利用微创血流动力学监测确定腹腔镜下嗜铬细胞瘤切除术患者的实际液体需要量：前瞻性试验
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The determination of real fluid requirements in laparoscopic resection of pheochromocytoma using minimally invasive hemodynamic monitoring: a prospectively designed tria
背景与目的
在嗜铬细胞瘤（PCC）的肾上腺切除术中经常观察到血流动力学不稳定性。指南建议术前给予足够液体容量。然而，目前尚不清楚液体不足或血管紧张是否引起了血流动力学的改变，以及用食管多普勒（EDM）进行微创血流动力学监测是否有助于观察术中的变化，从而避免液体过量和并发症发生。
方 法
对10例经生化检查确诊为PCC的患者和5例激素抑制性肾上腺肿瘤患者（HIAT；对照组）按照严格的治疗方案进行治疗。在腹腔镜肾上腺切除术中，采用EDM进行靶向液体治疗。记录了血流动力学和生化数据。主要结果变量为液体需求量和血流动力学参数。
结 果
应用EDM，PCC患者的术中液体总量略高于HIAT患者（2100 516 vs.1550 622 ml，P=0.097；12.9 4.8 vs.8.3 0.7 ml kg-1 h-1，P 0.014）。PCC组的血流动力学变化很大，与分泌儿茶酚胺的类型和水平有关。PCC切除后10分钟内，动脉血压和全身血管阻力指数均达到最低。在未给予大量液体的情况下，应用EDM，PCC患者的术中液体总剂量略高于HIAT患者（2100 516 vs.1550 622 ml，P=0.097；12.9 4.8 vs.8.3 0.7 ml kg-1 h-1，P 0.014）。PCC组的血流动力学变化很大，与分泌儿茶酚胺的类型和水平有关。PCC切除后10分钟内，动脉血压和全身血管阻力指数均达到最低。在未给予大量液体的情况下，将两组的基线测量值与手术结束时相比较，两组患者的心脏指数均增加。这一增加仅在PCC患者中具有统计学意义（PCC:2.31 vs.3.15 l m in-1 m-2，P 0.005；HIAT:2.08 vs.2.56 l min-1 m-2，P 0.225）。
结 论
由于肿瘤切除后出现血管痉挛，而非低血容量，没有证据表明PCC患者在腹腔镜肾上腺切除术中获益于充足的液体供应。为了避免液体用量过载，应常规使用非侵入性技术（如EDM）来观察术中生命体征的变化过程。
原始文献摘要
Martin B. Niederle, Edith Fleischmann， Barbara Kabon. The determination of real fluid requirements in laparoscopic resection of pheochromocytoma using minimally invasive hemodynamic monitoring: a prospectively designed trial. [J] Surgical Endoscopy,2019;66(4):356---362
BACKGROUND:
Hemodynamic instability is frequently observed during adrenalectomy for pheochromocytoma (PCC). Guidelines recommend liberal preoperative volume administration. However, it is unclear whether fluid deficiency or vasoplegia causes shifting hemodynamics and whether minimally invasive hemodynamic monitoring with esophageal Doppler (EDM) can help visualize intraoperative changes avoiding volume overload and complications.
Methed:
Ten patients with biochemically verified PCC and five patients with hormonally inactive adrenal tumors (HIAT; control group) were treated following a strict protocol. During laparoscopic adrenalectomy, goal-directed fluid therapy was performed using EDM. Hemodynamic and biochemical data were documented. The primary outcome variables were fluid requirement and hemodynamic parameters.
Results：
Applying EDM, total intraoperative fluid administration was slightly higher in PCC patients than in patients with HIAT (2100 ± 516 vs. 1550 ± 622 ml, p = 0.097; 12.9 ± 4.8 vs. 8.3 ± 0.7 ml kg-1 h-1, p = 0.014). Hemodynamics varied considerably within the PCC group and was associated with type and level of secreted catecholamines. Arterial blood pressure and systemic vascular resistance index reached their minimum in the 10-min period after resection of PCC. Without liberal fluid administration, an increase in cardiac index was observed in both groups comparing baseline measurements to end of surgery. This increase was statistically significant only in PCC patients (PCC: 2.31 vs. 3.15 l min-1 m-2, p = 0.005; HIAT: 2.08 vs. 2.56 l min-1 m-2, p = 0.225).
Conclusion:
As vasoplegia, but not hypovolemia, was documented after tumor resection, there is no evidence that PCC patients profit from liberal fluid administration during laparoscopic adrenalectomy. To avoid volume overload, noninvasive techniques such as EDM should be routinely used to visualize the variable intraoperative course.
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翻译：唐剑 编辑：何幼芹 审校：王贵龙