肝细胞癌合并肝硬化门静脉高压症腹腔镜同期联合手术术后肺部感染的危险因素分析

文静; 贾哲; 赫嵘; 张艳华; 张宏伟; 张珂

doi:10.3969/j.issn.1001-5256.2023.07.012

肝细胞癌合并肝硬化门静脉高压症腹腔镜同期联合手术术后肺部感染的危险因素分析

DOI: 10.3969/j.issn.1001-5256.2023.07.012

首都医科大学附属北京地坛医院普外科，北京 100015

基金项目:

国家自然科学基金 (31970566)

伦理学声明：本研究方案于2022年6月22日获首都医科大学附属北京地坛医院伦理委员会审批通过，批号：2022-032-01，符合临床研究伦理规范。

利益冲突声明：本文不存在任何利益冲突。

作者贡献声明：文静负责课题设计，资料分析，撰写论文；贾哲、赫嵘、张艳华、张宏伟参与临床数据库设计和数据收集，修改论文；张珂负责拟定写作思路，指导撰写文章并最后定稿。

详细信息

通信作者:
张珂，zhangke302@sina.com (ORCID: 0000-0002-5006-8674)

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出版历程
- 收稿日期: 2022-10-22
- 录用日期: 2022-12-01
- 出版日期: 2023-07-20

Risk factors for pulmonary infection after laparoscopic surgery in treatment of hepatocellular carcinoma with liver cirrhosis and portal hypertension

Department of General Surgery, Beijing Ditan Hospital, Capital Medical University, Beijing 100015, China

Research funding:

National Natural Science Foundation of China (31970566)

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Corresponding author: ZHANG Ke, zhangke302@sina.com (ORCID: 0000-0002-5006-8674)

摘要

摘要: 目的观察腹腔镜同期联合手术治疗肝细胞癌(HCC)合并肝硬化门静脉高压症(PHT)术后肺部感染发生率并分析危险因素。方法回顾性分析2017年1月—2022年2月首都医科大学附属北京地坛医院普外科105例HCC合并肝硬化PHT腹腔镜同期联合手术患者临床资料。记录可能引起肺部感染的30项因素，包括基本情况、疾病因素、手术因素和术后因素。观察手术恢复情况，记录肺部感染发生情况。计数资料两组间比较采用χ²或Fisher精确检验。Logistic多因素回归分析筛选肺部感染的独立危险因素。结果 105例患者中66例行腹腔镜断流联合肝切除术，39例行腹腔镜断流联合射频消融(RFA)，均顺利完成手术，无中转开腹和术后非计划再次手术病例，无术后30 d和住院期间死亡病例，中位住院时间20(14~25)d。肺部感染发生率为25.71%(27/105)。吸烟(OR=3.362，95%CI: 1.282~8.817，P=0.014)、MELD评分(OR=3.801，95%CI: 1.007~14.351，P=0.049)、肿瘤位置(OR=1.937，95%CI: 1.169~3.211，P=0.010)、手术方式(OR=0.006，95%CI: 0.001~0.064，P＜0.001)、术中输液量(OR=4.871，95%CI: 1.211~19.597，P=0.026)和术后合并胸水(OR=9.790，95%CI: 1.826~52.480，P=0.008)为肺部感染的独立危险因素。结论 HCC合并肝硬化PHT腹腔镜同期联合手术患者具有较高肺部感染风险。术后合并胸水是引发肺部感染的高危因素，断流联合RFA可显著降低肺部感染风险。应加强术前预康复、围手术期肝功能维护、术中损伤控制和目标导向性液体治疗、减轻术后第三间隙积液，以降低肺部感染发生。
- 癌, 肝细胞 /
- 肝硬化 /
- 高血压, 门静脉 /
- 外科手术 /
- 感染
Abstract: Objective To investigate the incidence rate of pulmonary infection after laparoscopic surgery and related risk factors in patients with hepatocellular carcinoma (HCC) comorbid with liver cirrhosis and portal hypertension (PHT). Methods A retrospective analysis was performed for the clinical data of 105 HCC patients with liver cirrhosis and PHT who underwent laparoscopic surgery in Beijing Ditan Hospital, Capital Medical University, from January 2017 to February 2022. A total of 30 factors that might cause pulmonary infection were recorded, including general information, disease factors, surgical factors, and postoperative factors. Postoperative recovery was observed and the occurrence of pulmonary infection was recorded. The chi-square test or the Fisher's exact test was used for comparison of categorical data between two groups, and the multivariate logistic regression analysis was used to investigate the independent risk factors for pulmonary infection. Results Among the 105 patients, 66 underwent laparoscopic devascularization combined with hepatectomy and 39 underwent laparoscopic devascularization combined with radiofrequency ablation (RFA). The surgery was successful for all patients, with no case of conversion to laparotomy or unscheduled reoperation. No death was observed within 30 days after surgery and during hospitalization, with a median length of hospital stay of 20 days (range 14-25 days). The incidence rate of pulmonary infection was 25.71% (27/105). Smoking (odds ratio [OR]=3.362, 95% confidence interval [CI]: 1.282-8.817, P=0.014), MELD score (OR=3.801, 95%CI: 1.007-14.351, P=0.049), tumor location (OR=1.937, 95%CI: 1.169-3.211, P=0.010), surgical procedure (OR=0.006, 95%CI: 0.001-0.064, P=0.000), intraoperative infusion volume (OR=4.871, 95%CI: 1.211-19.597, P=0.026), and postoperative pleural effusion (OR=9.790, 95%CI: 1.826-52.480, P=0.008) were independent risk factors for pulmonary infection. Conclusion There is a relatively high risk of pulmonary infection in HCC patients with liver cirrhosis and PHT undergoing laparoscopic surgery. Postoperative pleural effusion is the high risk factor for pulmonary infection, and devascularization combined with RFA can significantly reduce the risk of pulmonary infection. It is recommended to strengthen preoperative rehabilitation, perioperative liver function maintenance, intraoperative damage control, and goal-oriented fluid therapy and reduce postoperative fluid accumulation in the third space, so as to reduce the incidence rate of pulmonary infection.
- Carcinoma, Hepatocellular /
- Liver Cirrhosis /
- Hypertension, Portal /
- Surgical Procedures, Operative /
- Infection

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表 1 单因素分析术后肺部感染的危险因素

Table 1. Univariate analysis of risk factors of postoperative pulmonary infection

影响因素	例数 (n=105)	肺部感染 (n=27)	χ²值	P值	影响因素	例数 (n=105)	肺部感染 (n=27)	χ²值	P值
性别(例)				0.052	肿瘤位置(例)				＜0.001
男	73	23			左外叶	15	12
女	32	4			左内叶	21	0
年龄(例)			1.713	0.191	右前叶	33	0
＜50岁	71	21			右后叶	36	15
≥50岁	34	6			肿瘤直径(例)			2.439	0.118
吸烟(例)				0.028	＜30 mm	78	17
无或戒烟3年以上	55	11			≥30 mm	27	10
SI＜400	37	9			肿瘤个数(例)				0.290
SI≥400	13	7			单个	93	22
NRS 2002评分(例)				0.148	≥2	12	5
＜3分	72	22			肿瘤分期(例)				0.300
≥3分	33	5			Ⅰ a	99	24
糖尿病(例)	27	10	2.439	0.118	Ⅰ b	3	2
心脑血管疾病(例)	60	14	0.416	0.519	Ⅱ a	3	1
Child-Pugh分级(例)			0.418	0.518	曲张静脉分级(例)			0.986	0.321
A级	86	21			F2	74	17
B级	19	6			F3	31	10
MELD评分(例)			9.817	0.002	红色征(例)			0.806	0.668
＜9分	72	12			+	27	7
≥9分	33	15			++	44	13
WBC(例)			1.959	0.162	+++	34	7
＜2.0×10⁹/L	39	7			门静脉直径(例)			0.945	0.331
≥2.0×10⁹/L	66	20			＜13 mm	24	8
Hb(例)			0.169	0.681	≥13 mm	81	19
＜90 g/L	58	14			术前腹水(例)	49	18	5.841	0.016
≥90 g/L	47	13			手术方式(例)				0.022
PLT(例)			1.936	0.164	断流+肝切除	66	22
＜50×10⁹/L	51	10			断流+RFA	39	5
≥50×10⁹/L	54	17			手术时间(例)				0.114
ALT (例)			0.126	0.723	＜240 min	25	3
＜40 U/L	79	21			≥240 min	80	24
≥40 U/L	26	6			术中出血量(例)			0.147	0.702
AST(例)			0.261	0.609	＜500 mL	50	12
＜40 U/L	50	14			≥500 mL	55	15
≥40 U/L	55	13			术中输血(例)	29	11	3.130	0.077
TBil (例)			0.360	0.549	术中输液量(例)				0.018
＜17.1 μmol/L	71	17			＜3 500 mL	36	4
≥17.1 μmol/L	34	10			≥3 500 mL	69	23
Alb(例)			1.105	0.293	术后腹水(例)			4.022	0.045
＜35 g/L	27	9			＜1 000 mL/d	90	20
＜35 g/L	27	9			≥1 000 mL/d	15	7
≥35 g/L	78	18			术后合并胸水(例)	30	15	12.968	＜0.001
注: SI，吸烟指数。

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表 2 Logistical回归分析术后肺部感染的危险因素

Table 2. Logistic regression analysis of risk factors of postoperative pulmonary infection

变量	B值	SE	Wald	P值	OR	95%CI
吸烟(无或戒烟3年以上=0，SI＜400=1，SI≥400=2)	1.212	0.492	6.074	0.014	3.362	1.282~8.817
MELD评分(＜9分=0，≥9分=1)	1.335	0.678	3.882	0.049	3.801	1.007~14.351
肿瘤位置(左外叶=1，左内叶=2，右前叶=3，右后叶=4)	0.661	0.258	6.574	0.010	1.937	1.169~3.211
手术方式(断流+肝切=1，断流+RFA=2)	-5.037	1.168	18.607	＜0.001	0.006	0.001~0.064
术中输液量(＜3 500 mL=0，≥3 500 mL=1)	1.583	0.710	4.970	0.026	4.871	1.211~19.597
术后合并胸水(无=0，有=1)	2.281	0.857	7.091	0.008	9.790	1.826~52.480

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