Shirabe K, Shimada M, Gion T, Hasegawa H, Takenaka K, Utsunomiya T, Sugimachi K
Second Department of Surgery, Kyushu University, Fukuoka, Japan.
J Am Coll Surg. 1999 Mar;188(3):304-9. doi: 10.1016/s1072-7515(98)00301-9.
Postoperative liver failure is a life-threatening complication after hepatic resection. Because of recent advances in liver surgery technique and a more stringent patient selection, mortality after hepatic resection has steadily decreased, but its incidence still ranges from 10% to 20%. The factors linked to postoperative liver failure in major hepatic resection in the modern era should be reevaluated.
Of 80 patients with viral markers (hepatitis C viral antibody or hepatitis B surface antigen) who underwent major hepatic resections (no less than bisegmentectomies) for hepatocellular carcinoma between 1990 and 1996, 7 patients (8.8%) died of postoperative liver failure within 6 months after hepatectomy. The cause of liver failure was analyzed based on both the preoperative data and the intraoperative findings. In addition, since all the patients who died of liver failure underwent a right hepatic lobectomy, a further data analysis was also done in 47 patients who underwent a right lobectomy of the liver. A volumetric analysis by CT was then done to evaluate the remnant liver volume.
Between the patients with liver failure and those without liver failure who underwent a right lobectomy, there were no significant differences in preoperative data or intraoperative findings. Volumetric analysis revealed that the remnant liver volume of patients who died of liver failure was significantly smaller than that of patients who lived (p = 0.008). The incidence of liver failure in patients with a remnant liver volume of less than 250 mL/m2 was 7 of 20 (38%), while it was 0 of 27 in patients with a liver volume of no less than 250 mL/m2 (p = 0.0012). The only significant risk factor for liver failure in patients with a remnant liver volume of less than 250 mL/m2 was diabetes mellitus (p = 0.0072).
The expected remnant liver volume appears to be a good predictor for liver failure in patients who undergo a right lobectomy of the liver. In patients with diabetes mellitus and an expected remnant liver volume of less than 250 mL/m2, a major hepatectomy should be avoided. Careful patient selection based on volumetric analysis in major hepatectomy cases could help prevent the occurrence of postoperative liver failure.
术后肝衰竭是肝切除术后一种危及生命的并发症。由于肝脏手术技术的最新进展以及患者选择标准更加严格，肝切除术后的死亡率稳步下降，但其发生率仍在10%至20%之间。现代主要肝切除术中与术后肝衰竭相关的因素应重新评估。
在1990年至1996年间因肝细胞癌接受主要肝切除术（不少于双段切除术）的80例有病毒标志物（丙型肝炎病毒抗体或乙型肝炎表面抗原）的患者中，7例（8.8%）在肝切除术后6个月内死于术后肝衰竭。基于术前数据和术中发现对肝衰竭原因进行了分析。此外，由于所有死于肝衰竭的患者均接受了右肝叶切除术，因此还对47例行肝右叶切除术的患者进行了进一步的数据分析。然后通过CT进行体积分析以评估残余肝体积。
在接受右叶切除术的肝衰竭患者和未发生肝衰竭的患者之间，术前数据或术中发现无显著差异。体积分析显示，死于肝衰竭的患者的残余肝体积明显小于存活患者（p = 0.008）。残余肝体积小于250 mL/m²的患者中肝衰竭发生率为20例中的7例（38%），而残余肝体积不少于250 mL/m²的患者中肝衰竭发生率为27例中的0例（p = 0.0012）。残余肝体积小于250 mL/m²的患者中肝衰竭的唯一显著危险因素是糖尿病（p = 0.0072）。
预期残余肝体积似乎是行肝右叶切除术患者肝衰竭的良好预测指标。对于患有糖尿病且预期残余肝体积小于250 mL/m²的患者，应避免进行主要肝切除术。在主要肝切除病例中基于体积分析进行仔细的患者选择有助于预防术后肝衰竭的发生。
