Child-Pugh C级伴肝炎肝硬化的肝癌患者行肝癌切除术分析(1)
[摘要] 目的：探讨Child-Pugh C级伴有肝炎肝硬化的肝癌患者行肝癌切除术增加可行性的方法，减少手术死亡率。方法：对我院2005年6月~2010年6月收治的33例行肝癌切除术的Child-Pugh C级伴有肝炎肝硬化的肝癌患者进行回顾性分析。结果：手术失血量为300～3 500 ml，平均(1 407.3±122.0) ml；手术时间2.3～9.0 h，平均(5.3±1.2) h。33例肝癌患者死亡5例，余28例术后出现腹水、胆漏、感染、急性肾功能衰竭等各种并发症62例次，经对症治疗均痊愈出院。结论：Child-Pugh C级伴肝炎肝硬化的肝癌患者行肝癌切除术难度大、风险大，但只要选择合理术式，术中控制出血量，加强围术期治疗，手术是相对可行和安全的。
[关键词] Child-Pugh C级；肝癌切除术；肝炎肝硬化
[中图分类号] R735.7 [文献标识码] B [文章编号] 1673-7210(2011)06(c)-187-02
Analysis on hepatectomy for hepatocellular carcinoma in the treatment of patients with Child-Pugh C class hepatocarcinoma associated wih liver cirrhosis
YAO Weizhou
Department of General Surgery, The People's Hospital of Huaibei City, Anhui Province, Huaibei 235000, China
[Abstract] Objective: To investigate the method of increase the feasibility of hepatectomy for hepatocellular carcinoma in the treatment of patients with Child-Pugh C class hepatocarcinoma associated with cirrhosis. Methods: Data of 33 patients with hepatocarcinoma who were associated with cirrhosis were analyzed retrospectively in our hospital from June 2005 to June 2010. Results: In 33 patients, Surgical blood loss 300-3 500 ml, an average of (1 407.3±122.0) ml; operation time were 2.3-9.0 h with an average of (5.3±1.2) h; 5 patients died, the other 28 cases occurred 62 times complications such as ascites, bile leakage, infection, and acute renal failure after the operation, the symptomatic were cured after treatment. Conclusion: Hepatectomy for hepatocellular carcinoma in the treatment of patients with Child-Pugh C class hepatocarcinoma who are associated with cirrhosis is difficult and risky, but as long as a reasonable surgical would be chose, intraoperative blood loss can be controlled, perioperative treatment can be strengthened, the surgery is relatively feasible and safe.
[Key words] Child-Pugh C class; Hepatectomy for hepatocellular carcinoma; Hepatocarcinoma associated with cirrhosis
肝癌切除术是肝癌患者获得长期生存的最有效手段，但肝切除手术复杂，术后并发症、死亡率较高，尤其是合并肝硬化，患者肝储备功能下降，门静脉压力增高，常合并食管静脉曲张、凝血功能障碍，手术危险性大大增高[1]。近年大量研究证实[2-3]，肝癌切除术死亡率与肝硬化肝功能Child-Pugh分级密切相关，其中Child-Pugh C级手术死亡率高达60%～70%，多数临床医师将其列为手术禁忌证。但此类患者病情加重造成生活质量严重下降或危及生命时常不得不选择手术。本文回顾性分析我院2005年6月~2010年6月收治的行肝癌切除术的Child-Pugh C级伴有肝炎肝硬化的肝癌患者，旨在探讨增加手术可行性的方法，减少手术死亡率。
1 资料与方法
1.1 一般资料
本组33例，男23例，女10例；年龄35～68岁，平均(44.3±2.5)岁。术前肝功能Child-Pugh评级均为C级，并经肝脏CT和术后病理诊断证实，均伴有肝炎肝硬化。肿瘤直径2～12 cm，平均(7.3±2.0) cm；合并门静脉高压症25例，门静脉主干或分支癌栓8例，胆管癌栓5例。
1.2 方法
1.2.1 手术方法 以肿瘤的位置大小以及肝功能储备确定肝切除范围，采用肝段切除或肝段联合切除术，手术时肝血流阻断采用间歇性肝门阻断法或肝内双向阻断法。术式包括：半肝切除10例，肝段/叶切除/联合肝段切除12例，局限性肝切除11例；其中联合肝动脉和门静脉置双泵8例，肝动脉投药泵置放2例，门静脉投药泵置放2例，腹腔投药泵置放1例；同时行门静脉取栓8例，胆总管取栓5例。
1.2.2 围术期治疗 ①常规护肝及补充维生素K1和维生素C，改善凝血功能，有低蛋白血症者，补充人血白蛋白或少量血浆，合并门脉高压症者予生长抑素降低门静脉压力。②最大限度控制术中和术后出血，控制术中血压在正常或略低水平，凡凝血酶原时间延长超过3 s者，在术前、术后予新鲜血浆或静滴凝血酶原复合物。③术后继续护肝、补充维生素K1和维生素C，同时输注止血药物。术后72 h常规予广谱抗生素预防性抗感染。
2 结果
手术失血量300～3 500 ml，平均(1 407.3±122.0) ml；手术时间2.3～9.0 h，平均(5.3±1.2) h。33例肝癌患者死亡5例，死亡率为15.2%，其中2例术后24 h内腹腔引流管上出血量突然增多，经止血及输血治疗无效死亡；2例术后有腹水，反复出现上消化道出血，最后发生肝功能衰竭死亡；1例术后发生弥漫性血管内凝血(DIC)，经抢救无效死亡。余28例术后出现腹水、胆漏、感染、急性肾功能衰竭等各种并发症62例次，经对症治疗均痊愈出院。, 百拇医药(姚卫洲)
[关键词] Child-Pugh C级；肝癌切除术；肝炎肝硬化
[中图分类号] R735.7 [文献标识码] B [文章编号] 1673-7210(2011)06(c)-187-02
Analysis on hepatectomy for hepatocellular carcinoma in the treatment of patients with Child-Pugh C class hepatocarcinoma associated wih liver cirrhosis
YAO Weizhou
Department of General Surgery, The People's Hospital of Huaibei City, Anhui Province, Huaibei 235000, China
[Abstract] Objective: To investigate the method of increase the feasibility of hepatectomy for hepatocellular carcinoma in the treatment of patients with Child-Pugh C class hepatocarcinoma associated with cirrhosis. Methods: Data of 33 patients with hepatocarcinoma who were associated with cirrhosis were analyzed retrospectively in our hospital from June 2005 to June 2010. Results: In 33 patients, Surgical blood loss 300-3 500 ml, an average of (1 407.3±122.0) ml; operation time were 2.3-9.0 h with an average of (5.3±1.2) h; 5 patients died, the other 28 cases occurred 62 times complications such as ascites, bile leakage, infection, and acute renal failure after the operation, the symptomatic were cured after treatment. Conclusion: Hepatectomy for hepatocellular carcinoma in the treatment of patients with Child-Pugh C class hepatocarcinoma who are associated with cirrhosis is difficult and risky, but as long as a reasonable surgical would be chose, intraoperative blood loss can be controlled, perioperative treatment can be strengthened, the surgery is relatively feasible and safe.
[Key words] Child-Pugh C class; Hepatectomy for hepatocellular carcinoma; Hepatocarcinoma associated with cirrhosis
肝癌切除术是肝癌患者获得长期生存的最有效手段，但肝切除手术复杂，术后并发症、死亡率较高，尤其是合并肝硬化，患者肝储备功能下降，门静脉压力增高，常合并食管静脉曲张、凝血功能障碍，手术危险性大大增高[1]。近年大量研究证实[2-3]，肝癌切除术死亡率与肝硬化肝功能Child-Pugh分级密切相关，其中Child-Pugh C级手术死亡率高达60%～70%，多数临床医师将其列为手术禁忌证。但此类患者病情加重造成生活质量严重下降或危及生命时常不得不选择手术。本文回顾性分析我院2005年6月~2010年6月收治的行肝癌切除术的Child-Pugh C级伴有肝炎肝硬化的肝癌患者，旨在探讨增加手术可行性的方法，减少手术死亡率。
1 资料与方法
1.1 一般资料
本组33例，男23例，女10例；年龄35～68岁，平均(44.3±2.5)岁。术前肝功能Child-Pugh评级均为C级，并经肝脏CT和术后病理诊断证实，均伴有肝炎肝硬化。肿瘤直径2～12 cm，平均(7.3±2.0) cm；合并门静脉高压症25例，门静脉主干或分支癌栓8例，胆管癌栓5例。
1.2 方法
1.2.1 手术方法 以肿瘤的位置大小以及肝功能储备确定肝切除范围，采用肝段切除或肝段联合切除术，手术时肝血流阻断采用间歇性肝门阻断法或肝内双向阻断法。术式包括：半肝切除10例，肝段/叶切除/联合肝段切除12例，局限性肝切除11例；其中联合肝动脉和门静脉置双泵8例，肝动脉投药泵置放2例，门静脉投药泵置放2例，腹腔投药泵置放1例；同时行门静脉取栓8例，胆总管取栓5例。
1.2.2 围术期治疗 ①常规护肝及补充维生素K1和维生素C，改善凝血功能，有低蛋白血症者，补充人血白蛋白或少量血浆，合并门脉高压症者予生长抑素降低门静脉压力。②最大限度控制术中和术后出血，控制术中血压在正常或略低水平，凡凝血酶原时间延长超过3 s者，在术前、术后予新鲜血浆或静滴凝血酶原复合物。③术后继续护肝、补充维生素K1和维生素C，同时输注止血药物。术后72 h常规予广谱抗生素预防性抗感染。
2 结果
手术失血量300～3 500 ml，平均(1 407.3±122.0) ml；手术时间2.3～9.0 h，平均(5.3±1.2) h。33例肝癌患者死亡5例，死亡率为15.2%，其中2例术后24 h内腹腔引流管上出血量突然增多，经止血及输血治疗无效死亡；2例术后有腹水，反复出现上消化道出血，最后发生肝功能衰竭死亡；1例术后发生弥漫性血管内凝血(DIC)，经抢救无效死亡。余28例术后出现腹水、胆漏、感染、急性肾功能衰竭等各种并发症62例次，经对症治疗均痊愈出院。, 百拇医药(姚卫洲)