Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Asklepios Hospital Barmbek, Rübenkamp 220, 22291, Hamburg, Germany.
Semmelweis University of Medicine, Asklepios Campus Hamburg, Hamburg, Germany.
J Gastrointest Surg. 2020 Nov;24(11):2500-2507. doi: 10.1007/s11605-019-04419-2. Epub 2019 Nov 19.
Impaired postoperative renal function is associated with increased morbidity and mortality after liver resection. The role of impaired renal function in the two-stage hepatectomy setting of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is unknown.
An international multicenter cohort of ALPPS patients captured in the ALPPS Registry was analyzed. Particular attention was drawn to the renal function in the interstage interval to determine outcome after stage 2 surgery. Interstage renal impairment (RI) was defined as an increase of serum creatinine of ≥ 0.3 mg/dl referring to a preoperative value or an increase of serum creatinine of ≥ 1.5× of the preoperative value on the fifth postoperative day after stage 1.
A total of 705 patients were identified of which 7.5% had an interstage RI. Patients developing an interstage RI were significantly older. During stage 1, a longer operation time, higher rate of intraoperative transfusions, and additional procedures were observed in patients that developed interstage RI. After stage 1, interstage RI patients had more major complications and higher interstage mortality (1% vs. 8%, p < 0.001). Furthermore, these patients developed more and severe complications after completion of stage 2. Mortality of patients with interstage RI was 38% vs. 8% without interstage RI. In 41% of patients with interstage RI, the renal function recovered before stage 2; however, the mortality after stage 2 remained 28% in those patients. Risk factors for the development of an interstage RI were age over 67 years, prolonged operative time, and additional procedure during stage 1.
This study shows that interstage RI is a predictor for interstage and post-stage 2 morbidity and perioperative mortality. The causality of impaired renal function on outcome, however, remains unknown. Interstage RI may directly cause adverse outcome but may also be a surrogate marker for major complications.
术后肾功能受损与肝切除术后发病率和死亡率增加有关。在联合肝脏离断和门静脉结扎的两阶段肝切除术（ALPPS）的两阶段肝切除术设置中，肾功能受损的作用尚不清楚。
对 ALPPS 注册中心捕获的国际多中心 ALPPS 患者队列进行了分析。特别关注了两个阶段之间的肾功能，以确定阶段 2 手术后的结果。中间阶段肾功能障碍（RI）定义为血清肌酐增加≥0.3mg/dl，相对于术前值，或第 1 阶段手术后第 5 天血清肌酐增加≥术前值的 1.5 倍。
共确定了 705 例患者，其中 7.5%有中间阶段 RI。发生中间阶段 RI 的患者年龄明显较大。在第 1 阶段，发生中间阶段 RI 的患者手术时间较长、术中输血率较高、并且需要附加手术。在第 1 阶段之后，中间阶段 RI 患者有更多的主要并发症和更高的中间阶段死亡率（1%比 8%，p<0.001）。此外，这些患者在完成第 2 阶段后出现更多和更严重的并发症。中间阶段 RI 患者的死亡率为 38%，而无中间阶段 RI 的患者死亡率为 8%。在中间阶段 RI 患者中，有 41%的患者在第 2 阶段前肾功能恢复；然而，这些患者在第 2 阶段后的死亡率仍为 28%。发生中间阶段 RI 的危险因素是年龄大于 67 岁、手术时间延长和第 1 阶段的附加手术。
本研究表明，中间阶段 RI 是中间阶段和第 2 阶段发病率和围手术期死亡率的预测因素。然而，肾功能受损对结果的因果关系尚不清楚。中间阶段 RI 可能直接导致不良后果，但也可能是主要并发症的替代标志物。
