晚期移植肝功能不全的原因

总结复习晚期移植肝功能不全各方面的相关文献，综合分析肝移植术后晚期移植肝功能不全的原因。结果显示晚期移植肝功能不全是比较常见的远期并发症，其病因主要包括有排异、胆道或血管并发症、原发病的复发、感染、以及其他原因等，随着肝移植存活率的不断提高，晚期移植肝功能不全将日益受到重视。     

幽门螺杆菌及其根除治疗对肝功能不全的影响及机制

目的:研究幽门螺杆菌(Helicobacter Pylori,Hp)感染与肝功能不全的关系,探讨肝功能不全合并Hp感染予Hp根除治疗的有效性、安全性及其可能的作用机制。方法:确诊为肝功能不全患者60例,随机选取肝功能正常健康人60例为对照,采用~(13)C-呼气试验进行Hp测定,观察Hp感染与肝功能不全的相关性。选取肝功能不全Hp检测阳性者予以四联根除治疗,疗程10 d,治疗完成后2周进行肝功能评价,1月后复查~(13)C-呼气试验。结果:肝功能不全60例中Hp阳性者46例(76.7%),对照组60例中Hp阳性者25例(41.7%,P0.05)。肝功能不全合并Hp阳性予以Hp四联根除疗法,根除率73.9%,Hp根除后症状改善,凝血酶源活动度、肝酶及血氨水平好转,腹水减少,Child-pugh评分降低(P0.05)。结论:肝功能不全较易合并Hp感染,与其合并慢性胃炎、消化性溃疡及肝硬化有关。肝功能不全合并Hp感染应予以根除治疗,四联根除Hp疗法根除率高,能够改善患者临床症状及肝功能水平。     

浅谈肝癌术后肝功能不全常见临床表现及处理要点

肝癌术后并发症多而重，好发于年龄〉60岁、肝功能储备不足、大肝癌切除、肝硬化程度重及术前存在合并症的患者。术后肝功能不全是肝癌切除术后最常见的并发症，也是肝癌患者术后死亡的主要原因之一。近年来，由于肝外科手术技术的迅猛发展和治疗方式的增多，使许多肝癌患者得到较好的治疗效果，但同时术后肝功能衰竭发生几率也较以往增大。对于术后肝功能不全的积极防治，不仅有利于提高肝癌术后存活率，而且对于肝癌切除范围的扩大也有积极的意义。事实上，大多数肝癌患者术后发生肝功能不全时，其临床表现并未被及时认识，早期认识并积极处理术后肝功能不全，不仅可及时抑制肝功能衰竭的发展，也是降低肝癌患者术后死亡率的主要手段。     

再谈肝功能不全病人营养治疗

肝功能不全病人的营养状况与其疾病的严重程度紧密相关。据不完全统计，临床上该类病人营养不良的发生率约为65%~100%。随着现代社会的进步和发展，以及膳食结构的影响，罹患肝功能不全的人群特点和营养状况也发生了很大的改变。比如肥胖、糖尿病和胰岛素抵抗等，都是目前在肝病营养治疗方面争议较大和研究较多的领域，此外，国际上针对终末期肝病并发症，如肝性脑病、难治性腹水和肝肾综合征的营养观念在近几年也发生了转变。对于肝功能不全病人的营养治疗实施途径上，提倡“选择合理更重要”！本文对其个体化营养治疗方案给出了具体的实施意见和建议。     

术后慢性肝功能不全的TPN治疗

全胃肠外营养（TPN）对于慢性肝功能不全的治疗，目前尚有许多争议。我科对11例肝硬化、慢性肝功能不全病人进行了TPN支持治疗，取得了良好的临床效果，报告如下：1临床资料本组男性8例，女性3例，年龄29～72岁。术前均经B超、生化、手术及病理诊断为：肝硬变、门脉高压、脾肿大、并接受了不同的外科手术（见表1）。术后出现黄疽、腹水，其中胆红素18～36mmol／L3例，36～54mmol／L6例，＞54mmol／L2例，腹水均为中～重度。每天给予血浆200ml、白蛋白20g，血浆白蛋白未见升高，腹水增加，病情加重。3例出现切口裂开。遂采用TPN治疗，…     

肝切除术后肝功能不全的临床护理

肝切除术是一种常用手术,现已广泛应用于治疗各种肝脏外科疾患.对合并有弥慢性肝脏病变的患者进行肝切除术时,术后肝功能不全与术后死亡和并发症的关系密切相关[1].为了能防治肝切除术后肝功能不全,减少术后肝衰死亡率,现将2003年25例肝切除术后肝功能不全病人的护理报告如下.     

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。     

重视合并肝功能不全外科病人的围手术期处理

众所周知，全球肝病病人已逾3．5亿，特别是我国为肝炎高发区。有相当数量的肝炎病人伴有不同程度的肝功能不全，同时患有各种各样的外科疾病，须手术治疗。伴肝功能不全的病人围手术期处理不当，术后可加重肝功能的损害，产生急性肝功能衰竭，甚至死亡。因此，术前肝储备功能的正确评估、术中维持肝血流量以及肝细胞功能和术后护肝处理等．最大限度地保护肝功能，安全度过围手术期至关重要。     

血清前白蛋白水平对肝切除术后肝功能不全发生的影响

目的:探讨肝功能Child-Pugh A级患者行肝切除术后肝功能不全的危险因素。方法:选择2010年10月—2014年4月间427例连续的术前肝功能Child-Pugh A级行肝切除术的原发性肝癌患者。手术均由同一团队实施,均在肝门阻断下进行(肝门阻断15 min/间断5 min)。收集患者的临床资料,分析肝切除术后肝功能不全的危险因素。结果:427例患者中,男362例,女65例,平均年龄(51.1±10.4)岁;肝细胞癌391例,胆管细胞癌31例,两者混合型5例;86.4%(369/427)患者有肝炎背景,54.8%(234/427)患者同时伴有肝硬化;≤3个肝段切除与≥4个肝段切除的患者分别为358例(83.8%)及69(16.2%)例。17例(4.0%)发生肝切除术后发生功能不全,其中10例表现为非胆道阻塞、胆汁漏引起的高胆红素血症,6例患者表现为明显的腹水及凝血时间延长,1例患者因肝性脑病于术后21 d死亡。单因素分析发现年龄≥60岁、血清前白蛋白170 g/L与术后肝功能不全有关(P=0.045,P=0.009),多因素分析证实血清前白蛋白170 g/L是肝切除术后肝功能不全危险因素(HR=3.192,95%CI=1.185~8.601,P=0.022)。结论:血清前白蛋白水平是Child-Pugh A级患者行肝切除术后肝功能不全的独立影响因素,术前改善患者的营养状况可降低术后肝功能不全的发生率。     

肝癌行腹腔镜超声引导微波消融后肝功能不全的危险因素分析

目的:探讨原发性肝癌行腹腔镜超声引导微波消融治疗后肝功能不全的影响因素,为术前风险评估提供依据。方法:回顾分析2016年1月至2019年12月接受腹腔镜超声引导微波消融治疗的146例原发性肝癌患者的临床资料,应用Logistic多因素回归分析术后肝功能不全的相关危险因素。结果:治疗后出现肝功能不全36例,发生率24.7%(36/146),未出现肝功能衰竭病例。多因素分析结果显示,术前总胆红素高、低蛋白血症、吲哚菁绿清除试验15 min滞留率≥10%、肿瘤位置危险是原发性肝癌行腹腔镜超声引导微波消融治疗后发生肝功能不全的独立危险因素(P0.05)。结论:原发性肝癌行腹腔镜超声引导微波消融治疗后肝功能不全的发生受多种因素影响,其中术前总胆红素高、低蛋白血症、吲哚菁绿15 min滞留率≥10%及肿瘤位置危险等是独立危险因素,术前如能结合以上指标进行评估并采取相应措施,利于术后肝功能的恢复、提高疗效。     

Operations in injuries and strictures of bile ducts

Analysis of surgical treatment of 336 patients with cicatricial strictures and iatrogenic external fistulas of extrahepatic bile ducts is presented. The causes of these complications were intrasurgical injuries during cholecystectomy (n=302), resection of the stomach (n=21) and echinococcectomy (n=13). In all the cases correction of water-electrolytic balance, treatment and prophylaxis of hepatic and renal insufficiency, control of anaerobic infection were carried out before and after surgery. Restorative operations were performed in 31 (9.2%) patients, reconstructive surgeries -- in 305 (90.7%). Recurrence of the stricture required surgical intervention in 38 (11,3%) patients. Various postoperative complications were diagnosed in 119 (35.4%) patients, 26 (7.7%) patients died. The main causes of death were insufficiency of anastomotic sutures, intoxication, hepatic and renal insufficiency due to purulent cholangitis and cholangiolytic abscesses of the liver.     

肝癌肝切除术后并发症及其防治

目的总结和探讨肝切除患者术后常见并发症及其防治经验。方法回顾性分析288例肝癌肝切除术后围手术期并发症及其处理。结果术后并发症包括肝肾功能不全(44例),胸腔积液(10例),腹腔继发出血(8例),上消化道出血(6例),胆汁漏(6例),切口感染(6例),肺部感染(4例),切口疝(4例),腹腔脓肿(2例),自发性气胸(2例)。有并发症组和无并发症组患者的血浆白蛋白(ALB)、总胆红素(TB IL)、凝血酰原时间(PT),肝硬化情况以及术中失血量、手术时间、切除范围、肝门阻断时间存在差异(P<0.05)。全组因并发症死亡12例,病死率4.2%(12/288)。结论术前改善肝功能储备、提高手术技巧及了解各种并发症的发生时间和症状是防治肝切除术后并发症的关键因素。     

Mechanical jaundice in extrahepatic portal hypertension]

The authors consider the tactics of the treatment of mechanical jaundice in 9 patients suffering from an extrahepatic form of portal hypertension. The analysis of the results of the treatment proved that in case of pronounced bilirubinemia with colangitis manifestations and hepatic insufficiency it is indicated to use external controlled drainage of the thoracic lymphatic duct and transhepatic external drainage of the intrahepatic duct. The applied tactics allows to avoid carrying out emergent surgical interventions on extrahepatic bile passages, which is extremely dangerous, and to perform such operations when necessary only, under more favourable conditions after an adequate preparation of patients.     

A study on postoperative bile duct stricture with intrahepatic stones

From January 1976 through December 1988 we encountered ninety nine cases of intrahepatic stones. Eight of them were complicated with postoperative bile duct strictures which were formed on cholangiojejunostomy in 5 cases, cholangioduodenostomy, hepatic hilum and common hepatic duct in 1 case, respectively. Six cases of them are anastomotic strictures. The stones were mainly composed of bilirubin calcium. We guessed that the bile duct stricture resulted from cholangiojejunostomy without Roux-en-Y in 1 case and anastomotic insufficiency in 5 cases. Intrahepatic stones were removed by percutaneous transhepatic cholangioscopy (PTCS), and the treatment for the stricture was cholangiojejunostomy in 1 case and the dilatation by PTCS in 5 cases, including 3 endoprostheses by pig-tail silicone catheter and 2 internal-external biliary drainage. Two patients who did not undergo cholangioscopic dilatation died of sepsis due to cholangitis. Three of 5 patients who underwent endoscopic dilatation by PTCS could return to social life without recurrence of gallstones. In other two cases an endoprosthetic catheter was removed by PTCS because of dislodgement or obstruction of the catheter after confirming anastomotic strictures had improved. Authors recommended that PTCS should be applied for postoperative bile duct stricture complicated with intrahepatic stone.     

变异右肝管横跨与左肝管汇合的解剖学特点和临床意义

目的探讨变异右肝管横跨与左肝管汇合的解剖学特点和临床意义。方法回顾性分析经胆道影像学检出的52例变异右肝管横跨与左肝管汇合病例的临床经过和手术情况，并对其中部分特殊病例进行了随访。结果变异右肝管结石[60．52％（23／38）]和左肝管结石[86．84％（33／38）]的比例较高，伴随的胆管扩张和狭窄也较多见。变异导致的胆汁流体力学紊乱和血管鞘压迫可能是感染和结石高发的原因。变异右肝管的结石漏诊率为34．78％（8／23），结石残留比例高达86．95％（20／23）。1例在行左半肝切除时不慎将变异右肝管切断。结论变异右肝管横跨与左肝管汇合有易发生肝内胆管结石的倾向，其诊断治疗有其特殊性及困难性，应引起临床重视。     

Bile sorption in hepatic insufficiency in patients with mechanical jaundice

The author describes and substantiates the performance of bile sorption in the prevention and treatment of hepatic insufficiency in patients with obstructive jaundice who were subjected to external drainage of the bile tract. A total of 357 sessions of bile sorption were conducted in the pre- and postoperative periods in 51 elderly and old-aged patients with obstructive jaundice of benign (23 patients) and malignant (18 patients) character. Four patients died.     

腹腔镜与开腹胆总管探查术144例对比研究

目的 探讨胆囊结石合并胆总管结石行胆总管探查术的术式选择。方法 回顾性分析144例胆囊结石合并胆总管结石患者行腹腔镜与开腹胆总管探查术的临床资料。根据手术方式分为腔镜组（n=78）和开腹组（n=66）。结果 腔镜组一期缝合39例,T管引流32例,经胆囊管探查2例,中转开腹5例;术后胆漏7例,胆管炎4例,残余结石2例,肠穿孔1例,MODS 1例,电解质紊乱5例,伤口感染2例。开腹组术后胆漏合并胸、腹腔积液1例,胆管炎1例,残余结石2例,术后出血再次手术1例,电解质紊乱4例,伤口感染4例,肝肾功能不全2例,死亡1例。两组在术后并发症发生率方面比较差别无统计学意义（P＞0.05）。结论 与开腹手术比较,腹腔镜胆总管探查取石术具有微创、术中失血少、术后恢复快、术后住院时间短等优点,但尚不能完全替代传统开腹手术。     

复杂性肝内胆管结石的外科治疗

目的　总结复杂性肝内胆管结石的外科治疗方法及效果。 方法　 总结分析１９９２ ～１９９８ 年外科治疗复杂性肝内多段胆管结石并多处胆管狭窄３５ 例的手术方法,总结显露与切开肝内狭窄段胆管、取出结石、解除狭窄的经验和体会。 结果　３５ 例无手术死亡,术后近期并发感染、胆漏、肝功能不全或消化道出血共７ 例,均治愈;残留结石９ 例,术后经胆道镜取净结石７ 例。随访６ 个月至５ 年６ 个月２４ 例,优良２１ 例（８８ ％ ） ,好转２ 例（８ ％ ） ,无效１ 例（４ ％ ） 。 结论　复杂肝内胆管结石外科治疗的关键是显露和切开肝内各叶段胆管的狭窄段,取出结石、建立通畅的胆流通道。经肝门区或肝方叶可以显露和切开肝门胆管、左右肝管和左内叶、右前叶胆管,经肝膈面切开肝实质进路,可以显露和切开右肝内各叶段胆管。     

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.     

Cholostase und Leberinsuffizienz beim Intensivpatienten

Cornerstones of the diagnostic investigations of disturbances in liver function are analysis and sophisticated evaluation of serum liver enzymes, bilirubin and ammonia. Coagulation factors, serum albumin and cholinesterase levels are indicators of the hepatic metabolic capacity. Dynamic assessment of complex liver functions allows quantification of the hepatic metabolic activity and excretory function. Imaging techniques permit visualization of the size and texture of the liver, the vascular supply and perfusion as well as an assessment of the gall bladder and the extra-hepatic and intra-hepatic bile ducts. Manifold causes for cholestasis and/or liver dysfunction are known, such as ventilation with high pressure, total parenteral nutrition, shock, hypoxia and certain drugs. Obstructive cholestasis requires reconstitution of bile duct drainage, while non-obstructive cholestasis primarily requires treatment of the causative disease. The symptomatic therapy of liver insufficiency is rarely possible via direct treatment of the cause, but mostly requires specific management of secondary organ dysfunctions related to hepatic dysfunction including circulatory failure, hepatorenal syndrome and hepatic encephalopathy. In rare cases a temporary liver surrogate is necessary. The molecular absorbent recirculating system (MARS), a form of extracorporeal albumin dialysis, is introduced as a modality for the treatment of liver failure.