肝癌肝切除术后特殊类型急性肝功能衰竭临床特征与诊治分析

Features and treatments of a special type of acute liver failure after hepatectomy of liver cancer

目的分析以"弥漫性肝坏死、丙氨酸氨基转移酶(ALT)先升高后下降再急剧大幅升高"为特征的肝癌肝切除术后肝功能衰竭(POLF)的临床特征并总结诊治经验。方法回顾性分析2019年1—11月海军军医大学附属东方肝胆外科医院收治的肝切除术后ALT峰值>1000 U/L且具有完整临床病理资料的13例肝癌病人的临床资料。结果术中出血100~1500 mL,6例病人术中输血。10例病人术中采用Pringle法阻断第一肝门,肝门阻断时间为6~46 min;3例病人未行血流阻断。POLF发生于术后(5.1±2.3)d,主要表现为ALT先升后降再急剧大幅升高至<1000 U/L,CT检查显示弥漫性肝坏死。13例病人总胆红素(TBil)和凝血酶原时间均持续升高,3例病人出现顽固性的大量腹腔积液,6例病人出现肝性脑病,7例病人出现不同程度的肾功能不全。病死率为53.8%(7/13)。所有病例住院时间为(21.9±11.9)d。TBil峰值>150μmol/L的6例病人全部死亡,而TBil峰值<150μmol/L的7例病人仅1例死亡(P=0.004)。ALT峰值>3000 U/L的6例病人中5例死亡,而ALT峰值<3000 U/L的7例病人仅有2例死亡(P=0.102)。结论肝癌切除术后肝脏弥漫性坏死引起的POLF起病隐匿、发展迅速,是围手术期死亡的重要原因,术后密切监测肝肾功能,早发现、早干预,降低ALT和TBil的峰值、保护重要器官功能等均对治疗至关重要。

Objective To explore the clinical characteristics and summarize the diagnosis and treatment of a special type of acute postoperative liver failure(POLF)after hepatectomy of primary liver cancer,characterized by diffuse liver necrosis,sharp deterioration of alanine aminotransferase(ALT)after a temporary recovery.Methods A retrospective analysis was performed on 13 patients who underwent hepatectomy of liver cancer with postoperative peak values of ALT over 1000 U/L and the complete postoperative clinicopathological data in the Eastern Hepatobiliary Surgery Hospital,Naval Military Medical University from January 2019 to November 2019.Results Intraoperative hemorrhage ranged from 100 to 1500 mL,and blood transfusion was performed in 6 patients.Pringle maneuver was applied in 10 patients with the time of 6 to 46 minutes;other 3 patients did not receive occlusion.The kind of POLF had an insidious onset which usually occurred on the day(5.1±2.3)days after hepatectomy.The main manifestation was a sharp increase in ALT after a temporary recovery.Simultaneously,it was accompanied by non-thrombotic,diffused liver necrosis.The total bilirubin and prothrombin time of13 patients were increased continuously,3 patients followed severe stubborn ascites,6 patients developed hepatic encephalopathy and 7 patients accompanied renal dysfunction.The mortality was53.8%(7/13).The hospitalization time for all cases was(21.9±11.9)days.All 6 patients with peak TBil>150μmol/L died,while only 1 of 7 patients with peak TBil<150μmol/L died(P=0.004).There were 5 deaths in 6 patients with peak ALT>3000 U/L,while only 2 of 7 patients died with peak ALT<3000 U/L(P=0.102).Conclusion Acute liver failure resulted from diffused liver necrosis after hepatectomy starts insidiously,develops fast and offers an important cause of postoperative death.It is vital of immediate detection and intervention to reduce the peaks of alanine aminotransferase and total bilirubin for cure from the kind of POLF.