郑州大学附属肿瘤医院 肝胆胰外科，河南 郑州 453003
黄长山， Email: email@example.com
Department of Hepatopancreaticobiliary Surgery, the Affiliated Tumor Hospital of Zhengzhou University, Zhengzhou 453003, China
背景与目的 肝切除术后肝功能失代偿是导致术后患者病死率升高的主要因素，因此术前有效的评估肝功能显得尤为重要。吲哚菁绿15 min滞留率（ICGR15）是临床常用的肝功能评估手段，可快速、准确的评估肝脏储备功能，术前ICGR15与肝脏切除术后肝功能失代偿密切相关，ICGR15<20%被认为是可耐受大块肝脏切除（≥3个肝段）的必要条件之一，临床上常见部分患者ICGR15介于20%~30%之间，在给予护肝等对症治疗后ICGR15可有改善。对于此类患者能否安全实施大块肝切除术后仍存争议，本研究旨在探讨术前改善ICGR15对肝癌患者术后并发症及术后近期肝功能的影响。方法 选取2015年5月—2017年10月收治的入院时ICGR15为20%~30%，术前对症治疗后ICGR15均<20%肝癌患者32例（观察组），及45例入院时ICGR15<20%的肝癌患者（对照组），两组均行开放肝癌切除术（≥3个肝段）。比较两组患者术中与术后指标、出院时以及术后1、3、6个月总胆红素（TBIL）、谷草转氨酶（AST）、白蛋白（ALB）、凝血酶原时间（PT）、美国东部肿瘤协作组（ECOG）活动状态评分等指标。结果 两组入院时ICGR15差异有统计学意义（P<0.05），其余术前一般资料与生化指标差异均无统计学意义（均P>0.05）。两组患者的切肝范围与其他术中指标差异均无统计学意义（均P>0.05）。两组均无围手术期死亡病例，观察组与对照组术后并发症发生率分别为37.5%（12/32）与31.1%（14/45），差异无统计学意义（P>0.05），观察组患者住院时间、引流管拔出时间较对照组延长（均P<0.05）。观察组出院时及术后1、3、6个月的TBIL均明显高于对照组（P<0.05）；观察组ALB水平与ECOG评分在出院至术后1个月均明显低于对照组（均P<0.05），两者在随后时间与对照组差异均无统计学意义（均P>0.05）；两组其余生化指标在出院至术后6个月各时间点差异均无统计学意义（均P>0.05）。结论 术前ICGR15 20%~30%之间的患者，经护肝治疗后ICGR15好转后，能安全耐受大块肝脏切除，未明显增加术后并发症发生率。术后短期内TBIL水平较高，并未对患者的生存质量造成不良影响，但患者长期预后情况尚须进一步随访观察。
Background and Aims Liver function decompensation is the main cause for the increased mortality in patients after liver resection. So, effective preoperative liver function assessment is of great importance. Indocyanine green retention rate at 15 minutes (ICGR15) is a simple and accurate test to evaluate preoperative liver function and is widely used in clinical practice. ICGR15 <20% is essential to major hepatectomy (≥3 segments). Patients with ICGR15 value ranging from 20% to 30% are frequently encountered in clinical practice, and their ICGR15 can be improved after symptomatic management such as hepatoprotective treatment. Whether the major hepatectomy can be safely performed in these patients remains controversial. Therefore, this study was to evaluate the effectiveness of preoperative ICGR15 improvement on complications and liver function in patients after hepatectomy for liver cancer.Methods Form May 2015 to October 2017, 32 liver cancer patients whose ICGR15 values were between 20% and 30% on admission and were improved to less than 20% after symptomatic treatment before operation (observation group), and the other 45 liver cancer patients with the ICGR15<20% on admission (control group) were selected. All patients underwent open liver cancer resection (≥3 segments). The intra- and postoperative variables, and the total bilirubin (TBIL), aspartate aminotransferase (AST), albumin (Alb), and prothrombin time (PT) as well as the ECOG physical status scores were compared between the two groups of patients.Results Between the two groups of patients, except the ICGR15 values on admission that were significantly different (P<0.05), all other preoperative general data and biochemical indexes showed no statistical difference (all P>0.05). There were no statistical differences in liver resection scopes and other intraoperative variables between the two groups of patients (all P>0.05). No perioperative death occurred in both groups, and the incidence rates of postoperative complications were 37.5% (12/32) in observation group and 31.1% (14/45) in control group, which had no statistical difference (P>0.05). The length of hospital stay and time to drainage tube removal were prolonged in observation group compared with control group (both P<0.05). The levels of TBIL at hospital discharge or 1 month, and 3 and 6 months after operation were all significantly higher in observation group than those in control group (all P<0.05). The levels of ALB and ECOG scores at hospital discharge or 1 month after operation were all significantly lower in observation group than those in control group (all P<0.05), but both variables showed no significant differences between the two groups later (all P>0.05). There were no significant differences in the remaining biochemical indexes between the two groups at each time point from the time of hospital discharge to 6 months after operation (all P>0.05).Conclusions Patients with the preoperative ICGR15 between 20% to 30% can tolerate major hepatectomy safely after improvement of ICGR15 to less than 20% by hepatoprotective treatment, without increase of postoperative complications. Although the TBIL level is relatively high during a short period after operation, it does not exert harmful effect on patients' quality of life. However, the long-term results of the patients still need further observations.