创伤后肝损害的法医病理学分析及对临床肝移植的指导意义

A Forensic Study of Hepatic Injury after Trauma and Its Value for Clinical Liver Transplantation

目的探讨创伤后肝脏的病理改变及肝损害的影响因素,为临床移植医师应用创伤后死亡的供肝提供指导作用,也为日后建立尸肝病理选择标准积累资料。方法对2010年1月-2014年12月的142例创伤后死亡的案例资料进行回顾性分析。根据142例创伤后死亡者伤后实验室检查是否发生急性肝功能损害分为两组,其中观察组均发生急性肝功能损害,对照组均未发生急性肝功能损害。结合案情、临床资料、尸体解剖资料,对创伤后肝脏的病理改变及急性肝损害可能的影响因素[年龄、性别、损伤方式、损伤部位、受伤到入院间隔时间、损伤程度、低血压(收缩压≤90 mm Hg,1 mm Hg=0.133 k Pa)持续时间、使用2种以上升压药物、大量输血(≥2 000 m L/24 h)、合并休克、合并感染、合并脏器疾病等]进行统计分析,确定其影响的风险因素。其中,损伤程度按创伤严重度评分(ISS)分为轻度损伤(ISS<16分)、重度损伤(ISS≥16分且<25分)和严重损伤(ISS≥25分)。结果 142例创伤后死亡者中,45例为观察组,显微镜下肝细胞不同程度变性坏死,其中轻度肝细胞坏死8例,中度肝细胞坏死14例,重度肝细胞坏死23例。97例未发生急性肝功能损害为对照组,显微镜下肝组织形态基本正常。创伤后肝损害与死者的年龄、性别、损伤方式、损伤部位及受伤到入院间隔时间等因素无关,与损伤程度、低血压持续时间≥0.5 h、使用2种以上升压药物、大量输血(≥2 000 m L/24 h)、合并休克、合并严重感染、合并心肺以外脏器疾病等因素显著相关(P<0.05)。结论若临床移植医师要运用创伤后心脏死亡或脑死亡者供肝,应当警惕上述加重肝细胞变性坏死的风险因素。若合并上述一个或多个风险因素时,建议临床医师在肝脏移植术前进行穿刺活体组织检查,并结合临床资料进行综合判断,选择合适的供肝,保障移植效果。

Objective To investigate pathological changes of liver and risk factors for hepatic injury after trauma, in order to provide the instructions for clinical liver transplantation and accumulate the pathological data. Methods We retrospectively analyzed the clinical data of 142 patients who died after trauma between lanuary 2010 and December 2014. Based on whether the patients had acute liver damage before dying, they were divided into two groups. The observation group had liver damage before dying, while the control group had not. Combined with the details of trauma, clinical data and autopsy results, we statistically analyzed the pathological changes of liver and risk factors for acute liver damage, including age, gender, trauma kind, trauma site, interval between trauma and hospitalization, damage degree, length of hypotension, the use of more than two vasopressors, large amount of blood transfusion, and complication of shock, infection, or underlying diseases. According to injury severity score （ISS） system, the damage degree was divided into mild damage （ISS 〈 16）, moderate damage （ISS ≥ 16 and 〈 25）, and severe damage （ISS ≥ 25）. Results Among the 142 patients, there were 45 in the observation group with varying degrees of liver cell necrosis, among whom there were 8 mild cases, 14 moderate and 23 severe. There were 97 patients in the control group without acute liver damage, and no significant changes were found in their hepatic tissue. Liver damage was not correlated with age, gender, damage kind, damage site, or pre-hospital time （P 〉 0.05）, while it was corrected with the degree of damage, time ofhypotension （ ≥ 0.5 hour）, the use of more than two vasopressors, large amount of blood transfusion （2 000 mL/24 hours）, and combination of shock, infection, and other disease except for cardiac and pulmonary diseases （P 〈 0.05）. Conclusions When using donor livers from patients dying from trauma for transplantation, physicians should be alert to the factors discussed previously which can increase the risk of hepatic injury. Biopsy is useful to assess the suitability of donor livers prior to transplantation.