Robson S C, Kahn D, Gordon P, Jacobs P
University of Cape Town Leukaemia Centre, Medical Research Council, Groote Schuur Hospital.
S Afr J Surg. 1995 Dec;33(4):154-8.
Orthotopic transplantation is the treatment of choice for selected patients with end-stage post-necrotic and cholestatic liver diseases. These individuals typically have disturbed haemostasis, which reflects both impaired hepatic synthesis of clotting factors and disseminated intravascular coagulation compounded by large-volume transfusions of blood products occasionally required during surgery. The latter contribute significantly to the cost of this procedure, but may approximate the cumulative consumption of that required for the support of patients in liver failure. Perspective is provided by prospective analysis of data from the first 10 patients in the current programme. There were striking, if transient, intra-operative changes in standard laboratory parameters of coagulation and fibrinolysis; all patients were readily controlled with replacement therapy administered according to serial haemostatic measurements combined with clinical judgement. In most patients these values had stabilised within 24 hours of surgery. Those with post-necrotic liver cirrhosis had the most marked degrees of hepatic dysfunction, reflected in more profound haemostatic disturbances; these patients required the largest amounts of blood products. Inclusive median costs for the first year were estimated at R35,000 and for the first 5 years at R60,000, with 80% of the patients expected to be alive between 5 and 10 years later and enjoying an excellent quality of life. These figures contrast with those estimated for optimal medical and non-transplant surgical management following variceal bleeding as a major complication of liver disease (R30,000 for the first year and R70,000 at 3 years). In addition, the latter patients would usually be unable to work and have a poor quality of life with minimal likelihood of survival beyond this point. We conclude that with a multidisciplinary approach in an academic centre, surgical replacement of the irreversibly damaged liver in properly selected patients is no more expensive and has a better outcome than acceptable alternative approaches.
原位肝移植是某些终末期坏死性和胆汁淤积性肝病患者的首选治疗方法。这些患者通常存在止血功能紊乱，这既反映了肝脏凝血因子合成受损，也反映了手术中偶尔需要大量输注血液制品导致的弥散性血管内凝血。后者显著增加了该手术的成本，但可能与支持肝衰竭患者所需的累计消耗量相近。通过对当前项目中前10例患者的数据进行前瞻性分析，可以提供一些观点。凝血和纤溶的标准实验室参数在术中出现了显著的（尽管是短暂的）变化；所有患者通过根据连续止血测量结果并结合临床判断进行替代治疗，都能得到很好的控制。在大多数患者中，这些值在手术后24小时内就已稳定。坏死性肝硬化患者的肝功能障碍最为明显，表现为更严重的止血紊乱；这些患者需要最多的血液制品。第一年的综合中位数成本估计为35,000兰特，前5年为60,000兰特，预计80%的患者在5至10年后仍存活且生活质量良好。这些数字与作为肝病主要并发症的静脉曲张出血后最佳药物和非移植手术治疗的估计数字形成对比（第一年为30,000兰特，3年时为70,000兰特）。此外，后一组患者通常无法工作，生活质量差，生存超过这一阶段的可能性极小。我们得出结论，在学术中心采用多学科方法，对适当选择的患者进行不可逆受损肝脏的手术替代，并不比可接受的替代方法更昂贵，而且效果更好。
