肝动脉结扎（栓塞）术后肝脓肿形成11例临床分析
摘要
目的研究肝动脉结扎(栓塞)术后肝脓肿形成的发病机制和诊治方法。
方法对2001年1月至2008年6月我院普外科收治的11例肝动脉结扎(栓塞)致肝脓肿形成的发病机制和诊治方法进行回顾性研究。
结果11例患者中,肝门部胆管癌4例,胆管细胞型肝癌4例,结肠癌术后肝转移1例,胰头癌2例;术中结扎左肝动脉1例,结扎右肝动脉4例,结扎肝固有动脉4例,肝固有动脉栓塞2例;行胆(肝)肠吻合9例。术后患者均形成肝脓肿,确诊脓肿形成时间为术后6—22天。11例均通过B超引导下穿刺抽脓,并给予抗炎、保肝及高能量营养支持等处理。其中9例一次治愈,另2例反复发作,多次穿刺,最终因肿瘤复发、肝功能衰竭死亡。
结论肝动脉结扎(栓塞)与术后肝脓肿形成密切相关,肝脓肿形成的发病机制与肝动脉结扎致胆管上皮细胞缺血、缺氧、坏死、感染继发肝组织大面积感染坏死有关,尤其在行胆肠吻合术或伴有门静脉狭窄、癌栓等受侵犯的患者。术中应尽量保留肝动脉,受肿瘤侵犯者切除肝动脉后应行肝动脉重建,对于肿瘤浸润严重、远端肝动脉完全闭塞、无法直接行动脉重建的患者,可以行门静脉动脉化等其他动脉重建方式,以保证肝组织和胆管细胞的血供。一旦形成肝脓肿,B超引导下穿刺引流结合抗炎治疗是治疗肝脓肿的较好办法
Objective: To study the mechanism、diagnosis and treatment of liver abscess formation after hepatic artery ligation (embolism) .
Methods: The data of 11 cases of liver abscess formation after hepatic artery ligation ( embolism) were gathered and analyzed retrospectively from January ,2001 to June ,2008.
Results: Among the 11 cases, there are 4 cases of hilar bile duct carcinoma、4 cases of bilecellular carcinomas、1 case of heptic metastasis after operation for cancer of colon、2 cases of carcinomas of head of pancreas. Left hepatic artery was ligated in 1 case, right hepatic artery in 4 cases, proper hepatic artery in 4 cases and proper hepatic artery was embolismed in 2 cases. Biliary-intestinal anastomosis was performed in 9 cases. Liver abscess developed in all the 11 cases. The time of liver abscess development was 6-22 days after operation. Treated with sonographic guided percutaneous puncture for clearing pus in coordination with sensitive antibiotics、liver function preservation and high nutrition support, 9 cases were cured and multiple liver abcess took place in the other 2 repeatedly.
Conclusions: Hepatic artery ligation is of great importance to liver abscess formation. The mechanism is related with the ischemia、anoxia and necrosis of cells of bile duct epithelia caused by hepatic artery ligation, which leads to infection and necrosis of a big area of liver tissue, especially in patients with biliary-intestine anastomosis or cancerous embolus in portal vein. Hepatic artery should be reserved as far as possible during operation. If invaded, hepatic artery reconstruction should be performed. To those whose hepatic artery is severely invaded and of which the distal terminal is totally blocked, hepatic artery reconstruction is unavailable and some other types of artery reconstruction like portal vein arterialization (PVA) could be performed to guarantee the blood supply of liver tissue as well as bile duct cells. Once hepatic abscess formed, sonographic guided percutaneous puncture drainage in coordination with sensitive antibiotics、liver function preservation and high nutrition support is an effective measurement.
方法对2001年1月至2008年6月我院普外科收治的11例肝动脉结扎(栓塞)致肝脓肿形成的发病机制和诊治方法进行回顾性研究。
结果11例患者中,肝门部胆管癌4例,胆管细胞型肝癌4例,结肠癌术后肝转移1例,胰头癌2例;术中结扎左肝动脉1例,结扎右肝动脉4例,结扎肝固有动脉4例,肝固有动脉栓塞2例;行胆(肝)肠吻合9例。术后患者均形成肝脓肿,确诊脓肿形成时间为术后6—22天。11例均通过B超引导下穿刺抽脓,并给予抗炎、保肝及高能量营养支持等处理。其中9例一次治愈,另2例反复发作,多次穿刺,最终因肿瘤复发、肝功能衰竭死亡。
结论肝动脉结扎(栓塞)与术后肝脓肿形成密切相关,肝脓肿形成的发病机制与肝动脉结扎致胆管上皮细胞缺血、缺氧、坏死、感染继发肝组织大面积感染坏死有关,尤其在行胆肠吻合术或伴有门静脉狭窄、癌栓等受侵犯的患者。术中应尽量保留肝动脉,受肿瘤侵犯者切除肝动脉后应行肝动脉重建,对于肿瘤浸润严重、远端肝动脉完全闭塞、无法直接行动脉重建的患者,可以行门静脉动脉化等其他动脉重建方式,以保证肝组织和胆管细胞的血供。一旦形成肝脓肿,B超引导下穿刺引流结合抗炎治疗是治疗肝脓肿的较好办法
Objective: To study the mechanism、diagnosis and treatment of liver abscess formation after hepatic artery ligation (embolism) .
Methods: The data of 11 cases of liver abscess formation after hepatic artery ligation ( embolism) were gathered and analyzed retrospectively from January ,2001 to June ,2008.
Results: Among the 11 cases, there are 4 cases of hilar bile duct carcinoma、4 cases of bilecellular carcinomas、1 case of heptic metastasis after operation for cancer of colon、2 cases of carcinomas of head of pancreas. Left hepatic artery was ligated in 1 case, right hepatic artery in 4 cases, proper hepatic artery in 4 cases and proper hepatic artery was embolismed in 2 cases. Biliary-intestinal anastomosis was performed in 9 cases. Liver abscess developed in all the 11 cases. The time of liver abscess development was 6-22 days after operation. Treated with sonographic guided percutaneous puncture for clearing pus in coordination with sensitive antibiotics、liver function preservation and high nutrition support, 9 cases were cured and multiple liver abcess took place in the other 2 repeatedly.
Conclusions: Hepatic artery ligation is of great importance to liver abscess formation. The mechanism is related with the ischemia、anoxia and necrosis of cells of bile duct epithelia caused by hepatic artery ligation, which leads to infection and necrosis of a big area of liver tissue, especially in patients with biliary-intestine anastomosis or cancerous embolus in portal vein. Hepatic artery should be reserved as far as possible during operation. If invaded, hepatic artery reconstruction should be performed. To those whose hepatic artery is severely invaded and of which the distal terminal is totally blocked, hepatic artery reconstruction is unavailable and some other types of artery reconstruction like portal vein arterialization (PVA) could be performed to guarantee the blood supply of liver tissue as well as bile duct cells. Once hepatic abscess formed, sonographic guided percutaneous puncture drainage in coordination with sensitive antibiotics、liver function preservation and high nutrition support is an effective measurement.
引文
1. Mitra S K. The teriminal distribution of the hepatic artery with special reference to arterio-portal anastomosis [J]. J Anatomy , 1966 , 100( Pt 3) :651 - 663.
2. Michels N A. Newer anatomy of the liver and its variant blood supply and collateral circulation [J] . Am J Surg , 1966 ,112 (3) :337 - 347.
3. Charnsangavej C , Chuang V P , Wallace S , et al . Angiographic classification of hepatic arterial collaterals[J]. Radiology ,1982 ,144 (3) :485 - 494.
4. Kono N, Nakanuma Y. Ultrastructural and immunohistochemical studies of the intrahepatic peribiliary capillary plexus in normal livers and extrahepatic biliary obstruction in human beings.Hepatology,1992, 15:411-418.
5. Roselino J E , De Cast ro2e2Silva J unior O , Ceneviva R. Lack of control of liver gluconeogenesis in cholestatic rat s with reduced portal blood flow [J]. Hepatology ,1992 ,16 (4) :1055 - 1060.
6. Huang CJ , Pitt HA , Lip sett PA , et al. Pyogenic hepatic abscess: Changing trends over 42 years . Ann Surg, 1996 , 223 : 600 - 609.
7. Wong WM , Wong BC , Hui CK, et al. Pyogenic liver abscess:Retrospective analysis of 80 cases over a 1 0 -year period. J Gastroenterol Hepatol , 2002 , 17 : 1001 - 1007.
8. Branum GD , Tyson GS, Branum MA , et al. Hepatic abscess: Changes in etiology, diagnosis , and management . Ann Surg, 1990 , 212: 655 -662.
9. Kubo S, KinoshitaH, Hirohashi K, et al. Risk factors for and clinical findings of liver abscess after biliary-intestinal anastomosis. Hepatogastroenterology, 1999,46 : 116 - 120.
10. Shimizu Y, Miyazaki M , Shimizu H , et al . Beneficial effects of arterialization of the portal vein on extended hepatectomy[J]. Br J Surg,2000,87(6):784-789.
11.Kondo S,Hirano S,Ambo Y,et al.Arterioportal shunting as an alternative to microvascular reconstruction after hepatic artery resection[J].Br J Surg,2004,91(2):248-251.
12.黄志强编著.肝脏外科手术学.第二版.北京:人民军医出版社,2007.14-15.
13.Uchiyama K,KawaiM,Ueno M,et al.Reducing residual and recurrent stones by hepatectomy for hepatolithiasis.J Gastrointest Surg,2007,11(5):626-630.
14.刘允怡,余俊豪.肝段为本的肝切除手术.中华普通外科杂志2003,2:123-125.
1.朱禧星主编.现代糖尿病学.第一版.上海:上海医科大学出版社,2000.76.
2.皮执民主编.消化外科学.第一版.上海:人民卫生出版社,2002.727-733.
3.侍立志.细菌性肝脓肿的诊断与治疗.中国实用外科杂志,2000,20:413-414.
4.罗庆锋,许乐.糖尿病并发细菌性肝脓肿临床特点及诊治探讨.国外医学·消化系疾病分册 2005.5:328-331.
5.Lee KH,Hui HP.Klebsiella bacteraemia;a report of 101 cases from National university hospital.J Hosp mfect,1994;27:301.
6.黄晓强.肝胆管结石病合并胆管炎及肝脓肿的诊治.中国实用外科杂志2004.2:74-75.
7.Shoda J,Ueda T,Kawamoto T,et al.Prostaglandin E receptors in bile ducts of hepatolithiasis patients and the pathobiological significance for cholangitis[J].Clin Gastroenterol Hepatol,2003,1(4):285-296.
8.陆立,冯平,张瑞峰等,细菌性肝脓肿高危因素的多元回归分析.临床军医杂志.2002.2:27-29.
9.Severi C,Zippi M,Baccini F,et al.Amebic liver abscess,Mirizzi syndrome,and acute hepatic failure[J].Dig Dis Sci,2004,49(2)304-307.
10.Poole T J,Coffin J D.Vasculogenesis and angiogenesis:two distinct morphogenetic mechanisms establish embryonic vascular pattern[J].J Exp Zool,1989,251(2):224-231.
11.Pardanaud L,Yassine F,Dieterlen2Lievre F.Relationship between vasculogenesis,angiogenesis and haemopoiesis during avian ontogeny [J].Development,1989,105(3):473-485.
12.Terada T,Nakanuma Y.Development of human peribiliary capillary plexus:a lectin histochemical and immunohistochemical study[J]Hepatology,1993,18(3):529-536.
13.Mitra S K.The teriminal distribution of the hepatic artery with special reference to arterio-portal anastomosis[J].J Anatomy,1966,100(Pt 3):651-663.
14.Michels N A.Newer anatomy of the liver and its variant blood supply and collaterai circulation[J].Am J Surg,1966,112(3):337-347.
15.Charnsangave j C,Chuang V P,Wallace S,et al.Angiographic classification of hepatic arterial collaterals[J].Radiology,1982,144(3):485-494.
16.Roselino J E,De Cast ro2e2Silva Junior O,Ceneviva R.hack of control of liver gluconeogenesis in cholestatic rat s with reduced portal blood flow[J].Hepatology,1992,16(4):1055-1060.
17.周宁新,黄志强,冯玉泉,等.肝门部胆管癌根治性切除手术方式的改进[J].中华普通外科杂志,2001,16(2):82-84.
18.Gerhards M F,van Gulik T M,de Wit L T,et al.Evaluation of morbidity and mortality after resection for hilar cholangiocarcinoma —a single center experience[J].Surgery,2000,127(4):395-404.
19.Tabata M,Kakuuchi M,Takayama T,et al.Long—term survival and prognostic factors in the surgical treatment of mass2forming type cholangiocarcinoma[J].Surgery,2000,127(5):498-505.
20.Miyazaki M,Ito H,Nakagawa K,et al.Unilaleral hepatic artery reconst ruction is unnecessary in biliary tract carcinoma involving lobar hepatic artery:implications of interlobar hepatic artery and it s preservation[J].Hepatogast roenterology,2000,47(36):1526-1530.
21.Yamanaka N,Yasui C,Yamanaka J,et al.Left hemihepatectomy with microsurgical reconst ruction of the right2sided hepatic vasculature.A st rategy for preserving hepatic function in patients with proximal bile duct cancer[J].hangenbecks Arch Surg,2001,386(5):364-368.
22.Stange B,Settmacher U,Glanemann M,et al.Hepatic artery thrombosis after orthotopic liver transplantation.Transplant Proc,2001,33:1408-1409.
23.Marco del pont J,De cicco L,Gallo G,et al.Hepatic arterial thrombosis due to Mucor species in a child following orthotopic liver transplantation.Transpl Infect Dis,2000,2(1):33.
24.MadaoIsso C,De Souza NF,Ilstrup DM,et al.Cytomegalovirus and its association with hepatic artery thrombosis after liver transplantation.Transplantation,1998,66(3):294.
25.Rhim H,Yoon KH,Lee JM,et al.Major complications after radio-frequency thermal ablation of hepatic tumors:spectrum of imaging findings.RadioGraphics 2003;23:123-134.
26.de Baere T,Risse O,Kuoch V,et al.Adverse events during radiofrequency treatment of 582 hepatic tumors.AJR 2003;181:695-700.
27.Dongil Choi,Hyo K.him,MAn Ju Kim,et al.Liver Abscess After Percutaneous Radiofrequency Ablation for Hepatocellular Carcinomas:Frequency and Risk Factors.AJR 2005;184:1860-1867.
28.Baere TD,Roche A,Amenabar JM,et al.Liver abscess formation after local treatment liver tumors.Hepatology,1996,23:1436-1440.
29.罗剑钧,颜志平,王建华等,肝动脉化疗栓塞后肝脓肿形成的原因及治疗.介入放射学杂志2001.1:24-26.
30.吴孟超主编.肝脏外科学.第二版.上海:上海科学技术文献出版社,2000.411-414.
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38.Kondo S,Hirano S,Ambo Y,et al.Arterioportal shunting as an alternative to microvascular reconstruction after hepatic artery resection[J].Br J Surg,2004,91(2):248-251.
39.黄志强编著.肝脏外科手术学.第二版.北京:人民军医出版社,2007.14-15.
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48.CHOU FF,SHENN2CHEN SM,CHEN YS,et al Single and multiple pyogenic liver abscesses:clinical course,etiology and results of treatment[J].World J Surg,1997,21(4):384.
49.Bamberger.Outcome of medical treatment of bacterial abscess without therapeutic drainage.Clin Infect Dis,1996;23:592-603.
2. Michels N A. Newer anatomy of the liver and its variant blood supply and collateral circulation [J] . Am J Surg , 1966 ,112 (3) :337 - 347.
3. Charnsangavej C , Chuang V P , Wallace S , et al . Angiographic classification of hepatic arterial collaterals[J]. Radiology ,1982 ,144 (3) :485 - 494.
4. Kono N, Nakanuma Y. Ultrastructural and immunohistochemical studies of the intrahepatic peribiliary capillary plexus in normal livers and extrahepatic biliary obstruction in human beings.Hepatology,1992, 15:411-418.
5. Roselino J E , De Cast ro2e2Silva J unior O , Ceneviva R. Lack of control of liver gluconeogenesis in cholestatic rat s with reduced portal blood flow [J]. Hepatology ,1992 ,16 (4) :1055 - 1060.
6. Huang CJ , Pitt HA , Lip sett PA , et al. Pyogenic hepatic abscess: Changing trends over 42 years . Ann Surg, 1996 , 223 : 600 - 609.
7. Wong WM , Wong BC , Hui CK, et al. Pyogenic liver abscess:Retrospective analysis of 80 cases over a 1 0 -year period. J Gastroenterol Hepatol , 2002 , 17 : 1001 - 1007.
8. Branum GD , Tyson GS, Branum MA , et al. Hepatic abscess: Changes in etiology, diagnosis , and management . Ann Surg, 1990 , 212: 655 -662.
9. Kubo S, KinoshitaH, Hirohashi K, et al. Risk factors for and clinical findings of liver abscess after biliary-intestinal anastomosis. Hepatogastroenterology, 1999,46 : 116 - 120.
10. Shimizu Y, Miyazaki M , Shimizu H , et al . Beneficial effects of arterialization of the portal vein on extended hepatectomy[J]. Br J Surg,2000,87(6):784-789.
11.Kondo S,Hirano S,Ambo Y,et al.Arterioportal shunting as an alternative to microvascular reconstruction after hepatic artery resection[J].Br J Surg,2004,91(2):248-251.
12.黄志强编著.肝脏外科手术学.第二版.北京:人民军医出版社,2007.14-15.
13.Uchiyama K,KawaiM,Ueno M,et al.Reducing residual and recurrent stones by hepatectomy for hepatolithiasis.J Gastrointest Surg,2007,11(5):626-630.
14.刘允怡,余俊豪.肝段为本的肝切除手术.中华普通外科杂志2003,2:123-125.
1.朱禧星主编.现代糖尿病学.第一版.上海:上海医科大学出版社,2000.76.
2.皮执民主编.消化外科学.第一版.上海:人民卫生出版社,2002.727-733.
3.侍立志.细菌性肝脓肿的诊断与治疗.中国实用外科杂志,2000,20:413-414.
4.罗庆锋,许乐.糖尿病并发细菌性肝脓肿临床特点及诊治探讨.国外医学·消化系疾病分册 2005.5:328-331.
5.Lee KH,Hui HP.Klebsiella bacteraemia;a report of 101 cases from National university hospital.J Hosp mfect,1994;27:301.
6.黄晓强.肝胆管结石病合并胆管炎及肝脓肿的诊治.中国实用外科杂志2004.2:74-75.
7.Shoda J,Ueda T,Kawamoto T,et al.Prostaglandin E receptors in bile ducts of hepatolithiasis patients and the pathobiological significance for cholangitis[J].Clin Gastroenterol Hepatol,2003,1(4):285-296.
8.陆立,冯平,张瑞峰等,细菌性肝脓肿高危因素的多元回归分析.临床军医杂志.2002.2:27-29.
9.Severi C,Zippi M,Baccini F,et al.Amebic liver abscess,Mirizzi syndrome,and acute hepatic failure[J].Dig Dis Sci,2004,49(2)304-307.
10.Poole T J,Coffin J D.Vasculogenesis and angiogenesis:two distinct morphogenetic mechanisms establish embryonic vascular pattern[J].J Exp Zool,1989,251(2):224-231.
11.Pardanaud L,Yassine F,Dieterlen2Lievre F.Relationship between vasculogenesis,angiogenesis and haemopoiesis during avian ontogeny [J].Development,1989,105(3):473-485.
12.Terada T,Nakanuma Y.Development of human peribiliary capillary plexus:a lectin histochemical and immunohistochemical study[J]Hepatology,1993,18(3):529-536.
13.Mitra S K.The teriminal distribution of the hepatic artery with special reference to arterio-portal anastomosis[J].J Anatomy,1966,100(Pt 3):651-663.
14.Michels N A.Newer anatomy of the liver and its variant blood supply and collaterai circulation[J].Am J Surg,1966,112(3):337-347.
15.Charnsangave j C,Chuang V P,Wallace S,et al.Angiographic classification of hepatic arterial collaterals[J].Radiology,1982,144(3):485-494.
16.Roselino J E,De Cast ro2e2Silva Junior O,Ceneviva R.hack of control of liver gluconeogenesis in cholestatic rat s with reduced portal blood flow[J].Hepatology,1992,16(4):1055-1060.
17.周宁新,黄志强,冯玉泉,等.肝门部胆管癌根治性切除手术方式的改进[J].中华普通外科杂志,2001,16(2):82-84.
18.Gerhards M F,van Gulik T M,de Wit L T,et al.Evaluation of morbidity and mortality after resection for hilar cholangiocarcinoma —a single center experience[J].Surgery,2000,127(4):395-404.
19.Tabata M,Kakuuchi M,Takayama T,et al.Long—term survival and prognostic factors in the surgical treatment of mass2forming type cholangiocarcinoma[J].Surgery,2000,127(5):498-505.
20.Miyazaki M,Ito H,Nakagawa K,et al.Unilaleral hepatic artery reconst ruction is unnecessary in biliary tract carcinoma involving lobar hepatic artery:implications of interlobar hepatic artery and it s preservation[J].Hepatogast roenterology,2000,47(36):1526-1530.
21.Yamanaka N,Yasui C,Yamanaka J,et al.Left hemihepatectomy with microsurgical reconst ruction of the right2sided hepatic vasculature.A st rategy for preserving hepatic function in patients with proximal bile duct cancer[J].hangenbecks Arch Surg,2001,386(5):364-368.
22.Stange B,Settmacher U,Glanemann M,et al.Hepatic artery thrombosis after orthotopic liver transplantation.Transplant Proc,2001,33:1408-1409.
23.Marco del pont J,De cicco L,Gallo G,et al.Hepatic arterial thrombosis due to Mucor species in a child following orthotopic liver transplantation.Transpl Infect Dis,2000,2(1):33.
24.MadaoIsso C,De Souza NF,Ilstrup DM,et al.Cytomegalovirus and its association with hepatic artery thrombosis after liver transplantation.Transplantation,1998,66(3):294.
25.Rhim H,Yoon KH,Lee JM,et al.Major complications after radio-frequency thermal ablation of hepatic tumors:spectrum of imaging findings.RadioGraphics 2003;23:123-134.
26.de Baere T,Risse O,Kuoch V,et al.Adverse events during radiofrequency treatment of 582 hepatic tumors.AJR 2003;181:695-700.
27.Dongil Choi,Hyo K.him,MAn Ju Kim,et al.Liver Abscess After Percutaneous Radiofrequency Ablation for Hepatocellular Carcinomas:Frequency and Risk Factors.AJR 2005;184:1860-1867.
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