目的 探讨肝部分切除术后连续性监测吲哚菁绿15分钟滞留率(ICG-R15)联合标准残肝体积(SRLV)对术后肝功能不全发生率的预测价值.方法 收集天津市第一中心医院肝胆外科2016年11月—2017年5月收治的70例肝细胞癌患者的临床资料.根据患者术后是否发生肝功能不全的情况,分为肝功能良好组(n=56)与肝功能不全组(n=14).根据术前肝功能评估及强化CT计算切除肝体积和剩余肝体积以及肝脏三维重建,术中B超定位决定手术方案,根据术中情况决定采用选择性肝门入肝血流阻断或间断全肝门阻断,CUSA联合双极滴水电凝镊离断肝实质.计算SRLV并连续监测患者ICG-R15.计量资料两组间比较采用成组t检验;计数资料组间比较采用χ2检验;采用受试者工作特征曲线(ROC曲线)下面积(AUC)评估预测术后肝功能不全的准确性.多因素Logistic回归分析建立术后肝功能不全的预测模型,制订SLRV联合术后ICG-R15动态监测对术后肝功能不全的诊断标准.结果 两组术前以及术后即时、3 d、5 d的ICG-R15,以及SRLV、Child分级比较,差异均有统计学意义(P值均＜0.05).术前、术后即时、术后3 d、术后5 d 患者术后肝功能不全发生率均随ICG-R15升高而升高(P值均＜0.001).进一步两两比较,术前、术后即时、术后3 d、术后5 d ICG-R15＞20%组与其他两组患者肝功能不全发生率比较,差异均有统计学意义(P值均＜0.001);术后即时,ICG-R15＜10%组与10%≤ICG-R15≤20%组肝功能不全发生率比较,差异有统计学意义(P＜0.001).术前ICG-R15、术后即时ICG-R15、术后3 d ICG-R15、术后5 d ICG-R15预测术后肝功能不全的AUC分别为0.790、0.857、0.855、0.870,术后即时、3 d、5 d ICG-R15的AUC均大于术前,差异均有统计学意义(P值均＜0.05).多因素分析结果显示,SRLV以及ICG-R15术后动态监测(术后即时、术后3 d、术后5 d)水平升高均为术后肝功能不全的独立危险因素,术前BMI升高则为独立保护因素(P值均＜0.05).建立多因素Logistic回归预测模型,依据预测模型分别对术后(术后即时、术后3 d、术后5 d)肝功能不全进行预测,ROC曲线显示术后即时、术后3 d、术后5 d预测模型的AUC分别为0.963、0.967、0.967(P值均＜0.01).制订SLRV联合术后ICG-R15动态监测对于术后肝功能不全的诊断标准:SLRV＞1 240 mL/m2、术后即时ICG-R15＞20%、术后3 d或5 d ICG-R15＞25%,符合其中任意一项即可诊断术后肝功能不全,灵敏度100%,特异度60.71%,符合度68.57%.结论 连续性监测术前及术后ICG-R15水平对于术后肝功能不全的预估均具有指导意义,术后5 d ICG-R15的准确性相对最高;SRLV联合术后ICG-R15动态检测能有效预测肝切除术后肝功能不全的发生,可指导临床医生预估肝癌患者术后肝功能不全的发生,并尽早进行临床干预.
Predictive value of continuous monitoring of indocyanine green retention rate at 15 minutes combined with standard residual liver volume for hepatic insufficiency in patients with hepatocellular carcinoma after partial hepatectomy
Objective To investigate the value of continuous monitoring of indocyanine green retention rate at 15 minutes(ICG-R15)combined with standard residual liver volume(SRLV)in predicting hepatic insufficiency after partial hepatectomy.Methods Clinical data and SRLV data were collected from 70 patients with hepatocellular carcinoma who were admitted to Department of Hepatobiliary Surgery,Tianjin First Central Hospital,from November 2016 to May 2017.According to the presence or absence of hepatic insufficiency after surgery,the patients were divided into good liver function group with 56 patients and hepatic insufficiency group with 14 patients.Based on preoperative liver function evaluation and contrast-enhanced CT scans,resected liver volume and residual liver volume were calculated,and three-dimensional reconstruction of the liver was performed.Intraoperative ultrasound localization was performed to determine the surgical regimen,and selective hepatic inflow occlusion or intermittent hepatic portal occlusion was selected based on intraoperative conditions.CUSA combined with BIPOLAR drip electric coagulation forceps were used for the partition of liver parenchyma.SRLV was calculated,and ICG-R15 was monitored continuously.The independent-samples t test was used for comparison of continuous data between two groups,and the chi-square test was used for comparison of categorical data between two groups;the area under the ROC curve(AUC)was used to investigate the accuracy in predicting hepatic insufficiency after surgery.A multivariate Logistic regression analysis was used to establish a predictive model for postoperative hepatic insufficiency,and diagnostic criteria were developed for SLRV combined with postoperative ICG-R15 dynamic monitoring in the diagnosis of postoperative hepatic insufficiency.Results There were significant differences between the two groups in ICG-R15 before surgery,immediately after surgery,and on days 3 and 5 after surgery,as well as significant differences in SRLV and Child class(all P＜0.05).The incidence rate of postoperative hepatic insufficiency increased with the increase in ICG-R15 before surgery,immediately after surgery,and on days 3 and 5 after surgery(all P＜0.001).Further comparison between two groups showed that there was a significant difference in the incidence rate of hepatic insufficiency between the ICG-R15＞20%group and the other two groups before surgery,immediately after surgery,and on days 3 and 5 after surgery(all P＜0.001),and there was a significant difference in the incidence rate of hepatic insufficiency between the ICG-R15＜10%group and the 10%≤ICG-R15≤20%group immediately after surgery(P＜0.001).ICG-R15 before surgery,ICG-R15 immediately after surgery,ICG-R15 on day 3 after surgery,and ICG-R15 on day 5 after surgery had an AUC of 0.790,0.857,0.855,and 0.870,respectively,in predicting postoperative hepatic insufficiency,and ICG-R15 immediately after surgery and on days 3 and 5 after surgery had a significantly larger AUC than ICG-R15 before surgery(all P＜0.05).The multivariate analysis showed that increases in SRLV and postoperative ICG-R15 dynamic monitoring(immediately after surgery and on days 3 and 5 after surgery)were independent risk factors for postoperative hepatic insufficiency,while increased body mass index before surgery was an independent protective factor(all P＜0.05).A multivariate Logistic regression predictive model was established and was used to predict hepatic insufficiency after surgery(immediately after surgery and on days 3 and 5 after surgery),and the ROC curve analysis showed that the model had an AUC of 0.963,0.967,and 0.967,respectively,in predicting hepatic insufficiency immediately after surgery and on days 3 and 5 after surgery(all P＜0.01).Diagnostic criteria were developed for SLRV combined with postoperative ICG-R15 dynamic monitoring in the diagnosis of postoperative hepatic insufficiency,i.e.,SLRV＞1 240 mL/m2,ICG-R15＞20%immediately after surgery,or ICG-R15＞25%on day 3 or 5 after surgery,and postoperative hepatic insufficiency could be diagnosed if a patient met any one criterion.These diagnostic criteria had a sensitivity of 100%,a specificity of 60.71%,and a conformity degree of 68.57%.Conclusion Continuous monitoring of ICG-R15 before and after surgery is of guiding significance for predicting postoperative hepatic insufficiency,and ICG-R15 on day 5 after surgery has the highest accuracy.SRLV combined with postoperative ICG-R15 dynamic monitoring can effectively predict the onset of hepatic insufficiency after hepatectomy and can guide clinicians to predict the onset of postoperative hepatic insufficiency in patients with liver cancer and perform clinical intervention as soon as possible.
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