中文摘要：

目的分析外科医师手术操作对肝细胞癌（HCC）患者预后的影响因素。方法对实施根治性肝切除、随访资料和临床资料完整的234例HCC患者,COX单因素和多因素回归分析年龄、性别、术中出血量（≤800 ml和〉800 ml）、输血（是与否）、手术持续时间（≤300 min和〉300 min）、肝门是否阻断、肝门阻断次数（0、1和≥2次）、肝门阻断时间（〈15、15-30和≥30 min）、医源性肝癌被膜破裂、门奇静脉断流术、肝切除程度（超半肝切除、半肝切除和单纯尾叶切除为大手术;亚肝段切除或不规则肝叶切除为中小手术）和术后并发症如大量腹水（〈1 L和≥1L）、胆漏、胸腔积液、切口感染等对HCC预后的影响。log-rank检验比较生存时间差异,等级资料的双变量相关分析进行Kendall＇s tau等级相关分析。结果COX回归单因素分析显示术中出血量（χ^2=19.721,P〈0.001）、输血量（χ^2=7.769,P=0.005）、手术持续时间（χ^2=4.793,P=0.029）、术后大量腹水（χ^2=4.452,P=0.035）、医源性肝癌被膜破裂（χ^2=6.401,P=0.011）与HCC术后预后相关。术中出血量（RR：2.138,95%CI：1.556-2.939）、医源性肝癌被膜破裂（RR：2.260,95%CI：1.182-4.321）、术后出现大量腹水（RR：1.648,95%CI：1.088-2.469）是HCC预后的独立影响因素。双变量相关分析显示输血与出血量（Kendall＇s τ=0.416,P〈0.001）和肝切除程度（Kendall＇s τ=0.185,P=0.004）有显著相关性;出血量与肝切除程度（Kendall＇s τ=0.057,P=0.383）无相关性。术后大量腹水与肝功能Child分级（Kendall＇s τ=0.151,P=0.024）有显著相关性。结论外科医师在术中避免过多出血和医源性肝癌被膜破裂,有可能改善HCC肝切除的预后。部分病例因手术较大,外科医师可能放宽了输血指征;Child B或C级等肝功能较差的患者,术后容易出现大量腹水,预后不良,应考虑肝移植的可能。

英文摘要：

Objective To evaluate the prognostic value of surgical operation-related factors in patients with hepatocellular carcinoma（HCC）.Methods The clinical data of 234 patients after hepatic resection（214 men and 20 women） were retrospectively studied.Univariate and multivariate COX regression analyses wereperformed for surgical operation-related prognostic factors including age,gender,intraoperative blood loss,iatrogenic tumour rupture,transfusion,operation duration,hepatectomy extent,Pringle manoeuvre,with or without devarscularization,and complications（e.g.postoperative ascites,biliary leakage,incision infection,and pleural effusion）.Kaplan-Meier and log-rank tests were used to compare survival rates.Kendall＇s tau bivariate analyses were used to examine the correlations of these surgical operation-related factors.Results Univariate COX regression analysis revealed that iatrogenic blood loss（χ^2=19.721,P〈0.001）,transfusion（χ^2=7.769,P=0.005）,tumour rupture（χ^2=6.401,P=0.011）,operation duration（χ^2=4.793,P=0.029）,and postoperative ascites（χ^2=4.452,P=0.035） were statistically significant predictors in patients with HCC after hepatic resection.Multivariate COX regression analysis revealed that pathological factors,such as blood loss（RR：2.138,95%CI： 1.556-2.939）,tumour rupture（RR：2.260,95%CI： 1.182-4.321）,and postoperative ascites（RR：1.648,95%CI： 1.088-2.469）,independently influenced the HCC prognosis.Blood loss correlated with transfusion（Kendall＇s τ=0.416,P〈0.001）.There was no correlation between hepatectomy extent and blood loss（Kendall＇s τ=0.057,P=0.383）,while transfusion closely correlated with the hepatectomy extent（Kendall＇s τ=0.185,P=0.004）.The postoperative ascites closely correlated with Child classification（Kendall＇s τ=0.151,P=0.024）.Conclusions The long-term survival of patients with HCC after hepatectomy may be improved by avoiding blood loss and iatrogenic tumour rupture.The indications of blood transfusion may no