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中华肝脏外科手术学电子杂志

中华肝脏外科手术学电子杂志 ›› 2017, Vol. 06 ›› Issue (04): 293 -297. doi: 10.3877/cma.j.issn.2095-3232.2017.04.013

所属专题： 文献；

临床研究

围手术期血浆输注对肝切除术后并发症影响及其相关因素
卢强1, 李青山1, 张静1, 任一凡1, 张谞丰1, 吕毅1,†()   
  1. 1. 710061　西安交通大学第一附属医院肝胆外科　西安交通大学先进外科与工程研究所
  • 收稿日期:2017-05-17 出版日期:2017-08-10
  • 通信作者: 吕毅
  • 基金资助:
    国家自然科学基金(81372582)

Effects and correlative factors of perioperative fresh frozen plasma transfusion on complications after hepatectomy

Qiang Lu1, Qingshan Li1, Jing Zhang1, Yifan Ren1, Xufeng Zhang1, Yi Lyu1,†()   

  1. 1. Department of Hepatobiliary Surgery, the First Affiliated Hospital of Xi'an Jiaotong University; Institute of Advanced Surgical Technology and Engineering, Xi'an Jiaotong University, Xi'an 710061, China
  • Received:2017-05-17 Published:2017-08-10
  • Corresponding author: Yi Lyu
  • About author:
    Corresponding author:Lyu Yi, Email:
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目的

探讨围手术期新鲜冰冻血浆（FFP）输注对肝切除术后并发症影响及其相关因素。

方法

回顾性分析2009年8月至2015年9月在西安交通大学第一附属医院行肝切除术的613例患者临床资料。根据围手术期有否输注FFP将患者分为FFP输注组（FFP组）和FFP未输注组（对照组）。其中FFP组383例，男303例，女80例；平均年龄（53.0±1.0）岁。对照组230例，男173例，女57例；年龄（53.0±1.0）岁。患者均签署知情同意书，符合医学伦理学规定。采用倾向得分匹配（PSM）法对两组患者进行匹配，术后并发症发生率比较采用χ2检验或Fisher确切概率法，将患者临床参数纳入影响FFP输注的影响因素，相关因素分析采用Logistic回归。

结果

经过PSM之后共获得147对匹配患者，匹配后FFP组的术后总体并发症发生率为45.6%（67/147），明显高于对照组的33.3%（49/147） （χ2=4.61，P<0.05）。其中FFP组的术后腹腔积液发生率为31.3%（46/147），明显高于对照组的15.6%（23/147） （χ2=10.02，P<0.05）。Logistic回归分析显示，体重指数（BMI）≤18.50 kg/m2、美国麻醉医师协会（ASA）分级Ⅲ～Ⅳ级、ALB≤40 g/L、Plt≤100×109/L、手术时间>180 min、术中出血量>500 ml、有第一肝门阻断、半肝及半肝以上切除均为围手术期FFP输注的独立影响因素（OR=3.14，2.01，1.76，1.65，1.85，3.16，1.62，1.68；P<0.05）。

结论

围手术期FFP输注可增加肝切除术后腹腔积液的发生率，消瘦、麻醉耐受力差、手术范围大、术中出血量多为决定患者FFP输注的关键因素。

关键词: 肝切除术, 围手术期, 血浆, 术后并发症
Objective

To investigate the effects and correlative factors of perioperative fresh frozen plasma (FFP) transfusion on complications after hepatectomy.

Methods

Clinical data of 613 patients who underwent hepatectomy in the First Affiliated Hospital of Xi'an Jiaotong University between August 2009 and September 2015 were retrospectively analyzed. According to the patients received perioperative FFP transfusion or not, the patients were divided into the FFP transfusion group (FFP group, n=383) andnon-FFP transfusion group (control group, n=230). In the FFP group, 303 cases were males and 80 were females, aged (53.0±1.0) years old on average. In the control group, 173 cases were males and 57 were females, aged (53.0±1.0) years old on average. The informed consents of all patients were obtained and the local ethical committee approval was received. The patients were matched using propensity score matching (PSM) method, and the incidence of postoperative complications was compared using Chi-square test or Fisher's exact probability test. Clinical parameters of the patients were included as the influencing factors of FFP transfusion, and the correlation analysis was conducted using Logistic regression analysis.

Results

A total of 147 pairs of patients were matched using PSM method. After the patients were matched, the incidence of postoperative overall complications and peritoneal effusion in the FFP group was respectively 45.6% (67/147) and 31.3% (46/147), signifantly higher than 33.3% (49/147) and 15.6% (23/147) in the control group (χ2=4.61, 10.02; P<0.05). Logistic regression analysis indicated that body weight index (BMI)≤18.50 kg/m2, American Society of Anesthesiologists (ASA) grading Ⅲ-Ⅳ, ALB≤40 g/L, Plt ≤100×109/L, operation time >180 min, intraoperative blood loss >500 ml, the first hepatic portal occlusion, hemihepatectomy and major hepatectomy were the independent influencing factors of perioperative FFP transfusion (OR=3.14, 2.01, 1.76, 1.65, 1.85, 3.16, 1.62, 1.68; P<0.05).

Conclusions

Perioperative FFP transfusion can increase the incidence of peritoneal effusion after hepatectomy. Emaciation, poor tolerance to anesthesia, extensive surgical area and massive intraoperative blood loss are the pivotal factors of FFP transfusion.

Key words: Hepatectomy, Perioperative period, Plasma, Postoperative complication
表1 FFP组和对照组患者肝切除术前基线资料比较
参数 匹配前 匹配后
FFP组 对照组 统计值 P值 FFP组 对照组 统计值 P值
性别（例） ? ? χ2=1.260 >0.05 ? ? χ2=3.580 >0.05
? 男 303 173 ? ? 124 111 ? ?
? 女 080 057 ? ? 025 036 ? ?
年龄（岁，±s） 53.0±1.0 053.0±1.0 t=0.50 >0.05 052.0±1.0 54.0±1.0 0t=-1.28 >0.05
ASA分级（例） ? ? χ2=15.64 <0.05 ? ? χ2=0.400 >0.05
? Ⅰ～Ⅱ级 280 200 ? ? 125 121 ? ?
? Ⅲ～Ⅳ级 103 030 ? ? 022 026 ? ?
肿瘤直径（cm，±s） 07.0±0.2 005.4±0.2 t=5.65 <0.05 005.7±0.2 05.7±0.3 0t=-0.01 >0.05
AST（U/L，±s） 59±3 042±3 t=3.73 <0.05 046±3 44±4 t=0.45 >0.05
ALB（g/L，±s） 37.9±0.3 039.9±0.3 0t=-4.52 <0.05 039.3±0.4 39.4±0.4 0t=-0.10 >0.05
肝功能Child-Pugh分级（例） ? ? χ2=6.070 <0.05 ? ? χ2=0.510 >0.05
? A级 355 224 ? ? 144 142 ? ?
? B级 028 006 ? ? 003 005 ? ?
Hb（g/L，±s） 131.0±1.00 136.4±1.2 0t=-3.42 <0.05 135.4±1.7 134.1±1.50 t=0.57 >0.05
手术时间（min，±s） 261±50 194±5 t=8.94 <0.05 214±6 211±60 t=0.39 >0.05
术中出血量（ml，±s）第一肝门阻断（例） 978±48 0 363±24 t=8.16 <0.05 0 561±33 517±34 t=0.92 >0.05
263 127 χ2=11.23 <0.05 098 093 χ2=0.370 >0.05
手术方式（例） ? ? χ2=27.98 <0.05 ? ? χ2=0.490 >0.05
? 半肝以下切除 243 192 ? ? 112 117 ? ?
? 半肝及以上切除 140 038 ? ? 035 030 ? ?
表2 匹配后FFP组和对照组患者肝切除术后并发症比较（例）
参数 FFP组 对照组 χ2 P
总体并发症 67 49 4.61 <0.05
? 腹腔积液 46 23 10.020 <0.05
? 胸腔积液 11 14 0.39 >0.05
? 胆漏 04 05 0.12 >0.05
? 肝功能不全 04 01 1.83 >0.05
? 肺部感染 04 03 0.15 >0.05
? 腹腔感染 04 02 0.68 >0.05
? 败血症 04 00 - >0.05
? 术后出血 03 02 0.20 >0.05
? 伤口感染 01 01 <0.010 >0.05
? 肾功能不全 01 00 - >0.05
? 泌尿系统感染 00 01 - >0.05
? 其他 07 05 0.35 >0.05
并发症分级 ? ? 4.21 >0.05
? Ⅱ级 51 38 ? ?
? Ⅲ～Ⅴ级 16 11 ? ?
表3 613例患者肝切除围手术期FFP输注相关因素Logistic回归分析
参数 例数 单变量分析结果 多变量分析结果
OR（95% CI） P OR（95% CI） P
男性 476 1.24(0.84～1.83) <>0.050 ? ?
年龄>65岁 095 1.06(0.67～1.66) >0.05 ? ?
BMI≤18.50 kg/m2 421 2.18(1.09～4.39) <0.05 3.14(1.31～7.52) <0.05
ASA分级Ⅲ～Ⅳ级 133 2.42(1.55～3.77) <0.05 2.01(1.20～3.36) <0.05
ALB≤40 g/L 380 1.82(1.30～2.55) <0.05 1.76(1.15～2.70) <0.05
Plt≤100×109/L 179 1.52(1.05～2.20) <0.05 1.65(1.04～2.61) <0.05
手术时间>180 min 397 3.19(2.25～4.50) <0.05 1.85(1.19～2.86) <0.05
术中出血量>500 ml 281 5.44(3.73～7.95) <0.05 3.16(2.03～4.93) <0.05
第一肝门阻断（例） 390 1.78(1.25～2.47) <0.05 1.62(1.06～2.46) <0.05
半肝及半肝以上切除（例） 178 2.87(1.91～4.30) <0.05 1.68(1.01～2.81) <0.05
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