肝部分切除术后连续性监测吲哚菁绿15min滞留率对肝功能不全的评估价值

摘要

目的 探讨手术结束即时、术后3、5d的吲哚菁绿15 min潴留率(ICG-R15)对肝部分切除术后肝功能不全发生的评估价值.方法 前瞻性研究对象选取天津市第一中心医院肝胆外科2016年11月-2017年5月行肝部分切除术的肝癌患者70例.分析患者术前及术后连续性监测ICG-R15水平与术后肝功能不全的发生关系,对比术前及术后连续性监测ICG-R15在评估术后肝功能不全发生率之间的差别.计数资料组间比较采用x2检验;计量资料组间比较采用两独立样本t检验;术前、术后连续性监测ICG-R15预估术后肝功能不全发生的准确性采用受试者工作特征曲线下面积(AUC)进行分析.结果 70例患者中术后发生肝功能不全14例,术后肝功能恢复良好56例,肝功能不全发生率20.0％.肝功能良好组中术前以及术后即时、3、5d的ICG-R15平均值分别为(5.73±4.31)％、(12.36±7.41)％、(11.51-8.76)％、(9.60±7.00)％;肝功能不全组的术前以及术后即时、3、5d的ICG-R15平均值分别为(18.02±13.48)％、(32.54±18.67)％、(34.73±18.49)％、(25.34±11.49)％,2组间术前、术后连续性监测ICG-R15水平差异均有统计学意义(t值分别为3.368、3.966、4.571、4.901,P值均＜0.05);术前ICG-R15＜ 10％、10％＜ICG-R15 ＜20％、ICG-R15＞ 20％的3组患者术后肝功能不全发生率分别为11.10％、18.2％、62.5％,术后即时分别为0、20.0％、100％,术后3d分别为6.3％、11.1％、50.0％,术后5d分别为5.3％、12.5％、62.5％,术后肝功能不全的发生率均伴随ICG-R15升高而升高,差异均有统计学意义(x2值分别为22.374、28.024、14.810、21.159,P值均＜0.001);术后即时3组进一步两两比较组间差异均有统计学意义(P值均＜0.001),术前、术后3、5d中除ICG-R15＜ 10％与10％＜ ICG-R15 ＜20％以外,其余组间进一步两两比较差异均有统计学意义(p值均＜0.05);分析术前、术后连续性监测ICG-R15水平受试者工作特征曲线,术前、术后即时、3、5d的ICG-R15 AUC及95％可信区间分别为0.790(0.676 ～0.878)、0.857(0.752 ～0.929)、0.855(0.750～ 0.927)、0.870(0.768～0.938),术后连续性监测ICG-R15水平AUC均大于术前,差异均有统计学意义(P值均＜0.05).结论 术后连续性监测ICG-R15比术前ICG-R15评估术后肝功能不全的发生率更准确,可指导临床医生预估肝癌患者术后肝功能不全的发生,并尽早临床干预.%Objective To investigate the value of indocyanine green retention rate at 15 minutes (ICG-R15) immediately and at 3 and 5 days after partial hepatectomy in assessing the incidence of postoperative hepatic insufficiency.Methods This prospective study included 70 patients with hepatocellular carcinoma who underwent partial hepatectomy from November 2016 to May 2017 in the First Central Hospital of Tianjin.The relationship between preoperative and postoperative ICG-R15 and postoperative hepatic insufficiency was analyzed,and the difference between the preoperative and postoperative continuous monitoring of ICG-R15 in assessing the incidence of postoperative hepatic insufficiency was also analyzed.Comparison of categorical data was made by chi-square test.Continuous data were compared using twoindependent-samples t test.The area under the receiver operating characteristic curve (AUC) was used to determine the accuracy of preoperative and postoperative ICG-R15 in assessing the incidence of postoperative hepatic insufficiency.Results Of the 70 patients,14 (20％) had postoperative hepatic insufficiency,and the other patients had good recovery of liver function.The means of ICG-R15 before operation and immediately and at 3 and 5 days after operation were 5.73％ ±4.31％,12.36％ ±7.41％,11.51％ ± 8.76％,and 9.60％±7.00％,respectively,in the patients with good recovery of liver function,and were 18.02％ ± 13.48％,32.54％ ± 18.67％,34.73％± ± 18.49％,and 25.34％ ± 11.49％,respectively,in the patients with postoperative hepatic insufficiency,with significant differences between the two groups of patients (t =3.368,3.966,4.571,and 4.901,all P ＜ 0.05).The incidence rates of postoperative hepatic insufficiency were 11.10％,20.0％,and 100％,respectively,in patients with ICG-R15 ＜ 10％,10％ ＜ ICG-R15 ＜ 20％,and ICG-R15 ＞20％ preoperatively,were 0,18.2％,and 62.5％,respectively,in patients with ICG-R15 ＜ 10％,10％ ＜ ICG-R15 ＜ 20％,and ICG -R15 ＞20％ immediately after operation,were 6.3％,11.1％,and 50.0％,respectively,in patients with ICG-R15 ＜ 10％,10％ ＜ICG-R15 ＜20％,and ICG-R15 ＞20％ at 3 days after operation,and were 5.3％,12.5％,and 62.5％,respectively,in patients with ICG-R15 ＜ 10％,10％ ＜ ICG-R15 ＜ 20％,and ICG-R15 ＞ 20％ at 5 days after operation;the incidence of postoperative hepatic insufficiency increased significantly as ICG-R15 increased (x2 =22.374,28.024,14.810,and 21.159,all P ＜ 0.001).There were significant differences in the incidence of postoperative hepatic insufficiency between any two of the groups with ICG-R15 ＜ 10％,10％ ＜ ICG-R15 ＜20％,and ICG-R15 ＞20％ preoperatively (all P ＜0.001),and between any two of the groups with ICG-R15 ＜ 10％,10％ ＜ ICG-R15 ＜ 20％,and ICG-R15 ＞20％ (except ICG-R15 ＜ 10％ and 10％ ＜ ICG-R15 ＜20％ groups) before operation and at 3 and 5 days after operation (all P ＜0.05).The AUCs (confidence intervals) of ICG-R15 before operation and immediately and at 3 and 5 days after operation were 0.790 (0.676-0.878),0.857 (0.752-0.929),0.855 (0.750-0.927),and 0.870 (0.768-0.938),respectively,and the postoperative ICG-R15 values had a significantly larger AUC than the preoperative ICG-R15 (all P ＜ 0.05).Conclusion Postoperative continuous monitoring of ICG-R15 is more accurate than preoperative ICG-R15 in assessing the incidence of hepatic insufficiency among liver cancer patients after partial hepatectomy,and can guide clinicians to provide early clinical intervention.