TACE术后并发肝脓肿的临床诊治分析

Clinical diagnosis and treatment of liver abscess after TACE

目的探讨TACE术后并发肝脓肿的临床特征、危险因素及预后。方法回顾性分析2020年11月至2022年3月江南大学附属医院收治的857例肝肿瘤患者临床资料。患者均签署知情同意书,符合医学伦理学规定。其中男518例,女339例;年龄38~80岁,中位年龄61岁。分析TACE术后肝脓肿发生情况、临床特征、危险因素及预后等。结果857例患者共行1164例次TACE手术,7例发生肝脓肿,其中含气液平面肝脓肿5例。肝脓肿发生率0.60%(7/1164),肝脓肿死亡率2/7。7例患者中男5例,女2例;平均年龄(70±9)岁;合并HBV感染4例,2型糖尿病2例;肝细胞癌3例,原发性肝神经内分泌癌1例,转移性肝癌3例;肿瘤直径(8.6±2.1)cm。每例患者TACE次数为(4±2)次;碘化油使用剂量(12±5)ml;载药微球5例,明胶海绵2例。术后出现肝脓肿时间3~20 d,中位时间7 d;治疗时间8~28 d,中位时间16 d。肝脓肿患者首发症状主要为发热、腹痛;7例均并发全身炎症反应综合征,使用抗生素治理;5例行穿刺引流术;并发双侧胸腔积液6例,右侧胸腔积液1例,其中3例行右侧胸腔穿刺引流。脓液送检阳性率1/8,其他培养均提示革兰氏阴性杆菌6例,其中1例产气肠杆菌兼为厌氧。与TACE术前比较,发生肝脓肿后患者的炎症指标明显升高,肝损伤主要表现为肝脏合成代谢功能下降。结论TACE术后肝脓肿发生率较低,脓肿大多含气液平面,细菌多为革兰氏阴性杆菌。肝脓肿对肝损害较大,抗生素及穿刺引流术是主要的治疗方式。其发生原因可能与患者年龄、肿瘤栓塞次数、脓肿大小及糖尿病等因素有关,对此类患者要严密随访,及早发现,及时治疗。

Objective To investigate clinical characteristics,risk factors and prognosis of liver abscess after TACE.Methods Clinical data of 857 patients with liver tumors admitted to Affiliated Hospital of Jiangnan University from November 2020 to March 2022 were retrospectively analyzed.The informed consents of all patients were obtained and the local ethical committee approval was received.Among them,518 patients were male and 339 female,aged from 38 to 80 years,with a median age of 61 years.The incidence,clinical characteristics,risk factors and prognosis of liver abscess after TACE were analyzed.Results 1164 TACE were performed in 857 patients,and 7 cases developed liver abscess,including 5 cases of air-fluid level liver abscess.The incidence of liver abscess was 0.60%(7/1164),and the mortality rate of liver abscess was 2/7.Among 7 patients,5 were male and 2 female,aged(70±9)years on average.4 cases were complicated with HBV infection and 2 cases of type 2 diabetes mellitus.3 patients were diagnosed with hepatocellular carcinoma,1 case of primary hepatic neuroendocrine carcinoma and 3 cases of metastatic liver cancer.The tumor diameter was(8.6±2.1)cm.The number of TACE was 4±2 for each patient.The dosage of iodized oil was(12±5)ml.Drug-loaded microspheres were utilized in 5 patients and gelatin sponge in 2 cases.Liver abscess occurred at postoperative 3-20 d,with a median time of 7 d.The treatment time was 8-28 d,with a median time of 16 d.The initial symptoms of patients with liver abscess mainly included fever and abdominal pain.All 7 cases were complicated with systemic inflammatory response syndrome and treated with antibiotics.Puncture and drainage were performed in 5 cases.6 cases were complicated with bilateral pleural effusion and 1 case of right pleural effusion,and 3 among them were treated with right pleural puncture and drainage.The positive rate of pus sample was 1/8.Other culture tests showed 6 cases of Gram-negative bacilli,including 1 case of anaerobic Enterobacter aerogenes.Compared with before TACE,the inflammatory indexes of patients with liver abscess were increased significantly after the diagnosis of liver abscess,and the main manifestations of liver function injury was the decline of liver synthesis and metabolism.Conclusions The incidence of liver abscess after TACE is relatively low.Air-fluid level can be observed in a majority of liver abscesses.Most of the bacteria are Gram-negative bacilli.Liver abscess poses severe injury to the liver.Antibiotics and puncture and drainage are the main treatment strategies.The incidence of liver abscess may be associated with patients’age,number of tumor embolization,the size of abscess and diabetes mellitus,etc.Intimate follow-up,early diagnosis and treatment should be performed in these patients.