中心静脉压差值对腹腔镜肝细胞癌肝切除术中出血的影响

doi:10.3877/cma.j.issn.2095-3232.2024.02.007

目的

探讨腹腔镜肝细胞癌（肝癌）肝切除术中断肝前和断肝期间中心静脉压差值（ΔCVP）对术中出血量的影响。

方法

回顾性分析2021年6月至2022年12月第九〇九医院行腹腔镜肝癌肝切除的57例患者临床资料。患者均签署知情同意书，符合医学伦理学规定。57例患者均采用控制性低中心静脉压技术（LCVP），计算断肝前和断肝期间ΔCVP。根据术中出血量中位数215 ml将57例患者分为A组（术中出血量≥215 ml，29例）和B组（术中出血量< 215 ml，28例），绘制ROC曲线分析ΔCVP对术中出血量的预测作用，Pearson线性分析ΔCVP与术中出血量的相关性，采用单因素和Logistic多因素分析术中出血量影响因素。

结果

ROC曲线分析显示，ΔCVP对术中出血量预测的曲线下面积（AUC）0.867，约登指数最大值0.648，ΔCVP最佳界值5.5 cmH₂O（1 cmH₂O=0.098 kPa），敏感度0.786，特异度0.862，95%CI：0.765～0.969，P<0.05。Pearson相关性分析显示，ΔCVP与术中出血量成负相关（r=-0.781，P<0.05）。单因素分析显示，A组中ΔCVP<5.5 cmH₂O、肝硬化、脂肪肝、肿瘤直径≥10 cm、占位效应、困难部位肝癌的术中出血发生率明显高于B组（χ²=24.097，6.908，5.179，5.695，5.221，8.211；P<0.05）。Logistic多因素分析显示，ΔCVP<5.5 cmH₂O、肝硬化、困难部位肝癌是腹腔镜肝切除术中出血的独立危险因素（OR=38.812，12.127，12.573；P<0.05）。

结论

腹腔镜肝切除术中出血量与断肝前和断肝期间ΔCVP相关，通过评估切肝前CVP大小将切肝过程中CVP维持在合理水平，有助于降低术中出血量。

关键词: 癌，肝细胞, 腹腔镜, 肝切除术, 中心静脉压, 肝功能, 并发症, 出血

Objective

To evaluate the effect of difference of central venous pressure (ΔCVP) before and during liver transection on intraoperative blood loss in laparoscopic hepatectomy for hepatocellular carcinoma (HCC).

Methods

Clinical data of 57 HCC patients who underwent laparoscopic hepatectomy in the No.909 Hospital from June 2021 to December 2022 were retrospectively analyzed. The informed consents of all patients were obtained and the local ethical committee approval was received. 57 patients were treated with controlled low central venous pressure (LCVP), and the ΔCVP before and during liver transection was calculated. According to the median intraoperative blood loss of 215 ml, 57 patients were divided into group A (intraoperative blood loss of≥215 ml, n=29) and group B (intraoperative blood loss of<215 ml, n=28). The predictive effect of ΔCVP on intraoperative blood loss was assessed by the ROC curve. The correlation between ΔCVP and intraoperative blood loss was determined by Pearson's linear analysis. The influencing factors of intraoperative blood loss were identified by univariate and multivariate Logistic regression analyses.

Results

ROC curve analysis showed that the area under the ROC curve (AUC) of ΔCVP for predicting intraoperative blood loss was 0.867. The maximum value of Youden's index was 0.648. The optimal threshold value of ΔCVP was 5.5 cmH₂O (1 cmH₂O=0.098 kPa). The sensitivity was 0.786 and the specificity was 0.862 (95%CI: 0.765-0.969, P<0.05). Pearson's correlation analysis indicated that ΔCVP was negatively correlated with intraoperative blood loss (r=-0.781, P<0.05). Univariate analysis showed that the incidence of intraoperative bleeding in patients with ΔCVP <5.5 cmH₂O, liver cirrhosis, fatty liver, tumor diameter of ≥10 cm, space-occupying effect and HCC at difficult sites in group A were significantly higher than those in group B (χ²=24.097, 6.908, 5.179, 5.695, 5.221, 8.211; P<0.05). Multivariate Logistic analysis showed that ΔCVP of<5.5 cmH₂O, liver cirrhosis and HCC at difficult sites were the independent risk factors for intraoperative bleeding of laparoscopic hepatectomy (OR=38.812, 12.127, 12.573; P<0.05).

Conclusions

The amount of blood loss during laparoscopic hepatectomy is correlated with ΔCVP before and during liver transection. Maintaining CVP at a reasonable level during liver transection by evaluating the CVP before liver transection contributes to reducing the amount of blood loss during hepatectomy.

Key words: Carcinoma, hepatocellular, Laparoscopes, Hepatectomy, Central venous pressure, Liver function, Complications, Blood loss

图1 ΔCVP对肝癌腹腔镜肝切除术中出血量预测的ROC曲线分析注：ΔCVP为中心静脉压差值

图2 ΔCVP与肝癌腹腔镜肝切除术中出血量的相关性分析注：ΔCVP为中心静脉压差值，1 cmH₂O=0.098 kPa

表1 腹腔镜肝癌肝切除术中出血的单因素分析

参数	A组	B组	统计值	P值
性别（例，男/女）	23/6	21/7	χ²=0.150	0.698
年龄（岁，±s）	51±7	54±7	t=-1.156	0.253
BMI（kg/m²，±s）	23.6±1.0	23.5±1.0	t=0.179	0.858
Child-Pugh A级（例）	24	24	χ²=0.094	1.000
ASA分级（例，Ⅰ/Ⅱ/Ⅲ）	19/8/2	19/7/2	χ²=0.049	0.976
ΔCVP<5.5 cmH₂O（例）	25	6	χ²=24.097	<0.001
肝门阻断（例）	22	20	χ²=0.144	0.704
解剖性肝切除（例）	20	22	χ²=0.678	0.410
肿瘤高分化（例）	13	15	χ²=0.436	0.509
HBsAg阳性（例）	20	19	χ²=0.008	0.928
肝硬化（例）	12	3	χ²=6.908	0.015
脂肪肝（例）	12	4	χ²=5.179	0.038
肿瘤部位（左叶/右叶）	12/17	12/16	χ²=0.013	0.910
肿瘤直径≥10 cm （例）	11	3	χ²=5.695	0.029
占位效应（例）	9	2	χ²=5.221	0.041
困难部位肝癌（例）	13	3	χ²=8.211	0.007

表1 腹腔镜肝癌肝切除术中出血的单因素分析

参数	A组	B组	统计值	P值
性别（例，男/女）	23/6	21/7	χ²=0.150	0.698
年龄（岁，±s）	51±7	54±7	t=-1.156	0.253
BMI（kg/m²，±s）	23.6±1.0	23.5±1.0	t=0.179	0.858
Child-Pugh A级（例）	24	24	χ²=0.094	1.000
ASA分级（例，Ⅰ/Ⅱ/Ⅲ）	19/8/2	19/7/2	χ²=0.049	0.976
ΔCVP<5.5 cmH₂O（例）	25	6	χ²=24.097	<0.001
肝门阻断（例）	22	20	χ²=0.144	0.704
解剖性肝切除（例）	20	22	χ²=0.678	0.410
肿瘤高分化（例）	13	15	χ²=0.436	0.509
HBsAg阳性（例）	20	19	χ²=0.008	0.928
肝硬化（例）	12	3	χ²=6.908	0.015
脂肪肝（例）	12	4	χ²=5.179	0.038
肿瘤部位（左叶/右叶）	12/17	12/16	χ²=0.013	0.910
肿瘤直径≥10 cm （例）	11	3	χ²=5.695	0.029
占位效应（例）	9	2	χ²=5.221	0.041
困难部位肝癌（例）	13	3	χ²=8.211	0.007

表2 腹腔镜肝癌肝切除术中出血的Logistic多因素分析

分组	b	SE（b）	Wald χ²	OR	95%CI	P值
ΔCVP<5.5 cmH₂O	3.659	1.041	12.361	38.812	5.049～298.369	<0.001
肝硬化	2.495	1.158	4.645	12.127	1.254～117.311	0.031
脂肪肝	1.114	1.039	1.150	3.046	0.398～23.320	0.284
肿瘤直径≥10 cm	2.419	1.432	2.853	11.229	0.678～185.883	0.091
占位效应	0.068	2.014	0.001	1.070	0.021～55.405	0.973
困难部位肝癌	2.532	1.135	4.977	12.573	1.360～116.234	0.026

表2 腹腔镜肝癌肝切除术中出血的Logistic多因素分析

分组	b	SE（b）	Wald χ²	OR	95%CI	P值
ΔCVP<5.5 cmH₂O	3.659	1.041	12.361	38.812	5.049～298.369	<0.001
肝硬化	2.495	1.158	4.645	12.127	1.254～117.311	0.031
脂肪肝	1.114	1.039	1.150	3.046	0.398～23.320	0.284
肿瘤直径≥10 cm	2.419	1.432	2.853	11.229	0.678～185.883	0.091
占位效应	0.068	2.014	0.001	1.070	0.021～55.405	0.973
困难部位肝癌	2.532	1.135	4.977	12.573	1.360～116.234	0.026

[1]	中华人民共和国国家卫生健康委员会医政医管局. 原发性肝癌诊疗指南(2022年版)[J]. 中国实用外科杂志, 2022, 42(3):241-273.
[2]	Wang W, Meng T, Chen Y, et al. Propensity score matching study of 325 patients with spontaneous rupture of hepatocellular carcinoma[J]. Hepatobiliary Surg Nutr, 2022, 11(6):808-821.
[3]	Wang J, Wang W, Chen X, et al. Laparoscopic versus open hepatectomy for intrahepatic cholangiocarcinoma in patients aged 60 and older: a retrospective cohort study[J]. World J Surg Oncol, 2022, 20(1):396.
[4]	Bao D, Hu Y, Zhang C, et al. Perioperative and short-term outcomes of laparoscopic liver resection for recurrent hepatocellular carcinoma: a retrospective study comparing open hepatectomy[J]. Front Oncol, 2022(12):956382.
[5]	Pan YX, Wang JC, Lu XY, et al. Intention to control low central venous pressure reduced blood loss during laparoscopic hepatectomy: a double-blind randomized clinical trial[J]. Surgery, 2020, 167(6):933-941.
[6]	许钊, 玉红, 梁鹏. 低中心静脉压在肝脏切除手术中的应用现状[J]. 中国普外基础与临床杂志, 2020, 27(1):107-112.
[7]	金泓宇, 张蔓, 李经纬, 等. 肝切除术中应用控制性低中心静脉压的研究进展[J]. 华西医学, 2021, 36(9):1303-1309.
[8]	石雪朵, 李冰冰. 控制性低中心静脉压在肝脏切除术中的应用[J]. 临床麻醉学杂志, 2021, 37(8):871-874.
[9]	Wu G, Chen T, Chen Z. Effect of controlled low central venous pressure technique on postoperative hepatic insufficiency in patients undergoing a major hepatic resection[J]. Am J Transl Res, 2021, 13(7):8286-8293.
[10]	Wang F, Sun D, Zhang N, et al. The efficacy and safety of controlled low central venous pressure for liver resection: a systematic review and meta-analysis[J]. Gland Surg, 2020, 9(2):311-320.
[11]	Yu L, Sun H, Jin H, et al. The effect of low central venous pressure on hepatic surgical field bleeding and serum lactate in patients undergoing partial hepatectomy: a prospective randomized controlled trial[J]. BMC Surg, 2020, 20(1):25.
[12]	Liu TS, Shen QH, Zhou XY, et al. Application of controlled low central venous pressure during hepatectomy: a systematic review and meta-analysis[J]. J Clin Anesth, 2021(75):110467.
[13]	Erkoç SK, Kırımker EO, Büyük S, et al. Reducing risk for acute kidney injury after living donor hepatectomy by protocolized fluid restriction: single-center experience[J]. Transplant Proc, 2022, 54(8):2243-2247.
[14]	Dai X, Volodarskiy A, Moustakakis E, et al. Low central venous pressure in patients presenting with acute submassive pulmonary embolism[J]. J Am Coll Cardiol, 2020, 76(23):2797-2798.
[15]	吕华燕, 胡崇辉, 蓝志坚. 控制性低中心静脉压技术对腹腔镜肝切除术患者脑氧饱和度的影响[J]. 中国内镜杂志, 2022, 28(4):49-54.
[16]	Okuda N, Kyogoku M, Inata Y, et al. Estimation of change in pleural pressure in assisted and unassisted spontaneous breathing pediatric patients using fluctuation of central venous pressure: a preliminary study[J]. PLoS One, 2021, 16(3):e0247360.
[17]	陈骏, 刘朋, 张国华, 等. 间歇低气道压力通气联合低中心静脉压技术在腹腔镜肝切除术中的应用:前瞻性随机对照研究[J]. 中国微创外科杂志, 2021, 21(7):595-599.
[18]	Ryckx A, Christiaens C, Clarysse M, et al. Central venous pressure drop after hypovolemic phlebotomy is a strong independent predictor of intraoperative blood loss during liver resection[J]. Ann Surg Oncol, 2017, 24(5):1367-1375.
[19]	Lin CX, Guo Y, Lau WY, et al. Optimal central venous pressure during partial hepatectomy for hepatocellular carcinoma[J]. Hepatobiliary Pancreat Dis Int, 2013, 12(5):520-524.
[20]	Chen H, Wang Y, Xie Z, et al. Application effect of ICG fluorescence real-time imaging technology in laparoscopic hepatectomy[J]. Front Oncol, 2022(12):819960.
[21]	Chiow AKH, Rho SY, Wee IJY, et al. Robotic ICG guided anatomical liver resection in a multi-centre cohort: an evolution from "positive staining" into "negative staining" method[J]. HPB, 2021, 23(3):475-482.

[1]	燕速, 霍博文. 腹腔镜食管胃结合部腺癌根治性切除术[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(01): 13-13.
[2]	母德安, 李凯, 张志远, 张伟. 超微创器械辅助单孔腹腔镜下脾部分切除术[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(01): 14-14.
[3]	李国新, 陈新华. 全腹腔镜下全胃切除术食管空肠吻合的临床研究进展[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(01): 1-4.
[4]	李子禹, 卢信星, 李双喜, 陕飞. 食管胃结合部腺癌腹腔镜手术重建方式的选择[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(01): 5-8.
[5]	李乐平, 张荣华, 商亮. 腹腔镜食管胃结合部腺癌根治淋巴结清扫策略[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(01): 9-12.
[6]	陈方鹏, 杨大伟, 金从稳. 腹腔镜近端胃癌切除术联合改良食管胃吻合术重建His角对术后反流性食管炎的效果研究[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(01): 15-18.
[7]	许杰, 李亚俊, 韩军伟. 两种入路下腹腔镜根治性全胃切除术治疗超重胃癌的效果比较[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(01): 19-22.
[8]	李刘庆, 陈小翔, 吕成余. 全腹腔镜与腹腔镜辅助远端胃癌根治术治疗进展期胃癌的近中期随访比较[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(01): 23-26.
[9]	刘柏隆, 周祥福. 女性尿失禁吊带手术并发症处理的经验分享[J/OL]. 中华腔镜泌尿外科杂志(电子版), 2025, 19(01): 127-127.
[10]	王庆亮, 党兮, 师凯, 刘波. 腹腔镜联合胆道子镜经胆囊管胆总管探查取石术[J/OL]. 中华肝脏外科手术学电子杂志, 2025, 14(02): 313-313.
[11]	杨建辉, 段文斌, 马忠志, 卿宇豪. 腹腔镜下脾部分切除术[J/OL]. 中华肝脏外科手术学电子杂志, 2025, 14(02): 314-314.
[12]	叶劲松, 刘驳强, 柳胜君, 吴浩然. 腹腔镜肝Ⅶ+Ⅷ段背侧段切除[J/OL]. 中华肝脏外科手术学电子杂志, 2025, 14(02): 315-315.
[13]	郭兵, 王万里, 何凯, 黄汉生. 腹腔镜下肝门部胆管癌根治术[J/OL]. 中华肝脏外科手术学电子杂志, 2025, 14(01): 143-143.
[14]	李凯, 陈淋, 苏怀东, 向涵, 张伟. 超微创器械在改良单孔腹腔镜巨大肝囊肿开窗引流及胆囊切除中的应用[J/OL]. 中华肝脏外科手术学电子杂志, 2025, 14(01): 144-144.
[15]	魏丽霞, 张安澜, 周宝勇, 李明. 腹腔镜下Ⅲb型肝门部胆管癌根治术[J/OL]. 中华肝脏外科手术学电子杂志, 2025, 14(01): 145-145.

阅读次数

全文

摘要

选择文件类型/文献管理软件名称

选择包含的内容

Effect of difference of central venous pressure on intraoperative blood loss in laparoscopic hepatectomy for hepatocellular carcinoma

模态框（Modal）标题

选择文件类型/文献管理软件名称

选择包含的内容

Effect of difference of central venous pressure on intraoperative blood loss in laparoscopic hepatectomy for hepatocellular carcinoma