RU2488113C1 - Method for prediction of postresection hepatic failure in patients with focal hepatic lesions - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: 9 morphological criteria are examined by the microscopic study of liver preparations in the preoperative period. A morphological severity index (MSI) of liver injury is determined with specifying a mild degree (5 points), a moderate degree (10 points) and a severe degree of the liver injury (15 points). If the MSI index is 15 points, a probability of developing hepatic failure following hepatic resection makes 100%. The MSI value being 10 points shows a low risk, while the MSI value being 5 points shows a favourable prognosis.

EFFECT: method enables reducing a percentage of acute hepatic failure in extensive hepatic resections and reducing a postoperative mortality.

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Description

The invention relates to medicine, namely to surgical hepatology, and can be used to predict liver failure after performing extensive liver resections.

A known method for predicting liver failure with intrahepatic cholestasis (RF patent for the invention No. 2372619 from 2009, Lazebnik LB et al.). The method is based on the assessment of a biochemical analysis of blood serum, in which the ratio of bile acids (cholesterol) to cholesterol (cholesterol), to triglycerides (TG), to low-density lipoproteins (LDL) and high-density lipoproteins (HDL) is mainly determined. When the value of LC / cholesterol in patients with liver failure class A less than 3, class B from 3 to 8, class C more than 8; and when the value of FA / TG in patients with liver failure class A less than 20, class B 20-30 and class C more than 30; when the value of LC / LDL in patients with liver failure class A less than 5, class B 5-10, class C more than 10; when the value of LC / HDL in patients with liver failure class A less than 20, class B 20-50, class C more than 50, the development of liver failure is predicted.

The disadvantages of this method is the limited method, as it is based on the assessment of some biochemical parameters in patients already in the presence of intrahepatic cholestasis. In addition, the method was not used by the authors for liver resection.

Closest to the proposed method in technical essence is a method consisting in the use of a metacene breath test as a marker for assessing the functional reserve of the liver. In this case, the resection index is determined, which reflects the function of the organ after surgery, the level of prealbumin as an indicator of the synthetic function of the liver. As an indicator, the volume of liver resection was calculated, calculated using ultrasound and hepatoscintigraphy before and after surgery, coinciding with an accuracy of 0.94. The sensitivity and specificity of scintigraphy were 88.7% and 50%, respectively (MS Novruzbekov et al. Prognostic criteria for liver failure after resection of the liver in its focal formations. Annals of surgical hepatology. - 2009. No. 1. - P.41).

However, the accuracy of predicting hepatic insufficiency after liver resection by this method is limited, since only the synthetic function of the liver was taken into account, without taking into account other important functions of this organ and its morphological and histological structure, which make it possible to evaluate the reserve capacity of the liver in the future.

The aim of the present invention is to increase the prognostic accuracy of the development of liver failure after extensive resections of the liver in volume formations.

The method is as follows. After a puncture biopsy of the liver was carried out in the preoperative period according to the standard method for assessing the degree of liver destruction, 9 morphological criteria were evaluated, which were observed during microscopic examination of drugs (hepatocyte dystrophy, cholestasis, inflammatory portal tract infiltration, destruction of the border plate, focal, step, bridge-like necrosis, peripolesis, table 1). Morphological changes in the liver were studied using light microscopy and immunomorphological studies.

Table 1 Assessment of morphostructural changes in the liver in focal formations Morphological factors Number of observations Hepatocyte dystrophy eighteen Killer effect fourteen Inflammatory portal tract infiltration 23 The state of the boundary plate (degree of destruction) 10 Focal (monocellular necrosis) 17 Periportal (step necrosis) 9 Bridge necrosis 7 The formation of cirrhotic nodules (cirrhosis) 2 Cholestasis (biliary thrombi in bile capillaries) 10

As a result of the study, the morphological index of severity (MIT) of liver damage was determined, which made it possible to distinguish a mild degree (5 points), an average degree (10 points) and a severe degree of liver damage (15 points). In the presence of inflammatory portal tract infiltration, hepatocyte peripolosis and dystrophy, the severity of the lesion was evaluated at 5 points, with focal and step necrosis attached, as well as destruction of the border plate - at 10 points and in the presence of all morphological signs - at 15 points. The sensitivity and specificity of the morphological study was 99.7% and 92.4%, respectively.

There were significant differences in the frequency of liver failure between mild and moderate degrees of liver damage, between mild and severe degrees. The differences between the moderate and severe degrees were not significant (Table 2).

table 2 Prediction of liver failure depending on morphological histological structural changes in the liver MIT Number of patients Liver failure Mortality Easy degree (5 points) 12 ^* 3 (25%) Medium (10 points) 25 ^** 11 (44%) 2 (8%) Severe (15 points) 10 ^*** 10 (100%) 4 (40%) Note: * p is the significance of differences between mild and moderate degrees (p _F = 0.0006), ** is between moderate and severe (p _F > 0.05), *** is between mild and severe (p _F = 0.001 )

In the presence of MIT of 15 points, the likelihood of developing liver failure after resection of the liver is 100%, that is, a similar grading of patients by the severity of morphological changes allowed us to identify the group of absolute risk of liver failure (15 points), relatively low (10 points) and a favorable outcome of the operation ( 5 points).

The method is confirmed by clinical examples.

Clinical example No. 1.

Patient G., 45 years old, medical history N23274 / 24754, was admitted to the hospital on 10/15/99 with complaints of pain in the right hypochondrium radiating to the spine. Considers himself ill for 2 months. General analysis of blood and urine without abnormalities. Biochemical blood tests: bilirubin total. 13.2 μmol / L, ALT - 0.12 mmol / L, ACT - 0.22 mmol / L, total protein - 74 g / L, glucose - 4.0 mmol / L, fibrinogen - 4.5 g / L creatinine - 0.08 mmol / l. The liver protrudes 3.0 cm from the edge of the costal arch; on palpation, its edge is painful. The spleen is not enlarged, ascites is not. With ultrasound, the liver is enlarged due to the right lobe, heterogeneous. In the projection of segments VI-VIII, hypoechoic formation is determined with dimensions of 14.0 × 12.0 cm.

According to CT data, the liver is enlarged, heterogeneous, and a focal formation with localization in segments VI-VIII with a density of 10-30 units is determined in it. And, with intravenous amplification - 42-52 units. N. With dynamic 'Y-scintigraphy, the absorption and excretory function of hepatocytes is observed within the normal range (T max = 12 min, T _1/2 = 24.7 min, T lat. = 7 min).

According to puncture biopsy, the morphological index of severity was 15 points (bridge-like and step necrosis, cholestasis, hepatocyte dystrophy, inflammatory portal tract infiltration).

Diagnosed with hemangioma of the right lobe of the liver.

Operation: 07/09/97, a thoracophrenolaparotomy on the right was performed. During the audit, the liver is enlarged due to the right lobe. In the VI-VII segments there is a large volumetric formation characteristic of a benign tumor 12.0 × 12.0 cm in size. A right-sided hemihepatectomy was performed. In the early postoperative period, the patient had severe liver failure.

After conservative treatment, including standard therapy and efferent detoxification methods, the patient's condition stabilized. Discharged 28 days after surgery, recovery.

Histological conclusion: benign hamartoma.

In this clinical observation, with a relatively satisfactory condition of the patient, compensated laboratory parameters and the functional state of the liver, but with pronounced morphostructural changes in the liver (MIT-15 points), severe liver failure developed in the postoperative period after right-sided liver resection.

Clinical example No. 2.

Patient X., 46 years old, medical history N896, was admitted to the clinic on 01/07/1996 with complaints of pain in the right hypochondrium. Considers herself ill for 10 months. Upon receipt, the condition is satisfactory. The skin is clean. In the lungs, breathing is heard in all departments without wheezing. Heart sounds are rhythmic, clear. Pulse 70 beats per minute. Blood pressure 140/80 mm Hg The abdomen is symmetrical, with palpation soft, painful in the epigastrium, the right half of the abdomen. Symptoms of peritoneal irritation are absent. The liver is enlarged, protrudes from under the edge of the costal arch by 5.0 cm, its edge is dense, painful. In the right lobe, a tumor-like formation with a tight-elastic consistency is palpated. Ascites is not. The spleen is not palpable.

General analysis of blood and urine without abnormalities. Biochemical blood test: bilirubin commonly. - 25.5 μmol / L, straight line, ALT - 0.26 mmol / L, ACT - 0.24 mmol / L, total protein - 76 g / L, sugar - 6.4 μmol / L, hematocrit - 42%, fibrinogen - 3.9 g / l, creatinine - 0.09 mmol / l, urea - 7.0 mmol / l, prothrombin index - 89%. With ultrasound, the liver is significantly increased in size due to the right lobe, the echostructure is heterogeneous. In the V, VII, VIII segments, hyperechoic formation up to 6 cm in diameter is determined. Single-photon emission tomography with labeled red blood cells: no radiopharmaceutical accumulation. CT: liver enlarged heterogeneous in structure. In the projection of the V, VII, VIII segments, the formation is determined in diameter up to 13.0 cm, with a density of 46 units. N, after intravenous amplification, accumulates contrast up to 65 units. N.

According to the puncture biopsy, the morphological index of severity was 15 points (bridge-like and step necrosis, destruction of the border plate, hepatocyte dystrophy, inflammatory portal tract infiltration).

Diagnosed with hemangioma of the liver.

Operation: 01/17/1996, thoracophrenolaparotomy was performed. A tumor-like formation resembling a hemangioma is determined in the right lobe. Given the nature and extent of liver damage, the patient performed extended right-sided hemihepatectomy. The postoperative period was difficult with hepatic cell failure. On January 23, 1996, against the background of increasing liver failure, the patient died.

The histological conclusion: cavernous hemangioma of the liver. In this case, death came from liver failure, which developed with initially expressed morphostructural disorders in the liver.

Post-resection liver failure was predicted in 56 patients with volumetric liver formations: hemangiomas - 32, cancer - 10, parasitic cysts - 8, non-parasitic cysts - 6. Men made 22 people, women 34. The average age of the patient was 46 ± 5.7 years. Studies have confirmed the achievement of the purpose of the invention is to increase the prognostic accuracy of the development of post-resection liver failure in patients with volumetric formations. Follow-up observations confirmed the accuracy of the prognosis of the course of the disease in each patient.

The proposed method allows to reduce the percentage of development of acute liver failure with extensive resections of the liver from 57.4% to 18.1% and to reduce postoperative mortality to 12% from 51.7%.

Claims (1)

A method for predicting postresection liver failure in patients with focal liver formations, which involves determining the severity of morphostructural changes, characterized in that the morphological index of the severity of liver damage is determined, in the presence of inflammatory infiltration of the portal tracts, peripolesis and hepatocyte dystrophy, the severity of the lesion is estimated at 5 points, when focal and step necrosis, as well as the destruction of the border plate - 10 points and in the presence of all morphol cal signs - 15 points, the greater the numerical score of the morphological index of the severity of liver disease, the greater the likelihood of developing liver failure in the postoperative period.