【摘要】：目的：探討肝臟切除手術中血流限流最佳比例，以期在減少除術中出血的同時，降低入肝血流限制帶來的肝臟功能損害以及對全身系統(tǒng)性的不良影響，降低手術并發(fā)癥，改善生存及預后。 方法：1.根據(jù)肝門解剖結構及血流特點，設計定量化肝門血流限制裝置，經(jīng)權威部門認證，研發(fā)、生產(chǎn)并用于動物實驗；2.應用定量化肝門血流限制器，研究不同限流比例下，對兔肝臟灌注的影響；3.構建肝切除兔模型，阻斷肝動脈，在不同門靜脈限流比例下，進行左葉、中葉肝切除，統(tǒng)計術中失血量，術后6h、3d、7d肝功能變化以及7天生存率，探討肝切除條件下，門靜脈最佳限流比例。 結果：1.定量化肝門血流限制器獲得國家知識產(chǎn)權局認可，授予實用新型專利。2.在肝動脈夾閉、門靜脈限流兔模型中，門靜脈血流量同肝臟灌注壓呈線性正相關，線性回歸方程：①絕對值：P（Pu）=85.825+2.051V（ml/min）。②百分比：P（Pu%）=0.296+0.662V（ml min-1%）（上述各方程各常量及回歸系數(shù)p均0.01）。肝靜脈血液回流維持肝臟灌注壓的貢獻比例約為29.6%。3.在兔肝切除（左葉、中葉）模型中，完全阻斷肝動脈，門靜脈限流45min：完全阻斷、限流90%、80%、70%和完全開放，7天生存率分別為0%、10%、60%、80%、100%。4.在兔肝切除（左葉、中葉）模型中，完全阻斷肝動脈，門靜脈限流30min：（1）在術中失血方面，限流80%同完全阻斷在術中失血量上沒有顯著差異。（2）在肝損傷方面，通過分析術后肝臟病理和血清肝酶學水平，，肝細胞損傷無論限流比例如何，術后6h損傷達到高峰，之后隨著術后時間逐漸恢復；限流70%同完全開放沒有顯著性差異（P0.05），限流超過80%損傷顯著性加重（P0.05），但是限流70%和80%沒有顯著性差異（P0.05）。（3）在由于門靜脈限流造成腹腔器官瘀血方面：腸粘膜壞死主要發(fā)生于術后6h急性期內(nèi)，限流80%以上則腸道損傷顯著性加重，至術后第3天及以后，腸道粘膜逐漸恢復，不同限流比例所造成的差異逐漸趨于不明顯。（4）在肝切除術后肝再生恢復方面，術后恢復時間是決定肝臟再生的最主要因素；限流80%同完全開放沒有顯著性差異，限流超過80%肝臟再生顯著性下降，但是限流80%和90%沒有顯著性差異。 結論：我們研發(fā)的新型定量化血流限制裝置能夠應用于肝切除手術中血流限制，但是在已產(chǎn)品化實例中，調(diào)節(jié)效率尚待提高。在完全阻斷肝動脈血流的肝切除模型中，PV限流程度是影響生存的危險因素；PV限流80%，術中失血同完全阻斷沒有顯著性差異。門靜脈血流量同肝臟灌注壓具有線性正相關，是影響生存的保護性因素：當血流限制80%時，則保護作用不具有顯著意義；門靜脈限流70%-80%區(qū)間內(nèi)可能存在某一個IRI影響突然變化的閾值；門靜脈限流80%-90%區(qū)間內(nèi)可能存在某一個術后肝臟再生的閾值。
[Abstract]:Objective: to study the optimal proportion of blood flow limiting in hepatectomy, so as to reduce the hepatic function damage caused by blood flow restriction and the systemic adverse effects, and to reduce the complications of the operation. To improve survival and prognosis. Method 1: 1. According to the anatomical structure and blood flow characteristics of hepatic hilus, a quantitative hepatic portal blood flow limiting device was designed and developed, produced and used in animal experiments. 2. Quantitative hepatic portal blood flow limiter was used to study the effects of different flow limiting ratios on hepatic perfusion in rabbits. 3. A rabbit model of hepatectomy was established to block the hepatic artery. Zuo Ye and middle lobe hepatectomy were performed under different portal vein flow limiting ratios. The blood loss during the operation was counted. The changes of liver function and the 7 day survival rate at 6 hours and 3 days after hepatectomy were also studied in order to investigate the survival rate of 7 days after hepatectomy. Optimal flow limiting ratio of portal vein. Results: 1. Quantitative hepatic portal blood flow limiter has been approved by the State intellectual property Office, granted a utility model patent. 2. There was a linear positive correlation between portal vein blood flow and hepatic perfusion pressure in hepatic artery occlusion and portal vein limiting flow rabbit model. Linear regression equation: 1 absolute: P (Pu) = 85.825 2.051V (ml/min). 2%: P (Pu% = 0.296 0.662V (ml min-1%). The contribution ratio of hepatic venous blood flow to maintain hepatic perfusion pressure is about 29.6. 3. In the model of rabbit hepatectomy (Zuo Ye, middle lobe), the hepatic artery was completely blocked, the portal vein was controlled for 45 min: completely blocked, 90% and 80% were completely open and 70%. The 7-day survival rate was 0 ~ 1060,60,800.100. 4, respectively. In the model of rabbit hepatectomy (Zuo Ye, middle lobe), the hepatic artery was completely blocked and the portal vein was limited for 30 minutes. (1) there was no significant difference in blood loss between 80% and complete occlusion during the operation. (2) there was no significant difference in the amount of blood loss between the two groups. (2) there was no significant difference in the amount of blood loss between the two groups. According to the analysis of liver pathology and serum level of liver enzymes, no matter the proportion of liver cell injury was limited, the injury reached the peak at 6 h after operation, and then recovered gradually with the postoperative time. There was no significant difference between 70% and fully open current limit (P0.05). However, there was no significant difference between 70% and 80% of the limiting flow (P0.05). (3) in abdominal organ ecchymosis due to portal vein restriction: intestinal mucosal necrosis mainly occurred in the acute phase 6 hours after operation. More than 80% of the current limit increased significantly intestinal injury, and the intestinal mucosa gradually recovered on and after the third day after operation, and the differences caused by different flow limiting ratios tended to be insignificant. (4) the recovery of liver regeneration after hepatectomy; Postoperative recovery time was the most important factor in determining liver regeneration. There was no significant difference between 80% and 90% of the total opening, but there was no significant difference between 80% and 90%. Conclusion: the new quantitative blood flow limiting device developed by us can be applied to blood flow limitation in hepatectomy, but in the case of production, the regulation efficiency needs to be improved. In the hepatectomy model with complete occlusion of hepatic artery blood flow, the degree of PV flow limitation was the risk factor of survival, and the blood loss during operation was not significantly different from that of complete occlusion of PV flow limiting factor 80. Portal vein blood flow has a linear positive correlation with hepatic perfusion pressure and is a protective factor for survival: when the blood flow is limited to 80, the protective effect is not significant. There may be a threshold of sudden change of IRI in 70 ~ 80% of portal vein and a threshold of liver regeneration in 80 ~ 90% of portal vein.
【學位授予單位】：中國人民解放軍醫(yī)學院
【學位級別】：博士
【學位授予年份】：2013
【分類號】：R657.3

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相關期刊論文 前1條

1 陳永衛(wèi);董家鴻;;肝切除過程中入肝血流阻斷方法的探討[J];中國療養(yǎng)醫(yī)學;2011年03期

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