【摘要】：目的我國是肝癌的高發(fā)區(qū),肝切除術(partial hepatectomy,PH)仍然是其目前唯一的根治性治療手段。PH術后肝臟能否恢復功能,直接影響了手術治療的效果。隨著生活水平的提高,糖尿病、高血壓、高血脂等代謝相關疾病的發(fā)病率逐漸增高,脂肪肝已成為肝臟最常見的實質性病變之一。其對肝切除術圍術期的影響報道甚多,但多為基礎研究,目前尚缺乏可靠的臨床數(shù)據。因此,本文就肝臟脂肪變性對肝切除術術中及術后并發(fā)癥發(fā)生率、術后肝再生(liver regeneration,LR)等方面作一探討。方法選取南京鼓樓醫(yī)院2010年10月一2014年10月238例因肝癌行PH的患者的臨床資料�；仡櫺允占虢M病人的術前血清學、影像學數(shù)據,術中手術情況,術后恢復狀況及病理相關資料,測量術前及術后肝臟體積,探討肝臟脂肪變性對PH圍手術期并發(fā)癥發(fā)生率及術后肝再生的影響。結果238例患者中正常組176例,包括左半肝組92例,右半肝組84例,輕度脂肪變性組40例,包括左半肝組22例,右半肝組18例,中重度脂肪變性組22例,包括左半肝組12例,右半肝組10例。正常組、輕度脂肪變性組、中重度脂肪變性組在性別、年齡、肝硬化程度、有無肝炎等術前資料上無差異。輕度脂肪變性組、中重度脂肪變性組的體質指數(shù)(Body Mass Index,BMI)均高于對照組(P0.05)。術前血清學檢查中甘油三酯(Triglyceride,TG)、總膽固醇(total cholesterol,TCHO)、低密度脂蛋白(low densith lipoprotein, LDL)、谷丙轉氨酶(Alanine transaminase, ALT)、谷草轉氨酶(Aspartate transaminase,AST)、尿酸(Uric acid,UA)在脂肪肝組中的水平均明顯高于對照組(P0.05),且隨著脂肪肝的嚴重程度而逐漸升高。高密度脂蛋白(high densith lipoprotein,HDL)、AST/ALT值在脂肪肝組中低于正常組,且隨著脂肪肝程度的加重而逐漸降低(P0.05)。中重度脂肪肝組血小板(blood platelet, PLT)計數(shù)低于正常組(P0.05),輕度脂肪肝組與正常組PLT計數(shù)無差異(P0.05)。正常組、輕度脂肪變性組、中重度脂肪變性組之間膽紅素水平無明顯差異(P0.05)。術前用肝脾電子計算機斷層值(Computed Tomography,CT)比值標準診斷脂肪肝正確率為74.4%。用肝血管相對密度標準判斷,準確率為84.1%。相對于輕度脂肪變性組、正常組,中重度脂肪變性組的手術時間、肝血流阻斷時間、出血量、輸血率、ICU入住率、術后恢復時間、總住院時間,術后并發(fā)癥發(fā)生率及需要治療的并發(fā)癥發(fā)生率均明顯提高(P0.05),而正常組與輕度脂肪變性組間無差異。采用Logisitic多因素模型分析提示脂肪變性是影響PH術后并發(fā)癥發(fā)生率增高的獨立危險因素(P0.05)。正常組、輕度脂肪變性組、中重度脂肪變性組術后ALT、AST、總膽紅素在各個時象點雖有差異,但無統(tǒng)計學意義。輕度脂肪變性對肝再生的影響較小(P0.05),中重度脂肪變性明顯抑制肝再生(P0.05)。通過多重線性回歸分析模型提示肝切除量和肝脂肪變性均是影響PH術后肝再生的危險因素。結論1.中重度脂肪變性可延長肝切除術的手術時間、肝血流阻斷時間、術后恢復時間、總住院時間,增加出血量、術后并發(fā)癥發(fā)生率及需要治療的并發(fā)癥發(fā)生率。輕度脂肪變性對肝切除術圍術期未見明顯影響。2.輕度脂肪變性對肝切除術后肝再生無明顯影響,中重度脂肪變性明顯抑制肝再生。
[Abstract]:Objective: Our country is the high incidence area of liver cancer, and liver resection (PH) is still the only radical therapy. The recovery of liver function after PH directly affects the effect of surgical treatment. With the improvement of living standard, the incidence of metabolic related diseases such as diabetes, hypertension and hyperlipemia is increasing, fatty liver has become one of the most common pathological changes in liver. There are many reports on the perioperative period of hepatectomy, but there are no reliable clinical data at present. Therefore, the incidence of hepatic steatosis in liver resection and postoperative complications, liver regeneration (LR) and so on are discussed in this paper. Methods The clinical data of 238 patients with liver cancer underwent PH were selected from October, 2010 to October, 2014 in Nanjing Drum Tower Hospital. To retrospectively collect pre-operation serology, imaging data, intraoperative operative condition, postoperative recovery status and postoperative liver volume of patients in group, to investigate the influence of hepatic steatosis on the incidence of postoperative complications and post-operative liver regeneration in PH peri-operative period. Results Among 238 patients, 176 cases were normal group, including 92 cases of left half liver group, 84 cases of right half liver group and 40 cases of mild fatty degeneration group, including 22 cases of left half liver group, 18 cases of right half liver group and 22 cases of moderate to severe fat degeneration group, including 12 cases of left half liver group and 10 cases of right half liver group. There was no difference in sex, age, degree of liver cirrhosis, presence or absence of hepatitis, etc. in normal group, mild fatty degeneration group and moderate to severe fatty degeneration group. Body Mass Index (BMI) was higher in mild fatty degeneration group than in control group (P0.05). Triglycerides (TG), total cholesterol (TCHO), low density lipoprotein (LDL), glutamic pyruvic transaminase (ALT), glutamic oxaloacetic transaminase (AST), uric acid (Uric acid, The level of UA in the fatty liver was significantly higher than that in the control group (P0.05), and the level of fatty liver gradually increased with the severity of fatty liver. The values of high density lipoprotein (HDL) and AST/ ALT were lower in the fatty liver group than in the control group (P0.05). There was no difference in platelet count in patients with moderate and severe fatty liver (P0.05), and there was no difference between mild fatty liver and normal group (P0.05). There was no significant difference in bilirubin level between normal group and mild fatty degeneration group (P0.05). The accuracy of diagnosis of fatty liver was 74. 4% with computed tomography (CT) ratio standard before operation. The accuracy rate was 84.1%. Relative to mild fatty degeneration group, normal group, operation time of moderate to severe fatty degeneration group, hepatic blood flow occlusion time, blood loss, transfusion rate, ICU admission rate, postoperative recovery time, total hospital stay time, The incidence of postoperative complications and the incidence of complications requiring treatment were significantly increased (P0.05), and there was no difference between the normal group and the mild fatty degeneration group. Logistic multi-factor model analysis suggested that fat denaturation was an independent risk factor affecting the incidence of postoperative complications (P0.05). ALT, AST and total bilirubin were different in normal group, mild fatty degeneration group and moderate to severe fatty degeneration group, but there was no statistical significance. The effect of mild fatty degeneration on liver regeneration was small (P0.05). Through multiple linear regression analysis model, it is suggested that liver resection and liver fat degeneration are the risk factors affecting liver regeneration after PH. Conclusion 1. Moderate and severe fat degeneration can prolong the operation time of hepatectomy, hepatic blood flow blocking time, postoperative recovery time, total hospital stay time, increase blood loss, postoperative complication rate and complication rate needing treatment. Mild fatty degeneration did not significantly affect the peri-operative period of hepatectomy. Mild fatty degeneration has no obvious effect on liver regeneration after hepatectomy, and moderate to severe fat degeneration significantly inhibits liver regeneration.
【學位授予單位】：東南大學
【學位級別】：碩士
【學位授予年份】：2015
【分類號】：R657.3

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