Department of Thoracic and Cardiovascular Surgery, Julius-Maximilians-University, Würzburg, Germany.
Faculty of Medicine, Julius-Maximilians-University, Würzburg, Germany.
J Thorac Cardiovasc Surg. 2017 Sep;154(3):906-912. doi: 10.1016/j.jtcvs.2017.04.041. Epub 2017 Apr 27.
Secondary sclerosing cholangitis in critically ill patients is a rapidly progressing disease leading to biliary fibrosis and cirrhosis. We describe the course of sclerosing cholangitis in critically ill patients after cardiac surgery and compare this with matched patients.
A retrospective search for "secondary sclerosing cholangitis" and "liver and/or hepatic failure" in all adult patients (aged 18-93 years) who underwent cardiac surgery from April 2007 to March 2016 identified 192 of 8625 patients. Of those, 12 were diagnosed with sclerosing cholangitis in critically ill patients (incidence, 0.14%). A 3:1 matching was performed. Laboratory values, pharmacologic requirements, ventilation times, mechanical circulatory support, and endoscopic retrograde cholangiopancreatography studies were extracted from the hospital database.
A total of 9 men and 3 women were affected (age 71 years; range, 59.8-75.5 years). Critically ill patients with sclerosing cholangitis required vasoconstrictors and inotropes longer than control patients (norepinephrine 356.5 hours [264.5-621] vs 68 hours [15-132.5], P = .003; enoximone 177 hours [124.3-249.5] vs 48.5 hours [12-81 hours], P < .001, respectively). Critically ill patients with sclerosing cholangitis had longer intubation time (628.5 hours [377.3-883] vs 25 hours [9.8-117.5]; P < .001) and more surgical revisions (3 [2.5-6] vs 1 [0-2], P = .003) than the matching group. Bilirubin (23.3 mg/dL [14.4-32.9] vs 1 mg/dL [0.6-2.7]; P < .001), gamma-glutamyltransferase (1082.3 U/L [259.5-2265.7] vs 53.8 U/L [35.1-146]; P < .001), and alkaline phosphatase (751.5 U/L [372-1722.3] vs 80.5 U/L [53.3-122]; P < .001) were higher in critically ill patients with sclerosing cholangitis. One critically ill patient with sclerosing cholangitis underwent successful liver transplantation. A total of 11 patients sclerosing cholangitis died (92%) versus 12 patients (33%, P < .001) in the control group.
Sclerosing cholangitis in critically ill patients is a fatal complication in patients undergoing cardiac surgery who have a complicated postoperative course with prolonged vasoconstrictor, inotropic, and respiratory therapy, or who require frequent surgical revisions. Liver transplantation remains the only curative option but is often precluded by the age and critical state of patients undergoing cardiac surgery.
危重症患者的继发性硬化性胆管炎是一种进展迅速的疾病，可导致胆管纤维化和肝硬化。我们描述了心脏手术后危重症患者硬化性胆管炎的病程，并与匹配的患者进行了比较。
回顾性搜索 2007 年 4 月至 2016 年 3 月期间所有接受心脏手术的成年患者（年龄 18-93 岁）的“继发性硬化性胆管炎”和“肝脏和/或肝功能衰竭”，共确定了 8625 例患者中的 192 例。其中，12 例被诊断为危重症患者的硬化性胆管炎（发病率为 0.14%）。进行了 3:1 匹配。从医院数据库中提取了实验室值、药物治疗需求、通气时间、机械循环支持和内镜逆行胰胆管造影研究。
共有 9 名男性和 3 名女性受到影响（年龄 71 岁；年龄范围 59.8-75.5 岁）。患有硬化性胆管炎的危重症患者需要更长时间的血管收缩剂和正性肌力药物，与对照组相比（去甲肾上腺素 356.5 小时[264.5-621]与 68 小时[15-132.5]，P=0.003；依诺昔酮 177 小时[124.3-249.5]与 48.5 小时[12-81 小时]，P<0.001）。患有硬化性胆管炎的危重症患者的插管时间更长（628.5 小时[377.3-883]与 25 小时[9.8-117.5]；P<0.001），手术修订次数更多（3[2.5-6]与 1[0-2]，P=0.003）。与匹配组相比，胆红素（23.3mg/dL[14.4-32.9]与 1mg/dL[0.6-2.7]；P<0.001）、γ-谷氨酰转移酶（1082.3U/L[259.5-2265.7]与 53.8U/L[35.1-146]；P<0.001）和碱性磷酸酶（751.5U/L[372-1722.3]与 80.5U/L[53.3-122]；P<0.001）在患有硬化性胆管炎的危重症患者中更高。1 名患有硬化性胆管炎的危重症患者接受了成功的肝移植。共有 11 名硬化性胆管炎患者死亡（92%），对照组为 12 名（33%，P<0.001）。
心脏手术后危重症患者的硬化性胆管炎是一种致命的并发症，这些患者术后病程复杂，需要长时间使用血管收缩剂、正性肌力药物和呼吸治疗，或需要频繁进行手术修订。肝移植仍然是唯一的治愈方法，但由于心脏手术患者的年龄和危重症状态，往往被排除在外。
