全肝血流阻断和肝静脉阻断对肝肿瘤切除术中血流动力学的影响比较.doc

全肝血流阻断和肝静脉阻断对肝肿瘤切除术中血流动力学的影响比较 　　作者：傅思源，孙玉明，李爱军，周伟平，潘泽亚，俞卫锋，吴孟超　 作者单位：(第二军医大学附属东方肝胆外科医院 肝外三科，上海 200438) 　　【摘要】 目的 探讨阻断下腔静脉的全肝血流阻断(total hepatic vascular exclusion，THVE)和肝静脉阻断(selective hepatic vascular exclusion，SHVE)对肝肿瘤切除术中血流动力学的影响。方法 40例肝切除术患者随机分为THVE组和SHVE组，术中置入Swan-Ganz导管记录肝切除术血管阻断前后的血流动力学变化，比较两组临床资料。结果 THVE组外围循环阻力(SVR)和肺循环阻力(PVR)与SHVE组比较有明显的升高，而心脏指数(CI)、平均动脉压(MAP)和平均肺动脉压(MPAP)则有明显的下降(P0.05) 。前者术中输液量较后者多，两组术后肝肾功能及并发症差异无统计学意义(P0.05)。结论 肝切除术中SHVE和THVE均能有效控制出血和避免空气栓塞，而前者在保持全身血流动力学稳定并减少术中输液量方面更有优势。 　　【关键词】 肝肿瘤;肝切除术;全肝血流阻断;肝静脉阻断;血流动力学 　　Abstract Objective To explore and discuss the effects of total hepatic vascular exclusion (THVE) and selective hepatic vascular exclusion (SHVE) on hemodynamic changes in hepatic resections. Methods Patients undergone major liver resection were randomly allocated to the THVE and SHVE groups. Swan-Ganz catheter was inserted into patients to record the hemodynamic changes. Hemodynamic changes during the resections and after vascular occlusion between the two groups were compared. The postoperative course was also compared. Results Compared with the SHVE group during vascular clamping， the THVE group showed a significant elevation in PVR and SVR， and a significant reduction in CI， MAP and MPAP (P0.05). Patients undergone THVE received more crystalloids and blood， but showed no significant difference in liver and renal dysfunction， and postoperative complications (P0.05). Conclusion Both vascular exclusion techniques are equally effective in bleeding control in liver neoplasma resections. Hepatic veins occlusion in the hepatectomy is safer， more effective and better hemodynamics， especially for preventing from bleeding and air embolism. 　　Key words liver neoplasma; hepatectomy; total hepatic vascular exclusion; hepatic veins exclusion; hemodynamics 肝肿瘤切除术最严重的并发症是肝静脉破裂导致致命的大出血和空气栓[1]。以往的有效手段是阻断下腔静脉的全肝血流阻断(total hepatic vascular exclusion，THVE)，但这种方法有可能造成全身血流动力学紊乱，部分患者无法耐受[2]。肝静脉阻断(selective hepatic vascular exclusion，SH