Elias D, Dubé P, Bonvalot S, Debanne B, Plaud B, Lasser P
Department of Digestive Oncologic Surgery, Institute Gustave-Roussy, Villejuif, France.
Hepatogastroenterology. 1998 Mar-Apr;45(20):389-95.
BACKGROUND/AIMS: Complete intermittent vascular exclusion of the liver (IVEL) combines clamping of the hepatic pedicle with clamping of the hepatic veins without interruption of the caval flow. The major advantages of this technique are that patient preclamping fluid overload is avoided, major haemodynamic changes due to caval clamping are escaped, and it allows a very long clamping time. Disadvantage of this technique is the necessity of looping the terminal part of the hepatic veins.
In this prospective study, 41 cases of IVEL (Representing 19% of the hepatectomies carried out for cancer during the same period) used for difficult hepatectomies were analyzed, and the operative technique is presented.
IVEL was feasible in 90% of the 46 attempted cases, and completely controlled the bleeding in 90% of the cases. The mean duration of IVEL was 69.2 minutes (Range: 37 to 140), and was greater than 130 minutes in three patients. No liver failure occurred during the postoperative course.
We conclude that IVEL without caval clamping is a new, and valuable, technique of vascular exclusion of the liver. Its application is indicated in the following conditions: 1. For patients who should have classical vascular exclusion but cannot tolerate vena cava clamping (18% of the cases), 2. for patients with pathological liver parenchyma when intrahepatic venous pressure is high, 3. for patients with impaired liver parenchyma, requiring conservative surgery that leads to anatomic or non-anatomic resection close to a vein (Example: A tumor located in the dihedral angle of the terminal part of two hepatic veins), 4. for patients with tumors closely located to a hepatic vein that must be preserved and sharply dissected (Example: A left trisegmentectomy that requires pelting of the right hepatic vein), and 5. for the scarce patient with tumors infiltrating the major hepatic veins, constraining a hepatic vein reconstruction to preserve liver function.
背景/目的：肝脏完全间歇性血管阻断术（IVEL）是将肝蒂阻断与肝静脉阻断相结合，而不中断腔静脉血流。该技术的主要优点是避免了患者夹闭前的液体超负荷，避免了因腔静脉夹闭引起的主要血流动力学变化，并且允许非常长的夹闭时间。该技术的缺点是需要环绕肝静脉的末端部分。
在这项前瞻性研究中，分析了41例用于困难肝切除术的IVEL病例（占同期因癌症进行肝切除术的19%），并介绍了手术技术。
在46例尝试的病例中，90%可行IVEL，90%的病例出血得到完全控制。IVEL的平均持续时间为69.2分钟（范围：37至140分钟），3例患者的持续时间超过130分钟。术后过程中未发生肝衰竭。
我们得出结论，不进行腔静脉夹闭的IVEL是一种新的、有价值的肝脏血管阻断技术。其应用适用于以下情况：1. 对于应进行经典血管阻断但不能耐受腔静脉夹闭的患者（18%的病例）；2. 肝实质病理改变且肝内静脉压高的患者；3. 肝实质受损、需要进行保守手术且手术接近静脉导致解剖或非解剖切除的患者（例如：位于两条肝静脉末端二面角的肿瘤）；4. 肿瘤紧邻必须保留并进行锐性解剖的肝静脉的患者（例如：需要保留右肝静脉的左三叶切除术）；5. 肿瘤浸润主要肝静脉、需要进行肝静脉重建以保留肝功能的罕见患者。
