肝移植术后腹腔内活动性出血的防治体会(附69例报道)

Prevention and management of intra-abdominal active bleeding after liver transplantation: a report of 69 cases

目的探讨肝移植术后腹腔内活动性出血的预防和治疗。方法回顾性分析和总结了2006年5月～2008年4月该中心成功实施的69例肝移植,其中尸肝移植58例,亲体肝移植11例,女性占18.84%(13/69),男性占81.16%(56/69)。结果69例肝移植中早期腹腔大出血者9例,发生率为13.04%(9/69),病死率为0%(0/69)。出血发生在肝移植术后24h内6例(66.67%),2d内1例(11.11%),3d内2例(22.22%)。出血部位包括右肾上腺静脉丛出血3例、受体下腔静脉壁的分支出血2例、腹壁戳孔出血1例、腹腔渗血2例;其中,多个部位同时出血者5例。9例腹腔大出血均为成人肝移植患者,8例发生在肝移植的早期阶段(前13例肝移植),对肝移植术中手术操作,术中术后胶体和晶体液、中心静脉压的控制以及凝血功能的调控认识不够;仅1例发生在肝移植开展的后期(第63例肝移植)。均在确诊后1h内再次手术止血。结论肝移植术后早期腹腔大出血是肝移植术后死亡的严重的并发症之一。术中彻底止血、术中术后胶体和晶体液的调控、凝血功能的调控和术中术后中心静脉压的调控等在预防肝移植术后早期腹腔大出血中起着重要作用。

[Objective] To investigate prevention and treatment of intra-abdominal active bleeding after liver transplantation. [Methods] The clinical data of 69 patients who underwent liver transplantation between May in 2006 and March in 2008 were studied retrospectively, 58 patients of which underwent cadaver liver transplantation, wheas 11 patients unerwent living donor liver transplantation, 56 of 69 cases were male （81.16%）, the residue was female （18.84%）. [Results] Nine patients underwent intra-abdominal hemorrhea in 4 days early postoperatiun, the icidence was 13.04%, and no one died. The incidence related to female was 7.69% （1/13）, however, it was 14.29% （8/56） relating to male. Six cases （66.67%） of intra-abdominal hemorrhea occurred in 24 hours, one case （11.11%） in two days and other three cases （22.22%） in three days postoperation. Areas of early intra-abdominal hemorrhea after liver transplantation included the place of right adrenal gland veins （n =3）, inferior vena cava of the receiptor（n =2）, in- cision of abdominal wall （n =1）, intra-abdominal capillary hemorrhage （n =2）, which five cases underwent intra-abdominal hemorrhea in many areas of abdominal cavity above referred. Nine patients with intra-abdominal active bleeding were all adult, it was early stage of putting liver transplantation into practice that eight receiptors underwent intra-abdominal active bleeding, when there were short of knowledge for operative procedure, control of crystal body and colloid, regulation of blood coagulation function and control of CVP, only one underwent intra-abdominal active bleeding within post-stage of enforcing liver transplantation, which all underwent second operation for surgical hemostasis in one hours after positive diagnosis. [Conclusion] It was one of severe complications after liver transplantation that the patient accepted liver transplantation was diagnosed as intra-abdominal active bleeding. The main and important prevention methods of intra-abdominal active bleeding were control of crystal body and colloid, regnlation of blood coagulation function and control of CVP.