Lazarus H M, Creger R J, Fox R M, Cooper B W, Jacobs G, Stellato T A
Department of Medicine, University Hospitals of Cleveland, Case Western Reserve University, OH 44106.
J Am Coll Surg. 1994 Oct;179(4):433-9.
The use of intensive cytotoxic drug therapy for malignant disorders often results in hepatic dysfunction. It is important to determine the cause of hepatic injury to institute appropriate therapy; however, neutropenia and thrombocytopenia may prevent performance of hepatic biopsy to establish a cause.
We prospectively evaluated the cause of hepatic dysfunction using laparoscopic biopsy of the liver in 20 consecutive patients who were receiving intensive cytotoxic therapy, with or without bone marrow transplantation, or who were being treated for severe aplastic anemia. One to three direct-vision laparoscopic biopsies were performed in each patient during general anesthesia and bleeding was controlled with spatula electrocautery. Platelet concentrate transfusions were given before, during, and immediately after the biopsy.
Platelet and leukocyte counts at the time of hepatic biopsy ranged from 1,000 to 83,000 per microL (median of 23,500 per microL) and zero to 14,300 per microL (median of 2,200 per microL), respectively. Nineteen of 20 patients had platelet counts of less than 68,000 per microL. Bleeding at biopsy site was controlled during the procedure without evidence of bleeding or complications after biopsy. Biopsy specimens revealed graft-versus-host disease (n = 2), hepatic veno-occlusive disease (n = 1), steatosis (n = 5), cholestasis (n = 19), hemosiderosis (n = 19), and granuloma (n = 1).
In several patients, the knowledge derived from hepatic biopsy results altered the therapeutic strategy. The use of laparoscopic hepatic biopsy to assess the cause of hepatic dysfunction should be encouraged because it is a safe procedure, even in patients who are severely thrombocytopenic and immunocompromised.
使用强化细胞毒性药物治疗恶性疾病常导致肝功能障碍。确定肝损伤的原因以制定合适的治疗方案很重要；然而，中性粒细胞减少和血小板减少可能会妨碍通过肝活检来确定病因。
我们前瞻性地评估了20例连续接受强化细胞毒性治疗（无论是否进行骨髓移植）或正在接受严重再生障碍性贫血治疗的患者肝功能障碍的原因，采用腹腔镜肝活检。在全身麻醉下，对每位患者进行1至3次直视下腹腔镜活检，并用刮匙电灼控制出血。在活检前、活检期间和活检后立即输注浓缩血小板。
肝活检时血小板和白细胞计数分别为每微升1000至83000（中位数为每微升23500）和每微升0至14300（中位数为每微升2200）。20例患者中有19例血小板计数低于每微升68000。活检过程中活检部位的出血得到控制，活检后无出血或并发症迹象。活检标本显示移植物抗宿主病（n = 2）、肝静脉闭塞病（n = 1）、脂肪变性（n = 5）、胆汁淤积（n = 19）、含铁血黄素沉着（n = 19）和肉芽肿（n = 1）。
在一些患者中，肝活检结果所获得的信息改变了治疗策略。应鼓励使用腹腔镜肝活检来评估肝功能障碍的原因，因为即使在严重血小板减少和免疫功能低下的患者中，这也是一种安全的操作。
