老年肝移植受者围手术期处理12例

Perioperative treatment of liver transplantation in elder recipients： a report of 12 cases

目的探讨年龄≥60岁的老年肝移植受者术前和术后的评估、治疗特点及并发症的处理。方法2002年6月至2012年3月间单中心共进行肝移植110例，其中年龄≥60岁者12例（占10．9％），为老年组，以年龄〈60岁的受者98例为对照组，统计两组肝移植受者术前状况和术后恢复情况，并比较两组肝移植术中情况和术后免疫抑制剂应用情况。结果老年组术前终末期肝病模型评分为（16．4±5．7）分，对照组为（24．1±10.2）分（P〈0．05）。对照组术前消化道出血、肝性脑病、肾功能异常发生率均高于老年组（P〈0．05）。老年组拔除气管插管时间为术后12-72h，出现肺部感染3例；对照组拔除气管插管时间为术后6～48h，出现肺部感染8例。老年组减少了皮质激素用量，延迟并个体化应用免疫抑制剂。老年组12例术后均未发生排斥反应，对照组出现急性排斥反应5例，治疗后均逆转。老年组中，1例于术后1个月因肺部曲霉感染死亡，1例于术后16个月死于肿瘤复发，其他10例随访期间健康存活；对照组中，围手术期肺部曲霉感染死亡3例，术后死于肝癌复发23例，肝功能衰竭4例，胆道并发症3例，其他原因2例，余63例随访期间健康存活。随访期间，老年组心脑血管疾病的发生率高于对照组（P〈0．05）。结论经过严格筛选和术前仔细准备，老年肝移植可以取得较好的效果，但老年受者术后感染发生率高，并容易出现心脑血管意外，应予以注意。

Objective To investigate preoperatively and postoperatively the assess, treatment and complications of elderlytransplant recipients（aged≥60 years）. Methods Between June 2002 to March 2012 there were 110 patients received liver transplantation in one single center, of which Age≥ 60 years was 12 cases（10. 9%, older group）, and of which Age〈60 years was 98 cases（control group）. The preoperative and postoperative states were recorded. The surgery and use of immunosuppressant application were compared between two groups. Results Model for end-stage liver disease（MELD） score of older group was 16. 4 ± 5.7, which in control group was 24. 1 ± 10. 2（P 〈0. 05）. Control group had a significantly higher incidence of gastrointestinal bleeding, hepatic encephalopathy and renal dysfunction（P〈0. 05）. The postoperatively extubation time in older group was 12-72 hours, and which was 6-48 hours in control group. There were 3 cases of pulmonary infection in older group, and 8 cases in control group. The dosage of corticosteroids in older group was reduced, immunosuppression was delayed and individualized used. There was no rejection in older group, while there were 5 cases of rejection in contral group, which was recovered after treatment. In older group, one case died clue to lung aspergillosis at one month postoperatively, one case died due to tumor recurrence at 16 months postoperatively, rest 10 case was health survival. In contral group, 3 case died clue to lung aspergillosis perioperatively, 23 case died due to tumor recurrence postoperatively, 4 case died due to liver failure, 3 case died due to biliary complications, other reasons died 2 cases, rest 63 case was health survival. During follow-up, the incidence of cardiovascular and cerebrovascular disease in older group was significantly higher than control group （P 〈 0. 05）. Conclusion After strict selection and careful preparation, liver transplantation of older patients can get better results. In conclusion, older liver transplant recipients have a higer incidence of infection and cardio-cerebral vascular incidence, and attention must be give to them.