重型肝炎急性肝衰竭肝移植手术指征探讨

The operative indications for orthotopic liver transplantation in acute liver failure caused by severe hepatitis

目的总结重型肝炎实施急诊肝移植的经验，探讨其手术指征。方法回顾性分析34例拟行急诊肝移植治疗的重型肝炎并急性肝衰竭患者的临床资料，其中11例实施急诊肝移植手术。结果34例患者中，14例在等待供体中死亡，另9例在转入我科时已丧失手术机会，于3d内死亡。11例急诊肝移植均采用改良背驮式肝移植，其中1例术后7d死于肺部感染、急性呼吸窘迫综合征（ARDS），1例术后20d死于原发性移植肝功能不良合并肾功能衰竭，其他9例术后均恢复顺利。随访6～29个月，1例于术后12个月死于慢性排斥反应，余8例情况良好。结论急诊肝移植是治疗重型肝炎合并急性肝功能衰竭移植的有效方法，其指征为：（1）II级及Ⅱ级以上的进行性脑病；（2）PT延长158以上（或凝血酶原活动度〈30％）；（3）血清TBIL〉300μmol／L（17．5mg／d1）或TBIL进行性升高（每天〉17．1μmol／L）。

Objective To summarize the experience of emergency orthotopic liver transplantation （ EOLT ） for severe hepatitis, and discuss the operative indications. Methods The clinical data of 34 patients with severe hepatitis and acute liver failure, who were candidates for liver transplantation was retrospective reviewed. Results Among the 34 patients, 11 of them underwent liver transplantation, 14 of them died while waiting for donor liver and 9 cases lost the chance of undergoing transplantation. In the 11 cases with liver transplatation, one case died of pulmonary infection and acute respiratory distress syndrome （ARDS） on postoperative day 7, one case died of primary poor graft function and renal failure on postoperative day 20, and the other 9 cases made a good recovery. At follow up of 6 - 29 months, 1 case died of chronic rejection 12 months after operation. Conclusions Emergency liver transplantation is effective treatment for acute liver failure caused by severe hepatitis. The indications for the operation are： （ 1 ） Stage Ⅱ or higher degree of encephalopathy： （ 2 ） prolongation of PT 〉 15s; （ 3 ） Serum TBIL 〉 300μ mol/L （ 17. 5mg/dl ） or progressive daily increase of TBIL （ 〉 17. 1 μ mol/L）.