探讨选择性肝静脉血流阻断术（SHVE）在肝血管瘤切除术中的临床应用价值。

本回顾性研究对象为2003年1月至2010年12月在上海第二军医大学附属东方肝胆外科医院收治的肿瘤直径>5 cm，且肿瘤位于肝静脉、下腔静脉结合部，至少压迫1支主肝静脉（肝左、中、右静脉）的232例肝血管瘤切除术患者。患者均签署知情同意书，符合医学伦理学规定。根据肝血流阻断方法将患者分为SHVE组和Pringle肝门血流阻断组（Pringle组）。SHVE组首先采用Pringle第一肝门血流阻断，术中采用肝静脉止血带阻断和Satinsky钳阻断两种方式。SHVE组92例，男性41例，女性51例，平均年龄45岁；Pringle组140例，男性62例，女性78例，平均年龄43岁。记录两组患者的手术时间、肝脏热缺血时间、术中出血量、输血量、术后重症监护病房（ICU）监护时间及术后住院时间，观察术中、术后并发症及术中改用全肝血流阻断（THVE）、再次手术及死亡发生情况。采用t检验或秩和检验比较两组患者手术时间、肝脏热缺血时间、术中出血量、输血量、术后ICU监护时间及术后住院时间，采用χ²检验和Fisher确切概率法比较术中、术后并发症及改用THVE、再次手术及死亡发生情况。

SHVE组患者手术时间（140±65）min、术中出血量300~1 600（600）ml、输血量0~8（2）U，Pringle组分别为（127±40）min、500~7 000（1 000）ml、0~33（4）U，各项指标比较差异有统计学意义（P<0.05~P<0.01）。SHVE组中无输血者占70%（64/92），Pringle组占46%(65/140)，比较差异有统计学意义（χ²=12.0，P<0.01）。SHVE组主肝静脉撕裂者占13%（12/92），大出血者占7%（6/92），无空气栓塞；Pringle组主肝静脉撕裂者占12%（17/140），大出血者占19%（27/140），发生空气栓塞者占4%（5/140），两组大出血发生率比较差异有统计学意义（χ²=7.41，P<0.01）。SHVE组无改用THVE者，Pringle组10例改用THVE行肝静脉修补术，两组比较差异有统计学意义（P<0.01）。SHVE组术后ICU监护时间和术后住院时间比较差异无统计学意义（Z=0.87、0.34，均为P>0.05）。SHVE组和Pringle组术后并发症总体发生率分别为17%（16/92）和30%（42/140），两组比较差异有统计学意义（χ²=4.33，P<0.05）；两组大出血、肝衰竭、多器官功能障碍综合征（MODS）、胆漏、腹腔感染和胸腔积液发生率比较差异均无统计学意义（均为P>0.05）。两组各有2例患者因肝创面出血再次手术。SHVE组无发生手术相关死亡，Pringle组2例死亡，分别死于空气栓塞及MODS，两组手术相关死亡率比较差异亦无统计学意义（P=0.67）。

对位于肝静脉、下腔静脉结合部肝血管瘤行切除手术时，SHVE在控制因肝静脉撕裂导致的大出血及预防术后并发症等方面具有一定优势，能明显减少术中出血量及降低术后并发症的发生率。

To assess the application value of selective hepatic vascular exclusion (SHVE) in the resection for liver hemangioma.

Two hundred and thirty-two patients with liver hemangioma were included in this retrospective study. All the patients underwent liver hemangioma resection from January 2003 to December 2010 in the East Hepatobilliary Surgery Hospital with the tumor size over 5 cm and located in the junction of hepatic veins and postcava and oppressing at least one of the three major hepatic veins (right, middle or left). Local ethical committee approval was received and that the informed consent of all participating subjects was obtained. The patients were divided into SHVE group and Pringle maneuver (Pringle) group according to the methods vascular of occlusion. Pringle maneuver was conducted primarily in the SHVE group and hepatic vein tourniquet and Satinsky clamp were applied during the operation. In the SHVE group, there were 41 males and 51 females with average age of 45 years old. In the Pringle group, there were 61 males and 78 females with average age of 43 years old. The operation time, liver warm ischemia time, blood loss and transfusion during the operation, the postoperative Intensive Care Unit (ICU) stay and hospital stay were recorded and compared using the t test or Wilcoxon test. The complications during and after the operation, resorting to total hepatic vascular exclusion (THVE), reoperation and death were monitored and were compared using the χ² test or Fisher exact test.

In the SHVE group, the median operation time was (140±65) min, the blood loss during the operation was 300-1 600 (600 ml), the blood transfusion was 0-8 (2) units. However, the corresponding indexes were (127±40) min、500-7 000 (1 000) ml、0-33 (4) unites respectively in the Pringle group. There were significant differences between 2 groups in each index (P<0.05, P<0.01). The percentage of patients without a blood transfusion in the SHVE group was 70%(64/92) and 46%(65/140) in the Pringle group. There were significant differences between 2 groups(χ²=12.0, P<0.01). The percentages of patients in the SHVE group with lacerated major hepatic veins and massive blood loss were 13%(12/92) and 7%(6/92) respectively. And no air embolism occurred. While in the Pringle group, the percentages of patients lacerated major hepatic veins and massive blood loss were 12%(17/140) and 19%(27/140) respeetively. Five patients (5/140, 4%) in the Pringle group developed air embolism. There were significant differences between 2 groups in the incidence of massive blood loss(χ²=7.41, P<0.01). There were no patients resorted to THVE in the SHVE group while 10 cases converted to THVE in the Pringle group. There were significant differences between 2 groups(P<0.01). There was no significant difference between 2 groups in the postoperative ICU stay and hospital stay (Z=0.87, 0.34; all in P>0.05) . The incidence of postoperative complications in the SHVE group and Pringle group were 17(16/92) and 31%(43/140) respectively. There were significant differences between 2 groups(χ²=4.33, P<0.01). There was no significant difference between 2 groups in the incidence of massive blood loss, liver failure, multiple organ dysfunction syndrome(MODS), bile leak, abdominal infection, pleural effusion (all in P>0.05). Two patients underwent reoperation in both groups for the bleeding of liver wounds. No death was observed in the SHVE group. Two cases died of air embolism and MODS respectively in the Pringle group. There was also no significant difference between 2 groups in the operative mortality.

In the hepatectomy for liver hemangioma located in the junction of hepatic veins and postcava, SHVE has some advantages in controlling the massive blood loss of lacerated hepatic veins and preventing the postoperative complications. It can reduce the intraoperative bleeding and the incidence of postoperative complications.