肝細(xì)胞癌肝切除術(shù)后大量腹水的危險(xiǎn)因素分析
發(fā)布時(shí)間：2018-07-27 17:24
【摘要】：背景肝臟是人類(lèi)體內(nèi)最大的實(shí)質(zhì)器官,在維持機(jī)體多項(xiàng)生理功能的過(guò)程中扮演著至關(guān)重要的角色。如果肝臟發(fā)生疾病,那么人體的健康將會(huì)受到巨大的影響。在面對(duì)多種肝臟疾病時(shí),肝切除手術(shù)仍然是醫(yī)生們能夠解決問(wèn)題所可以采取的最好辦法。得益于手術(shù)疼痛、感染、止血、輸血等問(wèn)題的解決,現(xiàn)代外科學(xué)有了極大的發(fā)展,而肝臟外科發(fā)展至今也已有了百余年的歷史。目前肝切除手術(shù)所針對(duì)的主要對(duì)象是肝臟腫瘤(惡性腫瘤如原發(fā)性肝癌、繼發(fā)性肝癌;良性腫瘤如肝海綿狀血管瘤、肝腺瘤、肝脂肪瘤、肝纖維瘤等),兩者約占手術(shù)總比重的八成。其他的疾病包括肝內(nèi)膽管結(jié)石、肝內(nèi)膽道出血、外傷性肝破裂、肝膿腫、肝囊腫、肝包蟲(chóng)病等也都屬于肝切除術(shù)的適應(yīng)癥。但在臨床工作過(guò)程中,外科醫(yī)生在對(duì)接受肝切除手術(shù)治療的患者進(jìn)行圍手術(shù)期管理期間則面臨著諸多問(wèn)題,如何有效評(píng)價(jià)患者的肝儲(chǔ)備功能,制定合理的手術(shù)方案,并盡最大努力減少肝切除術(shù)后并發(fā)癥的發(fā)生率,提高患者術(shù)后的生活質(zhì)量,縮短住院時(shí)間,從而使病患獲得最大的受益則成為了重中之重。近年來(lái),伴隨著外科學(xué)技術(shù)的不斷發(fā)展,盡管一些新材料、新技術(shù)(如射頻消融技術(shù))等的相繼問(wèn)世并投入臨床應(yīng)用,病人的圍手術(shù)期管理亦得到日益改善,肝切除術(shù)后并發(fā)癥的發(fā)生率及死亡率有了明顯下降[1],然而,肝切除手術(shù)的風(fēng)險(xiǎn)仍然不容忽視。大量腹水、感染、膽漏、切口愈合不良、肝性腦病等術(shù)后并發(fā)癥的出現(xiàn),導(dǎo)致患者術(shù)后生活質(zhì)量明顯下降,住院時(shí)間也有所延長(zhǎng),這些狀況一旦出現(xiàn)便會(huì)加大患者的經(jīng)濟(jì)壓力,同時(shí)也將使其和家屬背負(fù)上更為沉重的心理負(fù)擔(dān),甚至有可能引起危及患者生命的肝功能衰竭。為了盡可能地減少這種情況的發(fā)生,在對(duì)肝細(xì)胞癌等需要接受外科治療的肝病患者進(jìn)行手術(shù)前,完善的術(shù)前準(zhǔn)備以及合理的手術(shù)規(guī)劃是十分必要的。目的明確人口學(xué)特點(diǎn)、術(shù)前常規(guī)肝功能參數(shù)、肝病背景及手術(shù)情況等因素對(duì)肝切除術(shù)后大量腹水的影響;探究肝細(xì)胞癌肝切除手術(shù)后出現(xiàn)大量腹水的危險(xiǎn)因素。資料和方法匯總2015年1月至2015年12月期間因肝細(xì)胞癌在鄭州大學(xué)第一附屬醫(yī)院肝膽胰外科接受肝切除手術(shù)治療的106例患者的臨床資料,并進(jìn)行回顧性分析。所有患者均需接受完善的術(shù)前檢測(cè)及準(zhǔn)備,依據(jù)CT、超聲等影像學(xué)檢查結(jié)果,明確腫瘤的大小、所處的位置以及其與周?chē)苤g的關(guān)系,從而合理選擇手術(shù)切除方式。患者術(shù)后住院恢復(fù)期間,依據(jù)單日最大腹水引流量10m L/kg×術(shù)前體重(kg)[2]這一定義觀察有無(wú)術(shù)后大量腹水的發(fā)生,并將所收集到的資料據(jù)此分為術(shù)后大量腹水組和非大量腹水組。對(duì)兩組患者的人口學(xué)特點(diǎn)(如年齡、性別),術(shù)前肝功能參數(shù)(如血清谷丙轉(zhuǎn)氨酶水平、血清前白蛋白水平、血清總膽紅素水平、凝血酶原活動(dòng)度、Child評(píng)分等指標(biāo)),肝病背景(如病毒性肝炎、肝硬化等)以及手術(shù)情況(肝切除手術(shù)范圍、肝門(mén)阻斷情況、術(shù)中失血量和輸血情況等)進(jìn)行單因素和多因素logistic分析,以明確肝細(xì)胞癌肝切除手術(shù)后出現(xiàn)大量腹水的危險(xiǎn)因素。結(jié)果納入研究的106例患者中,共有26例患者出現(xiàn)了肝切除術(shù)后大量腹水,其發(fā)生率為24.5%。單因素分析結(jié)果表明,肝切除術(shù)后大量腹水組與非大量腹水組在Child分級(jí)、術(shù)中輸血情況、術(shù)前門(mén)靜脈高壓、凝血酶原時(shí)間(PT)、凝血酶原活動(dòng)度(PTA)、血清谷草轉(zhuǎn)氨酶(AST)水平、谷氨酰轉(zhuǎn)肽酶(GGT)水平、堿性磷酸酶(ALP)水平、前白蛋白(PA)水平、膽堿酯酶(CHE)水平、總膽紅素(TBIL)水平、ICGR15、術(shù)中出血量以及手術(shù)時(shí)間這14個(gè)變量之間的差異具有顯著的統(tǒng)計(jì)學(xué)意義(P0.05)。多因素Logistic分析結(jié)果顯示:凝血酶原活動(dòng)度(PTA)、血清堿性磷酸酶(ALP)水平、前白蛋白(PA)水平、手術(shù)時(shí)間和術(shù)前門(mén)靜脈高壓這5個(gè)因素為肝細(xì)胞癌肝切除術(shù)后大量腹水的獨(dú)立危險(xiǎn)因素。結(jié)論1.肝細(xì)胞癌肝切除術(shù)后大量腹水仍有著較高的發(fā)生率(24.5%)。2.術(shù)前凝血酶原活動(dòng)度低、前白蛋白(PA)水平低、血清堿性磷酸酶(ALP)水平高、存在術(shù)前門(mén)靜脈高壓以及手術(shù)時(shí)間較長(zhǎng)的肝細(xì)胞癌患者在接受肝切除術(shù)后更容易出現(xiàn)大量腹水。3.在對(duì)肝細(xì)胞癌患者施行肝切除手術(shù)前,全面、準(zhǔn)確的肝功能評(píng)估是十分必要的。外科醫(yī)生在對(duì)肝細(xì)胞癌手術(shù)患者進(jìn)行篩選及制定臨床治療方案時(shí)應(yīng)充分考慮手術(shù)治療益處和風(fēng)險(xiǎn)之間的平衡。
[Abstract]:The liver is the largest substance in the human body and plays a vital role in maintaining a number of physiological functions. If the liver is a disease, the health of the body will be greatly affected. In the face of a variety of liver diseases, hepatectomy is still a problem that doctors can take to solve the problem. The best way. Thanks to the problem of surgical pain, infection, hemostasis, and blood transfusion, modern surgery has developed greatly, and liver surgery has been developed for more than 100 years. The main target of hepatectomy is liver tumor (malignant tumor such as primary liver cancer, secondary liver cancer, and benign tumor such as the liver sea). Cavernous hemangioma, hepatic adenoma, hepatic lipoma, hepatofibroma, etc., which account for about 80% of the total proportion of the operation. Other diseases including intrahepatic bile duct stones, intrahepatic biliary bleeding, traumatic liver rupture, liver abscess, hepatic cyst, hepatic echinococcosis, etc. are also indications of hepatectomy, but in clinical work, surgeons are butting the liver. The patients undergoing surgical treatment are faced with many problems during the period of perioperative management. How to effectively evaluate the patient's liver reserve function and make a reasonable operation plan, and make the best efforts to reduce the incidence of complications after hepatectomy, improve the quality of life and shorten the time of hospitalization, so that the patients can get the most. In recent years, with the continuous development of surgical techniques, although some new materials and new technologies, such as radiofrequency ablation technology, have been developed and put into clinical application, the perioperative management of patients has been improved, the incidence and mortality of complications after hepatectomy have been significantly reduced by [1], The risk of hepatectomy is still not to be ignored. A large number of ascites, infection, bile leakage, poor healing of the incision, hepatic encephalopathy and other postoperative complications, resulting in a significant decline in the quality of life and prolonged hospitalization of the patients. These conditions will add to the economic pressure of the patients as soon as they appear, and they will also bring them to their families. A heavier psychological burden may even cause liver failure that threatens the life of the patient. In order to reduce the occurrence of this situation as much as possible, it is necessary to complete pre operation preparation and reasonable hand planning before surgery for hepatopathy, such as hepatocellular carcinoma, which need to be treated with surgical treatment. The effects of preoperative routine liver function parameters, liver disease background and operation conditions on a large number of ascites after hepatectomy, and the risk factors of massive ascites after hepatectomy for hepatectomy. Data and methods were collected from January 2015 to December 2015, due to hepatocyte carcinoma at the First Affiliated Hospital of Zhengzhou University, hepatobiliary and pancreatic surgery. The clinical data of 106 patients treated with hepatectomy were analyzed retrospectively. All patients were required to undergo complete preoperative examination and preparation. According to the results of CT, ultrasound and other imaging examinations, the size of the tumor, the location and the relationship with the peripheral vessels were clearly defined, and the surgical resection was reasonably selected. During the post hospital recovery, a large number of ascites were observed on the basis of the definition of 10m L/kg (kg) [2] before operation, and the data collected were classified into a large number of ascites and non large ascites. The demographic characteristics of the two groups (such as age, sex), and preoperative liver function parameters (such as blood, such as blood) Single factor and multiple factor Logistic analysis of the level of propane aminotransferase, serum prealbumin, serum total bilirubin, prothrombin activity, Child score, and liver disease background (such as viral hepatitis, cirrhosis, etc.) and operation (hepatectomy, hepatic portal blockage, intraoperative blood loss and blood transfusion) To determine the risk factors for a large number of ascites after hepatectomy for hepatocellular carcinoma. Results of the 106 patients enrolled in the study, a total of 26 patients had a large number of ascites after hepatectomy, the incidence of which was 24.5%. single factor analysis showed that a large number of ascites and non large ascites after hepatectomy were classified by Child and intraoperative blood transfusion, Preoperation portal hypertension, prothrombin time (PT), prothrombin activity (PTA), serum glutamic aminotransferase (AST) level, glutamyl transaminopeptidase (GGT) level, alkaline phosphatase (ALP) level, prealbumin (PA) level, cholinesterase (CHE) level, total bilirubin (TBIL) level, ICGR15, intraoperative hemorrhage and operation time between the 14 variables The difference had significant statistical significance (P0.05). The results of multifactor Logistic analysis showed that the 5 factors, prothrombin activity (PTA), serum alkaline phosphatase (ALP) level, prealbumin (PA) level, operation time and anterior portal hypertension were independent risk factors for massive ascites after hepatectomy for hepatocarcinoma. Conclusion 1. liver cell carcinoma liver After excision, a large number of ascites still have a high incidence (24.5%) before.2., prothrombin activity is low, prealbumin (PA) is low, serum alkaline phosphatase (ALP) is high. There is a lot of ascites in the patients with hepatocellular carcinoma with high pressure of anterior portal vein and long operation time, and a large amount of ascites.3. is more likely to be in the liver cell carcinoma after hepatectomy. A comprehensive and accurate assessment of liver function is necessary before the resection of the hepatectomy. Surgeons should take full consideration of the balance between the benefits and risks of surgical treatment when screening and formulating a clinical treatment for patients with hepatocellular carcinoma.
【學(xué)位授予單位】：鄭州大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類(lèi)號(hào)】：R735.7
本文編號(hào)：2148593
[Abstract]:The liver is the largest substance in the human body and plays a vital role in maintaining a number of physiological functions. If the liver is a disease, the health of the body will be greatly affected. In the face of a variety of liver diseases, hepatectomy is still a problem that doctors can take to solve the problem. The best way. Thanks to the problem of surgical pain, infection, hemostasis, and blood transfusion, modern surgery has developed greatly, and liver surgery has been developed for more than 100 years. The main target of hepatectomy is liver tumor (malignant tumor such as primary liver cancer, secondary liver cancer, and benign tumor such as the liver sea). Cavernous hemangioma, hepatic adenoma, hepatic lipoma, hepatofibroma, etc., which account for about 80% of the total proportion of the operation. Other diseases including intrahepatic bile duct stones, intrahepatic biliary bleeding, traumatic liver rupture, liver abscess, hepatic cyst, hepatic echinococcosis, etc. are also indications of hepatectomy, but in clinical work, surgeons are butting the liver. The patients undergoing surgical treatment are faced with many problems during the period of perioperative management. How to effectively evaluate the patient's liver reserve function and make a reasonable operation plan, and make the best efforts to reduce the incidence of complications after hepatectomy, improve the quality of life and shorten the time of hospitalization, so that the patients can get the most. In recent years, with the continuous development of surgical techniques, although some new materials and new technologies, such as radiofrequency ablation technology, have been developed and put into clinical application, the perioperative management of patients has been improved, the incidence and mortality of complications after hepatectomy have been significantly reduced by [1], The risk of hepatectomy is still not to be ignored. A large number of ascites, infection, bile leakage, poor healing of the incision, hepatic encephalopathy and other postoperative complications, resulting in a significant decline in the quality of life and prolonged hospitalization of the patients. These conditions will add to the economic pressure of the patients as soon as they appear, and they will also bring them to their families. A heavier psychological burden may even cause liver failure that threatens the life of the patient. In order to reduce the occurrence of this situation as much as possible, it is necessary to complete pre operation preparation and reasonable hand planning before surgery for hepatopathy, such as hepatocellular carcinoma, which need to be treated with surgical treatment. The effects of preoperative routine liver function parameters, liver disease background and operation conditions on a large number of ascites after hepatectomy, and the risk factors of massive ascites after hepatectomy for hepatectomy. Data and methods were collected from January 2015 to December 2015, due to hepatocyte carcinoma at the First Affiliated Hospital of Zhengzhou University, hepatobiliary and pancreatic surgery. The clinical data of 106 patients treated with hepatectomy were analyzed retrospectively. All patients were required to undergo complete preoperative examination and preparation. According to the results of CT, ultrasound and other imaging examinations, the size of the tumor, the location and the relationship with the peripheral vessels were clearly defined, and the surgical resection was reasonably selected. During the post hospital recovery, a large number of ascites were observed on the basis of the definition of 10m L/kg (kg) [2] before operation, and the data collected were classified into a large number of ascites and non large ascites. The demographic characteristics of the two groups (such as age, sex), and preoperative liver function parameters (such as blood, such as blood) Single factor and multiple factor Logistic analysis of the level of propane aminotransferase, serum prealbumin, serum total bilirubin, prothrombin activity, Child score, and liver disease background (such as viral hepatitis, cirrhosis, etc.) and operation (hepatectomy, hepatic portal blockage, intraoperative blood loss and blood transfusion) To determine the risk factors for a large number of ascites after hepatectomy for hepatocellular carcinoma. Results of the 106 patients enrolled in the study, a total of 26 patients had a large number of ascites after hepatectomy, the incidence of which was 24.5%. single factor analysis showed that a large number of ascites and non large ascites after hepatectomy were classified by Child and intraoperative blood transfusion, Preoperation portal hypertension, prothrombin time (PT), prothrombin activity (PTA), serum glutamic aminotransferase (AST) level, glutamyl transaminopeptidase (GGT) level, alkaline phosphatase (ALP) level, prealbumin (PA) level, cholinesterase (CHE) level, total bilirubin (TBIL) level, ICGR15, intraoperative hemorrhage and operation time between the 14 variables The difference had significant statistical significance (P0.05). The results of multifactor Logistic analysis showed that the 5 factors, prothrombin activity (PTA), serum alkaline phosphatase (ALP) level, prealbumin (PA) level, operation time and anterior portal hypertension were independent risk factors for massive ascites after hepatectomy for hepatocarcinoma. Conclusion 1. liver cell carcinoma liver After excision, a large number of ascites still have a high incidence (24.5%) before.2., prothrombin activity is low, prealbumin (PA) is low, serum alkaline phosphatase (ALP) is high. There is a lot of ascites in the patients with hepatocellular carcinoma with high pressure of anterior portal vein and long operation time, and a large amount of ascites.3. is more likely to be in the liver cell carcinoma after hepatectomy. A comprehensive and accurate assessment of liver function is necessary before the resection of the hepatectomy. Surgeons should take full consideration of the balance between the benefits and risks of surgical treatment when screening and formulating a clinical treatment for patients with hepatocellular carcinoma.
【學(xué)位授予單位】：鄭州大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類(lèi)號(hào)】：R735.7
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