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中华普外科手术学杂志(电子版)

中华普外科手术学杂志(电子版) ›› 2020, Vol. 14 ›› Issue (06) : 585 -589. doi: 10.3877/cma.j.issn.1674-3946.2020.06.015

所属专题： 文献；

论著

标准残肝体积联合瞬时弹性成像技术预测半肝切除的安全性研究
吴金柱1(), 蔡卫华1,†(), 徐磊1, 陈琳1, 肖锋1, 许甜1, 王建新1, 朱任飞1, 季汉珍1, 张鹏1   
  1. 1. 226006　江苏南通，南通大学附属南通第三人民医院肝胆外科
  • 收稿日期:2020-02-20 出版日期:2020-12-26
  • 通信作者: 吴金柱, 蔡卫华

Study on the prediction of the safety of hemihepatectomy by the standard remnant liver volume combined with transient elastography

Jinzhu Wu1,†(), Weihua Cai1(), Lei Xu1, Lin Chen1, Feng Xiao1, Tian Xu1, Jianxin Wang1, Renfei Zhu1, Hanzhen Ji1, Peng Zhang1   

  1. 1. Department Hepatobiliary Surgery, The Third People's Hospital of Nantong City, Jiangsu 226006, China
  • Received:2020-02-20 Published:2020-12-26
  • Corresponding author: Jinzhu Wu, Weihua Cai
  • About author:
    Corresponding author: Wu Jinzhu, Email:
  • Supported by:
    Key project of Science and Technology Bureau of Nantong City(MS12019021); General project of Health Commission of Nantong City(MA2019008)
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引用本文：

吴金柱, 蔡卫华, 徐磊, 陈琳, 肖锋, 许甜, 王建新, 朱任飞, 季汉珍, 张鹏. 标准残肝体积联合瞬时弹性成像技术预测半肝切除的安全性研究[J]. 中华普外科手术学杂志(电子版), 2020, 14(06): 585-589.

Jinzhu Wu, Weihua Cai, Lei Xu, Lin Chen, Feng Xiao, Tian Xu, Jianxin Wang, Renfei Zhu, Hanzhen Ji, Peng Zhang. Study on the prediction of the safety of hemihepatectomy by the standard remnant liver volume combined with transient elastography[J]. Chinese Journal of Operative Procedures of General Surgery(Electronic Edition), 2020, 14(06): 585-589.

目的

探讨肝细胞癌(HCC)患者应用标准残肝体积(SRLV)及肝脏瞬时弹性成像技术(TE)评估半肝手术患者肝储备功能的可行性及安全性。

方法

回顾性分析2016年1月至2020年1月27例行半肝切除并病理证实为HCC患者的资料，术前CT测定肝脏总体积、瘤体体积、残肝体积，术中排水法测定切除的半肝标本的体积，计算SRLV；采用IBM SPSS 25.0完成分析，计量资料以(±s)表示，采用t检验或方差分析；计数资料的组间对比采用χ2分析；采用ROC曲线分析不同因素ROC曲线下面积，检验水准P<0.05。

结果

半肝切除患者病理分期肝纤维化S2～S4期SRLV临界值均为0.329 L/m2，半肝切除术后发生肝功能不全患者13例，其中肝纤维化S2～S4期SRLV临界值均亦为0.329 L/m2; Child-Pugh分级预测术后肝功能代偿良好准确率为52.2%，而新评价模型预测术后肝功能代偿良好准确率为100.0%(P<0.05)；Child-Pugh分级预测术后肝功能代偿轻度不良准确率为25.0%，而新评价模型预测术后肝功能代偿轻度不良准确率为88.2%(P<0.05)。

结论

SRLV联合是评估HCC行半肝切除安全指标；Child-Pugh分级联合肝瞬时弹性值的新肝储备评估模型对半肝手术患者储备功能的评估有较好的临床指导意义。

关键词: 癌，肝细胞, 肝硬化, 肝切除术, 弹性成像技术
Objective

To explore the feasibility and safety of standard remnant liver volume (SRLV) and the transient elastography(TE) in the evaluation of liver reserve function of patients undergoing hemihepatectomy for hepatocellular carcinoma (HCC).

Methods

The clinical data of 27 patients undergoing hepatectomy with a pathological diagnosis of HCC from January 2016 to January 2020 were analyzed retrospectively; the total liver volume, tumor volume and remnant liver volume were detected by CT before operation; the volume of resected half liver was measured by using drainage method and SRLV was calculated during operation. IBM SPSS 25.0 was used for data analysis. Measurement data were expressed as (±s) and were analyzed by using t test or one-way analysis of variance. The comparison of count data between groups were performed by using χ2 analysis; ROC curve was used for analyzing the areas under the ROC curves of different factors. A P value <0.05 was considered as statistically significant difference.

Results

The threshold value of SRLV in all S2~S4 liver fibrosis patients undergoing hepatectomy was 0.329L/m2; hepatic insufficiency occurred in 13 patients after hemihepatectomy, of whom the safety threshold value of SRLV in S2~S4 liver fibrosis patients was 0.329L/m2 too; the accuracy rate of Child-Pugh score in predicting good postoperative liver function compensation was 52.2%, while the accuracy rate of the new evaluation model in predicting good postoperative liver function compensation was 100% (P<0.05); the accuracy rate of Child-Pugh score in predicting mildly poor postoperative liver function compensation was 25%, while the accuracy rate of the new evaluation model in predicting mildly poor postoperative liver function compensation was 88.24% (P<0.05).

Conclusion

SRLV combined with transient elastography is a safe index to evaluate the safety of hemihepatectomy for HCC, and the new liver reserve evaluation model of Child-Pugh score combined with instantaneous hepatic elasticity could achieve a better clinical guiding significance for the evaluation of the reserve liver function of patients undergoing hemihepatectomy.

Key words: Carcinoma, hepatocellular, Liver cirrhosis, Hepatectomy, Elasticity imaging techniques
表1 27例半肝切除术肝细胞癌患者的基线资料[(±s)，例(%)]
临床资料 数值 临床资料 数值
年龄(岁) 57.4±9.1 INR(s) 1.1±0.1
性别 ? 肝脏硬度( kPa) 13.6±5.6
? 　男 24(88.9) Child-Pugh分级 ?
? 　女 3(11.1) ? 　A 23(85.2)
身高(cm) 168.0±7.3 ? 　B 4(14.8)
BSA(m2) 1.7±0.2 CT测肿瘤大小(cm) 7.4±4.9
WBC(×109/L) 5.2±1.6 CT测肿瘤体积(cm3) 785.7±323.2
RBC(×1012/L) 4.5±0.5 肝门阻断时间(min) 15.6±19.5
PLT(×109/L) 134.9±62.4 手术时间(min) 137.6±69.9
ALT(U/L) 61.3±82.3 术中出血量(ml) 1237.0±1276.2
AST(U/L ) 51.4±48.4 手术方式 ?
TBIL(μmol/L) 16.8±8.4 ? 　左半肝 9(33.3)
ALB(g/L) 40.5±4.2 ? 　右半肝 18(66.7)
GGT(U/L) 126.6±133.5 病理肝纤维化 ?
Scr(μmol/L) 67.3±11.6 ? 　S0～S1 6(22.2)
PIVKA-II(μg/L) 2848.5±6244.7 ? 　S2～S3 11(40.8)
PT(s) 12.6±1.2 ? 　S4 10(37.0)
图1 肝细胞癌行半肝切除术的肝脏硬度测量示意图[注：此图为肝脏硬度值为14.3KPa，相对偏差为10%，成功率100%，有效次数10/10，经术后病理证实为HBV-CH-G2S3]
表2 27例半肝切除术患者Child-Pugh分级联合肝瞬时弹性值的新肝储备评估模型
指标 1分 2分 3分
HE 无 1～2 3～4
ABD 无 轻度 中、重度
TIBL(μmol/L) <34 34～51 >51
ALB(g/L) >35 28～35 <28
PT(s) <4 4～6 >6
LSM(kPa) <15 5～25 >25
图2 27例半肝术后病理不同肝纤维化分期(HE×200)注：A.肝纤维化S1期；B.肝纤维化S2期；C.肝纤维化S3期；D.肝纤维化S4期]
图3 27例半肝切除术后病理评估不同肝纤维化期相应SRLV的ROC曲线[注：A.肝纤维化S2～S3期；B.肝纤维化S4期]
表3 27例半肝切除术后不同肝纤维化分期SRLV(±s)
肝纤维化分期 术后病理不同的SRLV
例数 SRLV (L/m2) F P
S1 6 279.0±31.1 12.799 0.000
S2～S3 11 287.3±49.1
S4 10 419.9±94.2
肝纤维化分期 术后肝功能不全时的SRLV
例数 SRLV (L/m2) F P
S1 1 234.2 4.270 0.046
S2～S3 3 299.1±37.3 ? ?
S4 9 429.9±94.2
图4 半肝术后肝功能不全时不同肝纤维化分期相应SRLV的ROC曲线[注：A.肝纤维化S2～S3期；B.肝纤维化S4期]
表5 27例半肝切除肝功能两种评估方法比较[例(%)]
评估方法 例 分级 术前 术后
A (I) B(II) C(III)
Child-Pugh分级 27 A 23 12(52.2) 11(47.8) 0
? ? B 4 0 1(25.0) 3(75.0)
? ? C 0 0 0 0
新评估模型分级 27 Ⅰ 9 9(100)a 0 0
? ? Ⅱ 17 0 15(88.2)b 2(11.8)
? ? Ⅲ 1 0 0 1(100)
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