 Mar;20(2):132-8.
Over the last 5 years, a policy to limit blood transfusions has been adopted in patients undergoing liver resection. The aim of this retrospective study was to report the results of 150 liver resections performed during this period.
There were 63 major (42%) and 87 minor hepatectomies (58%). Resection was performed for malignant lesions in 64% of the patients. Vascular exclusion of the liver was used in large (> or = 10 cm) tumors and those located at the cavohepatic junction. Clamping of the portal triad or selective clamping of the pedicle of the portal lobe was used in peripheral lesions < 10 cm in diameter. Anesthesia was adapted to the type of vascular clamping and blood transfusions were deliberately limited. Red blood cells were transfused to maintain the hematocrit level above 25% in healthy patients and above 30% in patients with risk of coronary artery disease.
Ninety three patients (62%) did not receive blood transfusions. Three patients received more than 10 units of packed red blood cells (2%). 48% of patients with major hepatectomies and 72% with minor hepatectomies were not transfused. The rate of non transfused patients was 93% for benign lesions and 44% for malignant lesions. The presence of pathologic changes in non-tumor liver parenchyma did not influence the need for transfusions. Hospital mortality was 3% (5/150). There was no mortality in patients with normal non-tumorous livers, 14% in the presence of cirrhosis, and 12% in the presence of obstructive jaundice or steatosis > 50%. The specific morbidity rate was 7% in patients with normal livers and 54% in patients with abnormal livers.
This series shows that more than 60% of liver resections can be performed without blood transfusions. These results require an appropriate surgical technique and collaboration between anesthesiologist and surgeon. Thus hepatectomies in normal non-tumorous livers can be performed without mortality. In contrast, the presence of abnormalities of the non-tumorous liver parenchyma remains a major risk factor.
在过去5年里，肝切除患者中采用了限制输血的政策。这项回顾性研究的目的是报告在此期间进行的150例肝切除手术的结果。
有63例大肝切除（42%）和87例小肝切除（58%）。64%的患者因恶性病变接受手术。对于直径大于或等于10 cm的大肿瘤以及位于腔静脉肝门交界处的肿瘤，采用肝脏血管阻断法。对于直径小于10 cm的周边病变，采用门静脉三联钳夹或门静脉叶蒂选择性钳夹。麻醉方式根据血管钳夹类型进行调整，并且刻意限制输血。在健康患者中输注红细胞以维持血细胞比容水平高于25%，在有冠状动脉疾病风险的患者中高于30%。
93例患者（62%）未接受输血。3例患者输注了超过10单位的浓缩红细胞（2%）。大肝切除患者中有48%未输血，小肝切除患者中有72%未输血。良性病变患者未输血率为93%，恶性病变患者为44%。非肿瘤性肝实质中的病理改变不影响输血需求。医院死亡率为3%（5/150）。非肿瘤性肝脏正常的患者无死亡，有肝硬化的患者死亡率为14%，有梗阻性黄疸或脂肪变性>50%的患者死亡率为12%。肝脏正常的患者特异性发病率为7%，肝脏异常的患者为54%。
该系列研究表明，超过60%的肝切除手术可以在不输血的情况下进行。这些结果需要合适的手术技术以及麻醉医生和外科医生之间的协作。因此，正常非肿瘤性肝脏的肝切除手术可以无死亡地进行。相比之下，非肿瘤性肝实质存在异常仍然是一个主要危险因素。
