Pisani Ceretti A, Cordovana A, Pinto A, Spina G P
Divisione di Chirurgia 2o, Azienda Ospedaliera, Fatebenefratelli e Oftalmico, Milano.
Minerva Chir. 2000 Nov;55(11):771-8.
Patients with cirrhosis have reduced life expectancy. Surgery is often associated with clinical decompensation in this group of patients. The purpose of this paper is to study the surgical risk in cirrhotic patients undergoing nonderivative operations. Unfortunately, most of the studies in the literature about this problem are retrospective reviews with limitations. The conditions increasing surgical risk in cirrhotic patients are analysed. These include changes in the pharmacokinetics and pharmacodynamics of various drugs, altered hemostasis, poor resistance to infections, water retention, suture line insufficiency, chronic renal failure and congestive heart failure. Assessment of the disease stage in cirrhosis is very important, because the severity of hepatic abnormalities influences the prognosis. The Child-Pugh classification has been used extensively to risk-stratify patients with cirrhosis. However, the disregard for cardiorespiratory, renal, electrolyte balance and acid-base status limits its predictive accuracy. Recently a new scoring system, the Acute Physiology and Chronic Health Evaluation (APACHE III), has been introduced and seems to be superior to Child-Pugh for prognosticating short term survival of cirrhotic patients. In conclusion, surgery can be done safely only in cirrhotic patients with a good hepatic function. On the contrary, in patients with advanced cirrhosis, surgery causes a very high mortality. Finally, the patients with moderate hepatic failure can be operated only after a careful study of the disease and an adequate correction of the reversible risk factors.
肝硬化患者的预期寿命缩短。手术往往与这类患者的临床失代偿相关。本文的目的是研究接受非衍生手术的肝硬化患者的手术风险。不幸的是，文献中关于这个问题的大多数研究都是有局限性的回顾性综述。分析了增加肝硬化患者手术风险的因素。这些因素包括各种药物的药代动力学和药效学变化、止血功能改变、抗感染能力差、水潴留、缝线处愈合不良、慢性肾衰竭和充血性心力衰竭。评估肝硬化的疾病阶段非常重要，因为肝脏异常的严重程度会影响预后。Child-Pugh分类法已被广泛用于对肝硬化患者进行风险分层。然而，对心肺、肾脏、电解质平衡和酸碱状态的忽视限制了其预测准确性。最近引入了一种新的评分系统，即急性生理学与慢性健康状况评估（APACHE III），在预测肝硬化患者短期生存方面似乎优于Child-Pugh分类法。总之，只有肝功能良好的肝硬化患者才能安全地进行手术。相反，晚期肝硬化患者手术的死亡率非常高。最后，中度肝功能衰竭患者只有在对疾病进行仔细研究并充分纠正可逆性风险因素后才能进行手术。
