Man K, Fan S T, Ng I O, Lo C M, Liu C L, Wong J
Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong.
Ann Surg. 1997 Dec;226(6):704-11; discussion 711-3. doi: 10.1097/00000658-199712000-00007.
To evaluate whether vascular inflow occlusion by the Pringle maneuver during hepatectomy can be safe and effective in reducing blood loss.
Hepatectomy can be performed with a low mortality rate, but massive hemorrhage during surgery remains a potentially lethal problem. The Pringle maneuver is traditionally used during hepatectomy to reduce blood loss, but there is a potential harmful effect on the metabolic function of hepatocytes. There has been no prospective randomized study to determine whether the Pringle maneuver can decrease blood loss during hepatectomy, improve outcome, or affect the metabolism of hepatocytes.
From July 1995 to February 1997, we studied 100 consecutive patients who underwent hepatectomy for liver tumors. The patients were randomly assigned to liver transection under intermittent Pringle maneuver of 20 minutes and a 5-minute clamp-free interval (n = 50), or liver transection without the Pringle maneuver (n = 50). The surface area of liver transection was measured and blood loss during transection per square centimeter of transection area was calculated. Routine liver biochemistry, arterial ketone body ratio (AKBR), and the indocyanine green (ICG) clearance test were done.
The two groups were comparable in terms of preoperative liver function and in the proportion of patients having major hepatectomy. The Pringle maneuver resulted in less blood loss per square centimeter of transection area (12 mL/cm2 vs. 22 mL/cm2, p = 0.0001), a shorter transection time per square centimeter of transection area (2 min/cm2 vs. 2.8 min/cm2, p = 0.016), a significantly higher AKBR in the first 2 hours after hepatectomy, lower serum bilirubin levels in the early postoperative period, and, in cirrhotic patients, higher serum transferrin levels on postoperative days 1 and 8. The complication rate, the hospital mortality rate, and the ICG retention at 15 minutes on postoperative day 8 were equal for the two groups.
Performing the Pringle maneuver during liver transection resulted in less blood loss and better preservation of liver function in the early postoperative period. This is probably because there was less hemodynamic disturbance induced by the bleeding.
评估肝切除术中应用普林格尔手法阻断血管流入是否能安全有效地减少失血。
肝切除术可在低死亡率下进行，但手术期间的大量出血仍是一个潜在的致命问题。传统上，肝切除术中会使用普林格尔手法来减少失血，但这对肝细胞的代谢功能有潜在的有害影响。尚无前瞻性随机研究来确定普林格尔手法是否能减少肝切除术中的失血、改善预后或影响肝细胞的代谢。
1995年7月至1997年2月，我们研究了100例连续接受肝肿瘤肝切除术的患者。患者被随机分为两组，一组在间歇性普林格尔手法（阻断20分钟，无阻断间隔5分钟）下进行肝断面切割（n = 50），另一组不采用普林格尔手法进行肝断面切割（n = 50）。测量肝断面面积，并计算每平方厘米断面面积的术中失血量。进行常规肝功能检查、动脉酮体比率（AKBR）和吲哚菁绿（ICG）清除试验。
两组在术前肝功能及接受大肝切除术患者的比例方面具有可比性。普林格尔手法使每平方厘米断面面积的失血量减少（12 mL/cm² 对 22 mL/cm²，p = 0.0001），每平方厘米断面面积的切割时间缩短（2分钟/cm² 对 2.8分钟/cm²，p = 0.016），肝切除术后最初2小时的AKBR显著升高，术后早期血清胆红素水平降低，在肝硬化患者中，术后第1天和第8天血清转铁蛋白水平升高。两组的并发症发生率、医院死亡率以及术后第8天15分钟时的ICG潴留率相同。
肝断面切割时应用普林格尔手法可减少失血，并在术后早期更好地保护肝功能。这可能是因为出血引起的血流动力学干扰较小。
