Endogenous toxicity in acute hepatic failure and ways of eliminating it

The structure of causes of the endogenous intoxication in 39 patients with acute hepatic insufficiency is studied. Eleven toxic compounds of an organic nature were found responsible for genesis fo the disorders and outcomes of acute hepatic insufficiency. Possible use of hemosorption and hyperbaric oxygenation for the elimination of toxic products is analysed. A combination of them is proved to be expedient. The selectivity of sorption for each toxin separately in various types of hepatic insufficiency is established.     

原发性肝细胞癌切除术后肝功能不全60例的临床分析

目的分析原发性肝细胞癌切除术后肝功能不全的临床相关因素。方法以本院2009年1月-2016年10月收治的60例原发性肝细胞癌切除术后肝功能不全患者为研究组,选择同期100例无肝功能不全的原发性肝细胞癌患者为对照组,对两组年龄、性别、肿瘤大小等相关资料收集比较,并通过Logistic多因素回归分析切除术后肝功能不全的独立危险因素。结果肝切除术后肝功能不全患者中表现出高胆红素血症占58.33%,腹水明显、PT延长占35.00%,肝性脑病占6.67%;轻度肝功能不全占76.67%;研究组患者肝硬化比例、肝门阻断时间≥15min、肝切除量≥3叶比例、年龄均显著大于对照组,而ALB水平显著低于对照组,差异有统计学意义(P0.05);Logistic多因素回归分析显示肝切除术后肝功能不全发生独立危险因素包括肝门阻断时间(≥15min)、肝切除量(≥3叶),而ALB水平为其保护因子。结论原发性肝细胞癌切除术后肝功能不全以高胆红素血症表现为主,其发生与ALB水平、肝门阻断时间、肝切除量密切相关。     

Diagnosis and prognosis of hepatic insufficiency in focal hepatic lesions

The priority of surgical approach for focal hepatic affection is doubtless. Hepatic resection (HR) is the main method, securing notable lengthening of life and sometimes--radical reconvalescence of patients, suffering hepatic tumors. At the same time HR is a very high risk operation in sense of danger of the complications occurrence. The hepatic insufficiency occurrence or exacerbation constitutes one of the dangerous and frequent complications. The problem of an acute hepatic insufficiency is actual, because the necessity exists to perform HR in patients with insufficient postresectional residual parenchyma volume, the lowered regeneration capacity in presence of cirrhosis, chronic hepatitis, dystrophic changes, etc. That's why the only method for prophylaxis of this complication occurrence is its prognosis estimation. The hepatic functional reserve and residual parenchyma volume determination constitute the base of postoperative hepatic insufficiency prognosis.     

Estimation of efficacy of the correction methods for hepatic functional disorders in cholestasis of mechanical nature

Efficacy of the prophylaxis and treatment methods for hepatic insufficiency in obstructive jaundice was studied. The role of an energy-dependent processes and the tissue deficit of oxygen in the hepatic insufficiency occurrence and progress, possibility of these disorders medicinal correction was delineated. The expediency of introduction of preparations, improving the erythrocytes function and the oxygen delivery to tissues in conjunction with miniinvasive biliary decompression, in therapeutic complex for hepatic insufficiency of mechanical nature was noted.     

吲哚氰绿排泄试验及标准余肝体积与肝癌切除术后肝功能不全的相关性研究

目的 结合吲哚氰绿(ICG)排泄试验及标准余肝体积探讨预防肝切除术后肝功能中、重度代偿不全的安全切肝界限.方法 对2007年3月至2008年2月期间收治的75例因肝癌行肝切除术的患者进行研究分析,根据术后肝功能代偿状况分组,将术后发生肝功能中度代偿不全患者术前ICG 15 min潴留率(ICGR15)值与术后标准余肝体积进行直线回归分析.结果 全部患者中,术后发生肝功能轻度代偿不全60例,中度代偿不全12例,重度代偿不全3例.轻度代偿不全组与中重度代偿不全组患者的年龄[(50±13)岁和(53±9)岁]、术前Child-Pugh评分[(5.4±0.6)分和(5.7±0.9)分]、凝血酶原时间[(13.6±1.0)s和(13.5±1.0)s]、国际标准化比值(1.09±0.10和1.06±0.10)等指标的差异均无统计学意义(P>0.05);而两组ICG排泄试验中的K值(0.20±0.04和0.17±0.03)和ICGR15值(6±4和9±4)以及术后标准余肝体积[(545±93)ml和(398±82)ml]的差异均有统计学意义(P<0.05).将术后肝功能中度代偿不全患者术前ICGR15值和术后标准余肝体积进行直线回归分析,发现两者呈正相关(R=0.640,P=0.025),回归方程为:标准余肝体积(ml/m~2)=1594.6×ICGR15+265.结论 将ICG排泄试验和标准余肝体积结合起来评估患者肝脏储备功能,有助于预测患者术后发生肝功能损害的程度及预防患者术后发生肝功能中、重度代偿不全.     

Lymphosorption in the treatment of patients with hepatic insufficiency and jaundice

Results of the clinical use of lymphosorption in 57 patients with hepatic insufficiency of various etiology are described. Lymphosorption was found to be an effective method in exo- and endogenous hepatic insufficiency of the I and II degree. The detoxicating effect was decreased in patients with cholangitis and other purulent complications, hepatic coma with extensive necroses of the liver. Lymphosorption is thought to be inexpedient in malignant tumors of the liver with the symptoms of cancer intoxication.     

Postoperative liver insufficiency: Prevention and management

Postoperative hepatic insufficiency is a rare cause of liver failure. Consequences of this usually predictable complication can be limited by appropriate preventive measures and careful postoperative management. This report reviews the current experimental and clinical literature with regard to postoperative hepatic insufficiency.     

肝功能不全的不常见表现与治疗：附16例报告

作者报告了肝胆胰外科中不常见的胆总管引流白胆汁１４例和术后不寻常大出血２例，指出这些不常见表现实际上为肝功能不全的反映，当引起临床医师重视。同时还就肝功能不全的表现方式和治疗进行了讨论，强调保肝和营养支持治疗是其根本治疗措施     

The models of hepatic insufficiency and encephalopathy in animals

The majority of the investigation methods of biochemical, morphological and metabolic disorders in hepatic insufficiency and encephalopathy occurrence are inadequate in use in clinical conditions because their invasiveness frequently creates dangerous situations to the patient life and health. That's why, to characterize the mechanisms, constituting the hepatic and cerebral damages base, for testing of a new medicinal preparations, aprobation of a new theoretical and clinical hypotheses, the models of an acute and chronic hepatic insufficiency are applied on the animals, permitting to unify the age, genetic peculiarities and physiological parameters of the individuals involved in experiments, the pathology character, its severity and longevity. Homogeneity of these indexes permits to estimate molecular, structural and functional disorders, laying in the base of pathological process. We have analyzed the experimental models of hepatic insufficiency, basing on the hepatotoxins usage--acetaminophen (paracetamol), carbon tetrachloride, thioacetamide, D-galactosamine, concanavalin A, lipopolysaccharides. Every existing pharmacological model of hepatic insufficiency and encephalopathy for animals owes its own advantages and faults. The choice of a model depends on tasks of the investigation and of the animal species, involved in the procedures.     

Hepatic tissue respiration in pathology of the biliary system and the effect of hyperbaric oxygenation on the course of hepatic insufficiency]

Under study was the effect of hyperbaric oxygenation in 46 patients on the course of bile tract diseases, complicated with hepatic insufficiency. Hyperbaric oxygenation was found to render a positive effect on the course of hepatic insufficiency.     

Magnetic-laser irradiation of the liver in the treatment and prevention of hepatic insufficiency in mechanical jaundice

The effect of magnetolaser irradiation on the liver in obstructive jaundice was studied in experiments on 500 rats. Magnetolaser irradiation was found to have a favourable effect on the functional morphology of the liver; it levels many morphological signs of hepatic insufficiency and thus provides the grounds for carrying out an operation on the bile ducts under optimal conditions. The suggested method of magnetolaser therapy was applied in 142 patients with hepatic insufficiency in obstructive jaundice. The study showed that magnetolaser therapy applied in complex treatment of hepatic insufficiency promotes active restoration of the function of the organ, significantly raises the efficacy of treatment, and reduces the term of the patient's hospital stay.     

Treatment of High Output Cardiac Failure by Flow-Adapted Hepatic Artery Banding (FHAB) in Patients with Hereditary Hemorrhagic Telangiectasia

Involvement of abdominal organs in Osler’s disease may lead to the development of hepatic arteriovenous shunts with a dilatation of the hepatic artery. Right and subsequent global heart failure due to cardiac valvular insufficiency, pulmonary artery hypertension, and hepatomegaly as well as increased cardiac output may result. This hyperdynamic hepatic blood flow can be reduced by ligature or banding of the hepatic artery or by orthotopic liver transplantation. We report on two female patients suffering from Osler’s disease (68 and 76 years old) with severe heart insufficiency (NYHA III-IV) caused by the high hepatic shunt volumes. A gradual banding of the hepatic artery directed by intraoperative flow measurement in the hepatic artery and control of the systemic hemodynamics by Swan–Ganz or COLD catheters was performed in these patients. The banding was achieved by encasing the hepatic artery in a PTFE cuff (length, 1.0 cm). The high cardiac output could be reduced from 11.2 to 7.0 l/min and from 10.7 to 6.0 l/min, respectively. The respective hepatic artery flow was reduced from 2.0 to 0.3 l/min and from 4.0 to 0.7 l/min. An improvement of heart insufficiency, a reduction in the severity of the cardiac valvular insufficiency, and a reduction of the pulmonary arterial hypertension could be already observed intraoperatively. One patient died of right cardiac failure after an orthotopic liver transplantation 7 months later. The other one died 3 years after the banding. The banding of the hepatic artery controlled by hepatic arterial flow measurement can be considered as an effective and safe palliative procedure in intrahepatic HHT compared to therapeutic alternatives such as hepatic artery ligation or embolization.     

Use of therapeutic plasmapheresis in heart surgery patients with hepatic insufficiency

Therapeutic plasmapheresis is a highly effective method in the preparation of patients with hepatic insufficiency for operation on the heart under conditions of extracorporeal circulation. It leads to reduction of the bilirubin level and normalization of the main values of hepatic function. The positive effect of therapeutic plasmapheresis is less manifest in acute hepatorenal insufficiency developing after operation with extracorporeal circulation. The best effect of therapeutic plasmapheresis in the postoperative period was produced in patients in whom hemorrhages and the low cardiac output syndrome were removed.     

Treatment of severe hepatic insufficiency by perfusion of patients' blood through a suspension of cryopreserved hepatocytes

The results of hemoperfusion through a suspension of cryoconserved hepatocytes in 21 patients with severe hepatic insufficiency are analysed. It is shown that the manipulation had a beneficial effect on the clinical and biochemical indices, which was manifested by diminished jaundice and skin pruritus, increased physical activity, improved appetite; reduced levels of bilirubin, transaminase, alkaline phosphatase, bile acids, and cholesterol. The information gained is evidence that the method can be included in the complex treatment of patients with severe hepatic insufficiency.     

Correction of metabolic disorders by magnetic-laser irradiation (experimental study)

Five series of experiments were conducted on a model of hepatic insufficiency caused by obstructive jaundice to study the effect of semiconductor infrared laser in a range of 800-900 nm with a static magnetic field on some metabolic changes in the organism. Wistar rats weighing 200-250 g were used. The region of the liver was irradiated through an intact epilated skin. The results provide evidence that a definite role in the pathogenesis of hepatic insufficiency is played by intensification of LPO processes and diminution of antioxidant defence which leads, in turn, to reduction of the insulin-receptor interrelations and sharp decrease of hepatic cell metabolism.     

Acute cholecystitis and liver failure

The article presents results of treatment of 300 patients with acute cholecystitis, 285 of them (95%) being operated upon. Hepatic insufficiency was found to develop in 173 patients (57,6%). The operation of choice was cholecystectomy (97,1%). Cholecystostomy was fulfilled in 7 patients (2,4%), in 2 patients (0,5%) choledocholithotomy was made following a previous cholecystectomy. Lethality in patients with hepatic insufficiency was 4 times as high as in patients without it. In 34,1% of the operated patients hepatic insufficiency was the main cause of death.     

A logical approach to hepatocellular carcinoma presenting with jaundice.

OBJECTIVE: This prospective cohort study on patients with hepatocellular carcinoma (HCC) presenting with jaundice emphasized the importance of differentiating patients with hepatic insufficiency from patients with obstructive jaundice caused by tumor. SUMMARY BACKGROUND DATA: There are little data in the medical literature on the management of patients with HCC presenting with jaundice. Experience has accumulated mainly from case reports and retrospective studies. METHODS: Data were collected prospectively on 2095 patients with HCC seen over a 12-year period. All patients were investigated with blood tests, abdominal ultrasound, and chest radiography. Endoscopic retrograde cholangiopancreatography-percutaneous transhepatic cholangiography, computed tomography and hepatic angiography were carried out in selected patients. RESULTS: Of the 530 patients who had clinically detectable jaundice, 481 had jaundice due to hepatic insufficiency and 49 patients had obstructive jaundice. Patients with hepatic insufficiency had extremely poor prognosis, and 90% of them died within 10 weeks of first presentation. "Curative" resection, however, was possible in 9 of 49 patients with obstructive jaundice, and histologic analysis showed resectional margin involvement by tumor in 1 patient. In addition, 35 patients were treated with biliary stents to relieve the obstructive jaundice. Supportive treatment only was given to five patients who were considered too terminally ill. The overall survival of patients with HCC with obstructive jaundice was similar to those patients who presented with no clinical detectable jaundice and was much better than those with jaundice due to hepatic insufficiency (log-rank test, p < 0.001). CONCLUSIONS: The prognosis of patients with HCC who presented with jaundice due to hepatic insufficiency was dismal. It is important to identify the patients who had obstructive jaundice because with proper treatment, good palliation and occasional cure are possible.     

Liver transplantation in patients with Budd-Chiari syndrome

Patients with Budd-Chiari syndrome (obstruction of the hepatic veins) and associated hepatic insufficiency may be candidates for orthotopic liver transplantation (OLT). In our series of 405 OLT patients, 3 were transplanted due to Budd-Chiari syndrome (0.7%). The indication for liver transplantation in these patients was severe hepatic insufficiency (chronic in two and acute in the third one). Morphologic study of the obstructions revealed apparently different causes, including thrombi, membranous webs in hepatic veins, and hydatid cyst compression. The surgical technique employed in these transplantations was similar to that for other etiologies. Due to its implications for the future course of OLT, it is important to determine the exact etiology of Budd-Chiari syndrome in the pretransplant period and to treat the patients with early and long-term anticoagulant therapy to avoid syndrome recurrence.     

Hyperkalemia provoked by acute hepatic necrosis

Six patients with varying degrees of renal insufficiency developed severe hyperkalemia following hepatic necrosis. The hyperkalemia was seen prior to or concomitant with marked elevations in hepatic enzymes. The basis of the liver disease appeared to involve congestive heart failure and/or hypotension. Necrotic liver cells released intracellular potassium into the blood of patients who were unable to handle the additional potassium load because of renal insufficiency and metabolic acidosis. Furthermore, a shift of potassium into the intracellular space is impaired in uremics by defective Na-K ATPase activity, possibly induced by uremic toxins. The 3 diabetic patients in our series may additionally have had aldosterone deficiency leading to impaired cellular potassium uptake.     

伴肾功能不全的肝脏恶性肿瘤行消融治疗的临床观察

目的 探讨伴肾功能不全的肝癌行消融治疗的安全性与有效性,以及术后肾功能恶化的发生率.方法 2004年2月～2012年9月,16例伴肾功能不全的肝脏恶性肿瘤行24次经皮超声引导肝穿刺微波或射频消融治疗.肾功能分期:代偿期11例,失代偿期5例.10例消融1次,5例2次,1例4次.观察消融术后并发症、疗效以及肾功能变化情况.结果 16例初次消融术后围手术期肾功能衰竭发生率6.2％ (1/16);初次消融完全消融率87.5％(14/16).初次消融至末次消融后,肾功能恶化(肾功能分期由某一期进展为更高级别一期)发生率18.8％(3/16).结论 肾功能不全的肝脏恶性肿瘤行消融治疗有效,但可能增加术后肾功能衰竭的发生率.