Glisson蒂横断法与Pringle法在肝细胞癌肝切除术中的应用效果Meta分析
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1.四川省内江市第一人民医院 肝胆外科,四川 内江 641000;2.四川省内江市中医医院 院感科,四川 内江 641000

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舒强,四川省内江市第一人民医住院医师,主要从事肝胆胰外科方面的研究。

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Efficacy comparison of Glisson pedicle transsection and Pringle's maneuver in hepatectomy for hepatocellular carcinoma: a Meta-analysis
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1.Department of Hepatobiliary Surgery, Neijiang First People's Hospital, Neijiang, Sichuan 641000, China;2.Department of Department of Infection Prevention, Neijiang Hospital of Traditional Chinese Medicine, Neijiang, Sichuan 641000, China

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    摘要:

    背景与目的 Glisson蒂横断法与Pringle法在肝细胞癌(简称肝癌)肝切除术中的应用效果目前尚无一致结论,亦无大样本量的多中心研究予以证实。本研究通过Meta分析方法评价两种方法在肝癌肝切除术中的应用效果,以期在肝切除术术中阻断方式的选择上提供参考。方法 计算机检索中、英文数据库,检索时间为数据库建立至2021年10月,收集关于Glisson蒂横断法与Pringle法肝癌切除术中应用的临床研究。对纳入的研究进行质量评价和数据提取,采用RevMan 5.3软件进行Meta分析。结果 共纳入15项研究,合计1 349例患者,其中684例行Glisson蒂横断法(Glisson蒂横断组),665例行Pringle法(Pringle组)。Meta分析结果显示,Glisson蒂横断组术后第1、3、7天丙氨酸氨基转移酶水平(MD=-96.67,95% CI=-156.69~-36.65,P=0.002;MD=-55.57,95% CI=-87.03~-24.11,P=0.000 5;MD=-41.33,95% CI=-70.92~-11.73,P=0.006)与天门冬氨酸转氨酶水平(MD=-71.92,95% CI=-130.02~-13.81,P=0.02;MD=-41.45,95% CI=-60.62~-22.28,P=0.000 1;MD=-38.89,95% CI=-71.14~-6.65,P=0.02)以及第3、7天总胆红素水平(MD=-4.47,95% CI=-7.75~-1.18,P=0.002;MD=-5.09,95% CI=-10.05~-0.12,P=0.04)均低于Pringle组,两组第1、3、7天的白蛋白水平均无明显差异(均P>0.05);Glisson蒂横断组术中出血量(MD=-98.48,95% CI=-145.53~-51.43,P<0.000 1)及输血率(OR=0.25,95% CI=0.13~0.46,P<0.000 1)少于Pringle组,两组的手术时间无明显差异(P>0.05);Glisson蒂横断组术后总体并发症(OR=0.31,95% CI=0.22~0.43,P<0.000 01)及住院时间(MD=-2.94,95% CI=-4.12~-1.76,P<0.000 01)均少于Pringle组。结论 在肝癌肝切除术中,Glisson蒂横断法是一种安全有效的血流阻断方法。与Pringle法相比,Glisson蒂横断法能有效减轻肝损伤,减少术中出血、术后并发症的发生及缩短住院时间。但外科医生还应根据个人经验、患者病情以及术中具体情况选择适合患者的阻断方法。

    Abstract:

    Background and Aims There has been no consistent conclusion about the effect of Glissonean pedicle transection method and Pringle's maneuver in hepatectomy for hepatocellular carcinoma (HCC), and has no verification from the large multicenter clinical trials as well at present time. This study was conducted to evaluate the efficacy of the two methods in hepatectomy for HCC through Meta-analysis, so as to provide reference for the selection of inflow occlusion methods during hepatectomy for HCC.Methods The clinical studies comparing Glissonean pedicle transection method and Pringle's maneuver in liver resection for HCC were collected by computer-based searching in Chinese and English databases, with the retrieval time from inception of the database to October 2021. After the quality assessment and data extraction of the included studies, Meta-analysis was performed with RevMan5.3 software.Results A total of 15 studies was included involving 1 349 patients, of whom, Glissonean pedicle transection was used in 684 cases (Glissonean pedicle transection group) and Pringle's maneuver was performed in 665 cases (Pringle group). Results of Meta-analysis showed that the levels of alanine aminotransferase (MD=-96.67, 95% CI=-156.69--36.65, P=0.002; MD=-55.57, 95% CI=-87.03--24.11, P=0.000 5; MD=-41.33, 95% CI=-70.92--11.73, P=0.006) and aspartate aminotransferase (MD=-71.92,95% CI=-130.02--13.81, P=0.02; MD=-41.45, 95% CI=-60.62--22.28,P=0.000 1; MD=-38.89, 95% CI=-71.14--6.65, P=0.02) on postoperative day (POD) 1, 3 and 7 as well as the levels of total bilirubin (MD=-4.47, 95% CI=-7.75--1.18, P=0.002; MD=-5.09, 95% CI=-10.05--0.12, P=0.04) on POD 3 and 7 were lower in Glissonean pedicle transection group than those in Pringle group, and there were no significant differences in albumin levels on POD 1, 3 and 7 between the two groups (all P>0.05); the amount of intraoperative blood loss (MD=-98.48, 95% CI=-145.53--51.43, P<0.000 1) and transfusion rate (OR=0.25, 95% CI=0.13--0.46, P<0.000 1) in Glissonean pedicle transection group were lower than those in Pringle group, and the operative time had no significant difference between the two groups (P>0.05); the overall postoperative complications (OR=0.31, 95% CI=0.22--0.43, P<0.000 1) and hospital stay (MD=-2.94, 95% CI=-4.12--1.76, P<0.000 01) were less than those in Pringle group.Conclusion Glissonean pedicle transection is a safe and effective vascular occlusion method in hepatectomy for HCC. Compared with Pringle's maneuver, Glissonean pedicle transection can effectively alleviate liver injury, reduce intraoperative bleeding, postoperative complications and shorten hospital stay. However, surgeons should select a suitable method for occlusion based on their own personal experience, patients' conditions, and specific situation during surgery.

    表 2 纳入RCS的质量评估(NOS)Table 2 Quality Assessment of included RCSs (NOS)
    表 1 纳入文献基本特征Table 1 General characteristics of the included studies
    图1 术后第 1、3 、7天ALT比较Fig.1 Comparison of ALT levels at 1, 3 and 7 d after surgery
    图2 术后第1、3 、7天AST比较Fig.2 Comparison of AST levels a 1, 3 and 7 d after surgery
    图3 术后第1、3、7天ALB比较Fig.3 Comparison of ALB at day 1, 3 and 7 after surgery
    图4 术后第1、3、7天TBIL比较Fig.4 Comparison of TBIL levels at 1, 3 and 7 d after surgery
    图5 手术时间比较Fig.5 Comparison of the operative time
    图6 术中出血量比较Fig.6 Comparison of intraoperative blood loss
    图7 术中输血率比较Fig.7 Comparison of intraoperative blood transfusion rates
    图8 术后总体并发症比较Fig.8 Comparison of overall postoperative complications
    图9 住院时间比较Fig.9 Comparison of length of hospital stay
    图10 基于术后并发症发生率的漏斗图Fig.10 Funnel plot based on postoperative complication rates
    表 3 纳入RCT的质量评估(Jadad)Table 3 Quality Assessment of included RCTs (Jadad)
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舒强,刘小玲,徐波. Glisson蒂横断法与Pringle法在肝细胞癌肝切除术中的应用效果Meta分析[J].中国普通外科杂志,2022,31(1):42-54.
DOI:10.7659/j. issn.1005-6947.2022.01.005

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  • 收稿日期:2021-10-27
  • 最后修改日期:2021-12-10
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  • 在线发布日期: 2022-01-27