局部晚期肝癌肝移植患者围手术期凝血功能变化

背景与目的:肝移植逐渐成为治疗肝癌的一种有效措施,凝血功能改变是其同手术期管理的重要内容,本研究探讨局部晚期肝癌肝移植患者围手术期凝血功能改变,旨在为围手术期患者凝血功能的管珲提供依据.方法:同顾性分析我院2003年9月至2007年1月行肝移植的局部晚期肝癌31例患者资料,比较患者肝移植术前、术中无肝期、术后l周内的血小板(platelet, PI.T)计数、血浆凝血酶原时间(prothrombin time, PT)、活化部分凝血酶原时间(activated partial thromboplastin time,APTT)、血浆纤维蛋白原(fibrinogen, Fib)、血浆凝血酶时间(thrombin time, TT)和国际标准化比值(international normalized ratio, INR)等凝血指标的测定结果,分析围手术期凝血功能的变化,同时分别根据肝硬化程度和child-push评分进行分组分析.结果:凝血指标术前总体水平大致正常.术中无肝期及术后大部分天数中6项指标与术前相比有统计学意义(P<0.05).PT、APTT、TT 和INR的升高以及Fib和PLT的降低以无肝期最为显著PT(19.51±3.78) s vs (14.16±1.46) s;APTT (77.01±30.51) s vs (40.19±4.11) s;TT (27.50±15.10) s vs (19.46±3.05) s;INR (1.61±0.37) vs (1.11±0.16); Fib (1.73±0.70) g/L vs(3.38±1.00)g/L; PLT(108±60)×109/L vs (184±108)×109/L,所有指标P<0.01].在术后1周内,延长的PT,APTT、TT和升高INR逐渐回落.其中APTT低于术前观察值.且有显著统计学意义(32.05±6.50) s vs (40.19±4.11)s, P<0.01),这些指标的改变多发生在术后第1～2 d.降低的Fib和PLT恢复较慢,术后1周两者的观察值与术前相比仍有统计学差异Fib (2.13±0.53)g/L vs(3.38±1.00)g/L.P<0.01:PLT(145±90)×109/L vs (184±108)×109/L,P<0.05], 但其值已处在正常的参考值范围内.在肝硬化和Child-Pugh评分分组分析中,肝硬化中重度组及child-push水平B组患者同手术期低凝状念更为明显,但多集中在术前到术后1～2 d.结论:局部晚期肝痛患者肝移植围手术期,其凝血功能存在着由低凝向高凝或正常凝血状态渐变的趋势,术中无肝期、术日及术后1～2 d要预防出血.而术后1周左右要重点预防血栓形成.肝硬化程度及child-push水平分级对于评价术后凝血功能紊乱有一定价值.

Perioperative changes of coagulation functions in the local advanced liver cancer patients receiving liver transplantation

BACKGROUND & OBJECTIVE: Liver transplantation is widely accepted as an effective therapy of hepatoma. Perioperative dynamic observation of coagulation function is important for graft-receivers. This study was to explore perioperative changes of coagulation functions in the local advanced liver cancer patients who received liver transplantation. METHODS: Clinical data of 31 local advanced liver cancer patients, underwent liver transplantation from Sep. 2003 to Jan. 2007, were analyzed. Platelet (PLT) counting, prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin time (TT), fibrinogen (Fib) and international normalized ratio (INR) before operation, at anhepatic phase and the first week after operation were analyzed to evaluate congulation function. RESULTS: The coagulation functions of most patients were normal before operation. The six parameters varied significantly at anhepatic phase and on most days of the first week after operation when compared with the preoperative levels (P<0.05). The elevation of PT, APTT, TT and INR and the decrease of Fib and PLT were more apparent at anhepatic phase when compared with the preoperative levels PT: (19.51+/-3.78) s vs. (14.16+/-1.46) s? APTT: (77.01+/-30.51) s vs. (40.19+/-4.11) s? TT: (27.50+/-15.10) s vs. (19.46+/-3.05) s? INR: 1.61+/-0.37 vs. 1.11+/-0.16? Fib: (1.73+/-0.70) g/L vs. (3.38+/-1.00) g/L? PLT: (108+/-60)x10(9)/L vs. (184+/-108)x10(9)/L, all P<0.01]. In the first week after operation, the elevated PT, APTT, TT and INR levels decreased gradually, APTT was even lower than the preoperative level (32.05+/-6.50) s vs. (40.19+/-4.11) s, P<0.01]. These changes appeared usually on 1-2 days after operation. Decreased PLT and Fib regained slowly at the first week after operation when compared with the preoperative levels Fib: (2.13+/-0.53) g/L vs. (3.38+/-1.00) g/L, P<0.01? PLT: (145+/-90)x10(9)/L vs. 184+/-108]x10(9)/L, P<0.05], but the values were normal. According to stratification analysis, the hypocoagulability was more obvious in the patients with moderate or severe cirrhosis and those with Child-Pugh B level than in their counterparts. CONCLUSIONS: The coagulation functions of local advanced liver cancer patients shift from hypocoagulatory to hypercoagulatory or normal in perioperative period, therefore, prevention of bleeding should be focused on at anhepatic phase and on 1-2 days after operation while prevention of thrombosis should be focused on after the first week after operation. The degree of liver cirrhosis and Child-Pugh level could help to evaluate postoperative coagulation disorder.