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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 ›› 2024, Vol. 13 ›› Issue (02) : 158 -162. doi: 10.3877/cma.j.issn.2095-3232.2024.02.007

临床研究

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
杨建彬1, 陈建华1, 张文华2, 刘建东1,†()   
  1. 1. 363000　福建省漳州市，第九〇九医院（厦门大学附属东南医院）麻醉科
    2. 363000　福建省漳州市，第九〇九医院（厦门大学附属东南医院）普通外科
  • 收稿日期:2023-12-29 出版日期:2024-04-10
  • 通信作者: 刘建东
  • 基金资助:
    原南京军区医学科技创新面上项目(14MS090)

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

Jianbin Yang1, Jianhua Chen1, Wenhua Zhang2, Jiandong Liu1,†()   

  1. 1. Department of Anesthesiology, the No.909 Hospital (Southeast Hospital Affiliated to Xiamen University), Zhangzhou 363000, China
    2. Department of General Surgery, the No.909 Hospital (Southeast Hospital Affiliated to Xiamen University), Zhangzhou 363000, China
  • Received:2023-12-29 Published:2024-04-10
  • Corresponding author: Jiandong Liu
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引用本文：

杨建彬, 陈建华, 张文华, 刘建东. 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[J]. 中华肝脏外科手术学电子杂志, 2024, 13(02): 158-162.

Jianbin Yang, Jianhua Chen, Wenhua Zhang, Jiandong Liu. Effect of difference of central venous pressure on intraoperative blood loss in laparoscopic hepatectomy for hepatocellular carcinoma[J]. Chinese Journal of Hepatic Surgery(Electronic Edition), 2024, 13(02): 158-162.

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
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