肝癌合并门脉高压症患者腹腔镜肝癌切除术术中通气模式的临床研究

doi:10.3877/cma.j.issn.1674-3946.2020.06.012

目的

研究容量控制通气(VCV)、压力控制通气(PCV)及压力控制容量保证通气(PCV-VG)对行腹腔镜肝癌切除术的肝癌合并门脉高压症(HCPH)患者术中血流动力学、呼吸力学、血气指标和术后并发症的影响。

方法

前瞻性选择2017年1月至2019年6月行腹腔镜肝癌切除术的120例HCPH患者作为研究对象。采用随机数字表法将患者分为VCV组、PCV组及PCV-VG组，每组40例。采用SPSS20.0软件进行分析，并发症等计数资料使用卡方检验；患者围术期指标及各时间点[插管后气腹前10 min(T0)、气腹后30 min(T1)、气腹后1 h(T2)、气腹结束10 min(T3)]心率等用(±s)表示，多组间采用重复方差法分析，P<0.05为差异有统计学意义。

结果

与T0比较，T1～T2时三组患者术中平均动脉压(MAP)、气道平均压力(Pmean)、气道峰值压力(Ppeak)、动脉氧分压(PaO₂)、呼末二氧化碳分压(PETCO₂)、动脉二氧化碳分压(PaCO₂)显著升高(P<0.05)，动态肺顺应性(Cdyn)明显降低(P<0.05)。PCV-VG组在T1～T2时间段Ppeak均低于VCV组和PCV组(P<0.05)，在T1～T3时间段Pmean均低于VCV组(P<005)。PCV-VG组和PCV组在T1～T2时间段Cdyn均高于VCV组(P<0.05)，PCV-VG组在T2刻高于PCV组(P<0.05)。术后第7天PCV-VG组与PCV组并发症总发生率显著低于VCV组(P<0.05)；PCV-VG组肺不张发生率显著低于VCV组(P<0.05)。

结论

对于行腹腔镜肝癌切除术的HCPH患者，PCV-VG模式可以降低气道压力，改善肺顺应性，术后肺部相关并发症发生率较低，安全性更高。

关键词: 肝肿瘤, 高血压，门静脉, 腹腔镜, 肝切除术, 呼吸，人工, 呼吸力学, 手术后并发症

Objective

To investigate the clinical application of volume-controlled ventilation (VCV), pressure-controlled ventilation (PCV), and pressure-controlled volume-guaranteed ventilation (PCV-VG), and to observe the intraoperative hemodynamics, respiratory mechanics, blood gas indexes and postoperative complications of patients with liver cancer complicated with portal hypertension undergoing laparoscopic hepatectomy.

Methods

120 patients with liver cancer complicated with portal hypertension who underwent laparoscopic hepatectomy from January 2017 to June 2019 were prospectively selected as the research subjects. The patients were divided into VCV group, PCV group and PCV-VG group by random number table method, with 40 cases in each group. Statistical analysis were performed by using SPSS 20.0 software. Measurement data, such as perioperative indicators and heart rate at each time point [10 min before pneumoperitoneum after intubation (T0) , 30 min after pneumoperitoneum (T1), 1 h after pneumoperitoneum (T2), 10 min after pneumoperitoneum (T3)] were expressed as (±s), and were examined by using repeated variance analysis. Postoperative complications were analyzed by using χ² test A P value< 0.05 was arterial oxygen partial considered as statistically significant difference.

Results

Compared with T0, intraoperative mean arterial pressure (MAP), airway mean pressure (Pmean), airway peak pressure (Ppeak), pressure (PaO₂), respiratory partial carbon dioxide partial pressure (PETCO₂), and arterial partial carbon dioxide partial pressure (PaCO₂) in the three groups were significantly increased during T1~T2 (P<0.05), while dynamic lung compliance (Cdyn) was significantly decreased (P<0.05). Ppeak in PCV-VG group was lower than those in VCV group and PCV group during T1~T2 (P<0.05), and Pmean of PCV-VG group was lower than those in VCV group during T1~T3 (P<0.05). Both the PCV-VG group and the PCV group had higher Cdyn than the VCV group at T1~T2 (P<0.05), and the PCV-VG group had higher Cdyn than the PCV group at T2 (P<0.05). The total incidence of complications in PCV-VG group and PCV group was significantly lower than that of VCV group on POD 7 (P<0.05); The incidence of atelectasis in PCV-VG group was significantly lower than that in VCV group (P<0.05).

Conclusion

For patients with liver cancer and portal hypertension undergoing laparoscopic hepatectomy, the PCV-VG model could reduce airway pressure, improve lung compliance, and to decrease the incidence of postoperative pulmonary related complications with higher safety.

Key words: Liver neoplasms, Hypertension, portal, Laparoscopes, Hepatectomy, Respiration, artificial, Respiratory mechanics, Postoperative complications

表1 120例腹腔镜肝癌切除术不同术中通气模式的三组患者[(±s)，例]

组别	例数	年龄(岁)	BMI(kg/m²)	性别	Child分级
组别	例数	年龄(岁)	BMI(kg/m²)	男/女	A/B
VCV	40	54.9±6.5	22.8±2.6	26/14	35/5
PCV	40	55.6±6.6	22.2±2.5	23/17	33/7
PCV-VG	40	54.8±6.8	22.7±2.5	25/15	36/4
F/χ²	?	0.634	0.058	1.006	0.602
P值	?	0.357	0.971	0.137	0.524

表1 120例腹腔镜肝癌切除术不同术中通气模式的三组患者[(±s)，例]

组别	例数	年龄(岁)	BMI(kg/m²)	性别	Child分级
组别	例数	年龄(岁)	BMI(kg/m²)	男/女	A/B
VCV	40	54.9±6.5	22.8±2.6	26/14	35/5
PCV	40	55.6±6.6	22.2±2.5	23/17	33/7
PCV-VG	40	54.8±6.8	22.7±2.5	25/15	36/4
F/χ²	?	0.634	0.058	1.006	0.602
P值	?	0.357	0.971	0.137	0.524

表2 120例腹腔镜肝癌切除术不同术中通气模式的三组患者围术期指标比较(±s)

组别	例数	手术时间(min)	气腹时间(min)	术中出血量(ml)	住院时间(d)
VCV	40	181.4±45.9	121.5±26.5	51.6±7.3	11.6±2.3
PCV	40	190.2±49.8	116.2±26.0	53.4±6.9	10.9±2.5
PCV-VG	40	193.5±46.3	129.4±27.1	53.1±7.0	10.4±2.5
F/χ²	?	0.698	2.506	0.744	2.451
P	?	0.500	0.086	0.477	0.091

表2 120例腹腔镜肝癌切除术不同术中通气模式的三组患者围术期指标比较(±s)

组别	例数	手术时间(min)	气腹时间(min)	术中出血量(ml)	住院时间(d)
VCV	40	181.4±45.9	121.5±26.5	51.6±7.3	11.6±2.3
PCV	40	190.2±49.8	116.2±26.0	53.4±6.9	10.9±2.5
PCV-VG	40	193.5±46.3	129.4±27.1	53.1±7.0	10.4±2.5
F/χ²	?	0.698	2.506	0.744	2.451
P	?	0.500	0.086	0.477	0.091

表3 120例腹腔镜肝癌切除术不同术中通气模式三组患者术后并发症发生率比较[例(%)]

组别	例数	胸腔积液	肺部感染	肺不张	总发生率
VCV	40	20(50)	5(12.5)	12(30)^a	37(92.5)
PCV	40	14(35)	4(10)	7(17.5)	25(62.5)^a
PCV-VG	40	11(27.5)	2(5)	4(10)	17(42.5)^a
χ²	?	?	?	?	22.525
P	?	?	?	?	0.000

表3 120例腹腔镜肝癌切除术不同术中通气模式三组患者术后并发症发生率比较[例(%)]

组别	例数	胸腔积液	肺部感染	肺不张	总发生率
VCV	40	20(50)	5(12.5)	12(30)^a	37(92.5)
PCV	40	14(35)	4(10)	7(17.5)	25(62.5)^a
PCV-VG	40	11(27.5)	2(5)	4(10)	17(42.5)^a
χ²	?	?	?	?	22.525
P	?	?	?	?	0.000

表4 120例腹腔镜肝癌切除术不同术中通气模式三组患者术中血流动力学、呼吸力学和血气分析指标比较(±s)

观察指标	组别	T0	T1～T2	T3
心率(次/min)	VCV	63.2±8.6	62.6±9.0	63.1±8.5
	PCV	63.4±8.1	64.5±8.2	62.6±8.0
	PCV-VG	64.5±7.8	63.8±8.3	64.7±8.7
MAP(mmHg)	VCV	80.6±10.7	86.2±9.6^a	83.4±10.2
	PCV	78.7±9.5	85.6±10.2^a	82.8±9.4
	PCV-VG	79.5±9.4	84.1±10.0^a	81.6±9.7
Ppeak(cmH₂O)	VCV	13.8±1.1	26.4±2.1^a	14.5±1.8
	PCV	14.0±1.4	23.4±2.3^ab	14.2±1.3
	PCV-VG	13.7±1.5	20.4±2.2^abc	14.1±1.7
Pmean(cmH₂O)	VCV	8.5±1.1	10.4±1.7^a	9.7±1.3^a
	PCV	8.6±1.4	9.8±1.5^a	9.3±1.6^b
	PCV-VG	8.3±1.4	9.6±1.3^ab	8.6±1.2^b
Cdyn(ml/cmH₂O)	VCV	42.5±6.4	26.5±5.6^a	40.1±5.3
	PCV	41.9±5.9	29.4±5.3^ab	39.8±6.0
	PCV-VG	41.6±5.4	32.2±4.7^abc	40.3±5.2
PaO₂(mmHg)	VCV	180.2±31.6	202.5±32.4^a	180.6±31.5
	PCV	182.6±30.7	212.3±32.2^a	182.4±30.4
	PCV-VG	191.6±33.2	213.2±31.0^a	190.6±28.6
PETCO₂(mmHg)	VCV	32.2±3.1	35.4±3.6^a	32.4±3.4
	PCV	31.9±3.0	36.7±2.7^a	32.1±3.4
	PCV-VG	32.6±3.0	36.0±3.4^a	32.8±4.0
PaCO₂(mmHg)	VCV	36.5±3.6	41.5±3.7^a	37.5±3.4
	PCV	34.6±3.8	40.5±3.6^a	35.6±3.3
	PCV-VG	35.7±3.1	43.1±3.7^a	35.4±3.5

表4 120例腹腔镜肝癌切除术不同术中通气模式三组患者术中血流动力学、呼吸力学和血气分析指标比较(±s)

观察指标	组别	T0	T1～T2	T3
心率(次/min)	VCV	63.2±8.6	62.6±9.0	63.1±8.5
	PCV	63.4±8.1	64.5±8.2	62.6±8.0
	PCV-VG	64.5±7.8	63.8±8.3	64.7±8.7
MAP(mmHg)	VCV	80.6±10.7	86.2±9.6^a	83.4±10.2
	PCV	78.7±9.5	85.6±10.2^a	82.8±9.4
	PCV-VG	79.5±9.4	84.1±10.0^a	81.6±9.7
Ppeak(cmH₂O)	VCV	13.8±1.1	26.4±2.1^a	14.5±1.8
	PCV	14.0±1.4	23.4±2.3^ab	14.2±1.3
	PCV-VG	13.7±1.5	20.4±2.2^abc	14.1±1.7
Pmean(cmH₂O)	VCV	8.5±1.1	10.4±1.7^a	9.7±1.3^a
	PCV	8.6±1.4	9.8±1.5^a	9.3±1.6^b
	PCV-VG	8.3±1.4	9.6±1.3^ab	8.6±1.2^b
Cdyn(ml/cmH₂O)	VCV	42.5±6.4	26.5±5.6^a	40.1±5.3
	PCV	41.9±5.9	29.4±5.3^ab	39.8±6.0
	PCV-VG	41.6±5.4	32.2±4.7^abc	40.3±5.2
PaO₂(mmHg)	VCV	180.2±31.6	202.5±32.4^a	180.6±31.5
	PCV	182.6±30.7	212.3±32.2^a	182.4±30.4
	PCV-VG	191.6±33.2	213.2±31.0^a	190.6±28.6
PETCO₂(mmHg)	VCV	32.2±3.1	35.4±3.6^a	32.4±3.4
	PCV	31.9±3.0	36.7±2.7^a	32.1±3.4
	PCV-VG	32.6±3.0	36.0±3.4^a	32.8±4.0
PaCO₂(mmHg)	VCV	36.5±3.6	41.5±3.7^a	37.5±3.4
	PCV	34.6±3.8	40.5±3.6^a	35.6±3.3
	PCV-VG	35.7±3.1	43.1±3.7^a	35.4±3.5

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Clinical application of ventilation mode for patients with liver cancer complicated with portal hypertension undergoing laparoscopic hepatectomy

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Clinical application of ventilation mode for patients with liver cancer complicated with portal hypertension undergoing laparoscopic hepatectomy