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《中华消化外科杂志》2017年8月第16卷第8期论著

2048例腹腔镜肝切除术的临床疗效及经验总结

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引用本文:
李建伟,王小军,曹利,等.2048例腹腔镜肝切除术的临床疗效及经验总结[J].中华消化外科杂志,2017,16(8):818-821.DOI:10.3760/cma.j.issn.1673-9752.2017.08.012.
【摘要】

目的:探讨腹腔镜肝切除术的临床疗效及总结其经验。
方法:采用回顾性横断面研究方法。收集2007年3月至2016年10月第三军医大学西南医院收治的2 048例行腹腔镜肝切除术患者的临床病理资料。术前充分评估病灶可切除性及患者肝脏储备功能后,行腹腔镜肝切除术。观察指标:(1)手术及术中情况。(2)随访情况。采用门诊和电话方式进行随访,了解患者术后生存情况。随访时间截至2017年 6月。正态分布的计量资料以±s表示。计数资料以百分率表示。采用Kaplan-Meier法计算生存率。
结果:(1)手术及术中情况:2 048例患者均顺利完成手术,其中传统腹腔镜肝切除术1 985例,达芬奇机器人手术系统辅助联合腹腔镜肝切除术63例;行非解剖性肝切除术1 052例,解剖性肝切除术996例。 2 048例患者中转开腹率为6.738%(138/2 048)。 2 048例患者手术时间为(225±27)min,术中出血量为(455±152)mL,术中输血率为5.615%(115/2 048)。术后并发症发生率为11.816%(242/2 048),其中42.149%(102/242)的术后并发症为反应性胸腔积液和肝断面积液,其余并发症类型包括腹腔积液、肺部感染、腹腔感染、胆汁漏、出血、切口液化、血栓事件、急性肝损伤等。术后严重并发症发生率为0.488%( 10/2 048),其中腹腔内出血6例,ARDS、心衰竭、肝衰竭、肾衰竭各1例。242例术后并发症患者中,6例腹腔内出血行再次手术后好转,1例因术后门静脉系统广泛性血栓致肝衰竭治疗无效死亡,其余235例经保守治疗后好转。2 048例患者术后住院时间为(10.7±1.0)d。(2)随访情况:1 070例恶性肝肿瘤患者中,912例获得术后随访。随访时间为8~120个月,中位随访时间为51个月。912例获得术后随访的恶性肝肿瘤患者1、3、5年总体生存率分别为94.1%、82.2%、53.6%,1、3、5年无瘤生存率分别为82.3%、61.3%、32.8%。
结论:腹腔镜肝切除术安全可行,疗效确切,在术中出血控制、特殊部位显露等技术瓶颈突破的情况下,其适应证已不断拓展。

【Abstract】

Objective:To investigate the clinical efficacy of laparoscopic hepatectomy and summarize its experiences.
Methods:The retrospective cross-sectional study was conducted. The clinicopathological data of 2 048 patients who underwent laparoscopic hepatectomy in the Southwest Hospital of the Third Military Medical University from March 2007 to October 2016 were collected. The resectability of lesions and liver functional reserve were preoperatively evaluated, and then laparoscopic hepatectomy was conducted. Observation indicators:(1)surgical and intraoperative situations; (2) follow-up situations. Follow-up using outpatient examination and telephone interview was performed to detect the patients′ postoperative survival up to June 2017. Measurement data with normal distribution were represented as ±s. Count data were evaluated by the percentage. The survival rate was calculated by the KaplanMeier method.
Results:(1) Surgical and intraoperative situations: all the 2 048 patients received successful laparoscopic hepatectomy, including 1 985 undergoing traditional laparoscopic hepatectomy and 63 undergoing Da Vinci robotassisted and laparoscopic hepatectomy. Nonanatomical and anatomical hepatectomies were respectively applied to 1 052 and 996 patients. The rate of conversion to open surgery of 2 048 patients was 6738%(138/2 048). Operation time, volume of intraoperative blood loss and rate of intraoperative blood transfusion in 2 048 patients were (225±27)minutes, (455±152)mL and 5.615%(115/2 048), respectively. The incidence of postoperative complications was 11.816%(242/2 048), 42.149%(102/242) of postoperative complications included reactive pleural effusion and effusion in the resection margin, and other postoperative complications included peritoneal effusion, pulmonary infection, abdominal infection, bile leakage, bleeding, incision liquefied, thrombus and acute liver injury. The incidence of postoperative severe complications was 0488%(10/2 048), including 6 with intraperitoneal bleeding, 1 with acute respiratory distress syndrome, 1 with cardiac failure, 1 with hepatic failure and 1 with renal failure. Of 242 patients with postoperative complications, 6 with intraperitoneal bleeding received reoperations and were improved, 1 died of extensive thrombus of portal vein system induced liver failure, and 235 were improved by conservative treatment. Duration of hospital stay in 2 048 patients was (10.7±10)days. (2) Follow-up situations: 912 of 1 070 patients with malignant liver tumors were followed up for 8-120 months, with a median time of 51 months. The 1, 3 and 5 year overall survival rates and 1, 3 and 5 year tumorfree survival rates in 912 patients with malignant liver tumors and Follow-up were 94.1%, 82.2%, 53.6% and 823%, 61.3%, 32.8%, respectively.
Conclusions:Laparoscopic hepatectomy is safe and feasible, with definite effects. In the premise of breakthroughs of technical bottlenecks in the bleeding control and exposure of special liver segment, the indications for laparoscopic hepatectomy have been expanded and there is no restricted area.

DOI:10.3760/cma.j.issn.1673-9752.2017.08.012
基金项目:国家卫生和计划生育委员会公益性行业科研专项(201502014);第三军医大学西南医院临床新技术计划项目(SWH2016JSTSYB-50);第三军医大学西南医院重大领域技术创新项目(SWH2016ZDCX2015)
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