原发性肝癌切除术后门静脉血栓相关性肝坏死的临床分析

目的 探讨原发性肝癌切除术后门静脉血栓相关性肝坏死的临床表现及诊疗方法。方法 回顾性分析上海东方肝胆外科医院2018年11月至2019年10月8例原发性肝癌切除术后门静脉血栓相关性肝坏死患者的临床资料，包括患者的人口统计学特征、临床表现、手术方式、实验室检查及影像学检查结果、临床诊疗及预后等。结果 原发性肝癌切除术后门静脉血栓相关性肝坏死均发生在术后2周内，无特异性临床症状和体征，实验室检查主要表现为肝功能谷丙转氨酶、乳酸脱氢酶急剧升高，凝血功能指标异常。8例患者中增强CT显示肝脏呈广泛性坏死6例，局限性坏死2例，显示门脉血栓形成5例，肝脏坏死的发生部位与血栓形成的门静脉支血供区域并非完全相关。超声检查5例，均未能显示肝脏组织坏死改变，显示门脉血栓形成4例。8例患者中，7例予以抗凝、改善微循环、护肝等治疗，5例存活，2例死亡；1例患者病情较轻，给予低分子右旋糖酐、改善微循环等治疗后病情缓解。结论 肝功能急剧恶化为原发性肝癌切除术后早期发生门静脉血栓相关性肝坏死主要初发表现，肝脏广泛性坏死或局限性坏死、伴有或不伴有门脉血栓的增强CT表现为其影像学特征。抗凝、改善微循环治疗有一定效果。该病症确切的发病机制、有效的防治方法需要重视和进一步研究。

Clinical analysis of liver necrosis associated with portal vein thrombosis after hepatectomy for primary liver cancer

Objective To investigate the clinical manifestations, diagnosis and treatment of liver necrosis associated with portal vein thrombosis after hepatectomy for primary liver cancer. Methods The clinical date of 8 patients with primary liver cancer who had postoperative liver necrosis associated with portal vein thrombosis after hepatectomy for primary liver cancer between Nov. 2018 and Oct. 2019 at Shanghai Eastern Hepatobiliary Surgery Hospital were retrospectively analyzed, including demographic features, manifestations, surgical procedure, the results of the laboratory examination and imaging examination, clinical diagnosis, treatment and prognosis. Results Liver necrosis associated with portal vein thrombosis occurred within 2 weeks after operation, without specific clinical symptoms and signs. Laboratory examination mainly showed that patients’ALT and LDH had a sharp rise and coagulation function was impaired, which were the initial manifestation after surgery. Among the 8 cases, contrast-enhanced CT showed extensive necrosis in 6 cases, focal necrosis in 2 cases, and portal thrombosis in 5 cases. 5 cases with ultrasound examination showed no liver necrosis, and portal vein thrombosis found in 4 cases. Thrombus images were seen only in the main portal vein, and the left and right main branches of the portal vein. Among the 8 cases, 7 cases were treated mainly with anticoagulation and microcirculation promotion, etc. As a result, 5 cases survived and 2 cases died. One patient’s condition was mild, and was relieved after treatment with low molecular dextran and promoting microcirculation. ConclusionThe liver necrosis associated with portal vein thrombosis after hepatectomy for primary liver cancer is a rare and serious complication, characterized by rapid deterioration of liver function in the early course, extensive or focal hepatic necrosis with or without portal thrombosis showed in contrast-enhanced CT. Anticoagulation and microcirculation promotion have certain therapeutic effect. The precise mechanism, effective prevention and treatment require attention and further research.