肝硬变肝功能衰竭患者行肝移植时术前准备的重要性

Necessity of full preoperative preparation for hepatic failure patients undergoing orthotopic liver transplantation

目的 探讨肝功能衰竭患者行同种原位肝移植 (OLT)时术前准备的原则和方案。方法 回顾性比较分析 7例因肝硬变肝功能衰竭行OLT和 3例因非硬变性肝病行OLT术前凝血功能、一般状况、内环境状况、术中出血量与术后过程的关系。结果 7例肝硬变患者血小板计数均下降 ,凝血功能差 ,而 3例因非硬变性肝病者血小板下降不明显 ;7例肝硬变患者术前均进行了利尿和保肝支持治疗 ,而 3例因非硬变性肝病者除 2例进行了保肝支持、输少量全血和人白蛋白外 ,未输注凝血因子和血浆 ,也未进行利尿治疗。术中 7例肝硬变患者平均出血 845 5ml,除补充相应量的血以外 ,还平均输注人白蛋白 88.5 g和血浆95 7.1ml,但术毕血白蛋白仅 2 6 .1g/L ,术后 48h内内环境紊乱较明显 ,术后 1个月内 5例发生真菌感染 ,3例发生腹腔内出血 ,而 3例非硬变肝病患者平均出血 2 6 6 0ml,术中仅输很少人白蛋白 ,术毕血白蛋白 30 .7g/L ,内环境紊乱不明显 ,术后 1月内无感染和腹腔内出血发生。结论 肝硬变肝功能衰竭患者行肝移植术前完全纠正凝血功能障碍、低蛋白血症。

Objectives To sum up the principles and strategies of preoperative preparation for orthotopic liver transplantation (OLT) in patients with hepatic failure. Methods The relations of preoperative coagulability, the status of the patient, intraoperative bleeding amount to the postoperative recovery of 7 patients with liver failure and 3 cases of non cirrhotic liver disease were comparatively analyzed. Results All the 7 cirrhotics had Child C liver function with a mean platelet count of 28.85 ×10 9/L. Their mean prolongation of PT was 10.1 seconds with mean APTT prolongation of 27.8 seconds as compared with controls. Mean fibrenogen in the blood was only 1.5 ?g/L; and the 3 non cirrhotic liver disease patients had child B to child A liver function with nomal PT, APTT, fibrenogen level and unmarkedly decreased platelet count. All the 7 cirrohtics experienced diuretic and support treatment and had blood infusion of 571?ml, albumin of 57?g, frozen fresh plasma of 300 ml, platelet of 1.1 ×10 11 , cryoprecipitate of 1.4 units, lyophilized prothrombin complex concentrate of 1 000 units and fibrinogen of 2.0 ?g; nevertheless the 3 patients wiht non cirrhotic liver disease did not received coagulation factors, frozen fresh plasma and diuretics but a little blood and albumin. Intraoperative mean bleeding of the 7 cirrhotics was 8 455 ?ml, in addition to equivalent blood, albumin of 88.5 ?g and frozen fresh plasma of 957.1 ?ml were infused. However, the albumin level was only 26.1 ?g/L at the end of operation with markedly disturbance of internal milieu within 48?h of postoperative course, and 5 cases of fungal infection, and 3 cases of intraabdominal bleeding within one month. The 3 patients with non cirrhotic liver disease had intraoperative bleeding of 2 660 ?ml and received equivalent blood and a little albumin and had a albumin level of 30.7 ?g/L and unmarked internal milieu disturbance at the end of operation and no infection and bleeding into the abdomen occurred. Conclusions In the patients with hepatic failure undergoing OLT, full correction of coagulopathy, hypoalbuminemia, anemia and internal milieu disturbance is an important factor to ensure an uneventful operation and postoperative course.