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目的探讨创伤后肝脏的病理改变及肝损害的影响因素,为临床移植医师应用创伤后死亡的供肝提供指导作用,也为日后建立尸肝病理选择标准积累资料。方法对2010年1月-2014年12月的142例创伤后死亡的案例资料进行回顾性分析。根据142例创伤后死亡者伤后实验室检查是否发生急性肝功能损害分为两组,其中观察组均发生急性肝功能损害,对照组均未发生急性肝功能损害。结合案情、临床资料、尸体解剖资料,对创伤后肝脏的病理改变及急性肝损害可能的影响因素[年龄、性别、损伤方式、损伤部位、受伤到入院间隔时间、损伤程度、低血压(收缩压≤90 mm Hg,1 mm Hg=0.133 k Pa)持续时间、使用2种以上升压药物、大量输血(≥2 000 m L/24 h)、合并休克、合并感染、合并脏器疾病等]进行统计分析,确定其影响的风险因素。其中,损伤程度按创伤严重度评分(ISS)分为轻度损伤(ISS<16分)、重度损伤(ISS≥16分且<25分)和严重损伤(ISS≥25分)。结果 142例创伤后死亡者中,45例为观察组,显微镜下肝细胞不同程度变性坏死,其中轻度肝细胞坏死8例,中度肝细胞坏死14例,重度肝细胞坏死23例。97例未发生急性肝功能损害为对照组,显微镜下肝组织形态基本正常。创伤后肝损害与死者的年龄、性别、损伤方式、损伤部位及受伤到入院间隔时间等因素无关,与损伤程度、低血压持续时间≥0.5 h、使用2种以上升压药物、大量输血(≥2 000 m L/24 h)、合并休克、合并严重感染、合并心肺以外脏器疾病等因素显著相关(P<0.05)。结论若临床移植医师要运用创伤后心脏死亡或脑死亡者供肝,应当警惕上述加重肝细胞变性坏死的风险因素。若合并上述一个或多个风险因素时,建议临床医师在肝脏移植术前进行穿刺活体组织检查,并结合临床资料进行综合判断,选择合适的供肝,保障移植效果。
Objective To investigate the pathological changes of post-traumatic liver and the influencing factors of liver damage, which may provide guidance for clinicians to apply the post-traumatic donor's liver, and also accumulate data for future establishment of pathogenic selection criteria. Methods The data of 142 cases of post-traumatic death from January 2010 to December 2014 were retrospectively analyzed. According to 142 cases of post-traumatic deaths were laboratory test whether acute liver damage occurred in two groups, including acute liver injury in the observation group, and no acute liver injury in the control group. According to the case, the clinical data and the autopsy data, the pathological changes of the post-traumatic liver and the possible influencing factors of the acute liver injury [age, sex, mode of injury, site of injury, interval from injury to admission, degree of injury, hypotension ≤90 mm Hg, 1 mm Hg = 0.133 kPa for duration, using two or more antihypertensives, massive blood transfusion (≥2 000 m L / 24 h), combined shock, co-infection, combined with organ disease, etc.] Statistical analysis to determine the risk factors of its impact. The degree of injury was classified as mild injury (ISS <16 points), severe injury (ISS≥16 points and <25 points) and severe injury (ISS≥25 points) according to the severity of injury score (ISS). Results Among the 142 cases of post-traumatic death, 45 cases were observed. The hepatocytes were degenerated and necrotic under different microscopes. Among them, there were 8 mild hepatocyte necrosis, 14 moderate hepatocyte necrosis and 23 severe hepatocyte necrosis. 97 cases of acute liver damage did not occur in the control group, liver tissue morphology under the microscope was normal. The post-traumatic liver injury has nothing to do with the age, sex, type of injury, site of injury and the time between hospitalization and admission. The degree of injury, the duration of hypotension ≥ 0.5 h, the use of two or more antihypertensives, 2 000 m L / 24 h), combined shock, combined with severe infection, combined with cardiovascular and other organ diseases were significantly related (P <0.05). CONCLUSIONS: Clinicians should be alert to the above-mentioned risk factors that aggravate the degeneration and necrosis of hepatocytes if they are to be given post-traumatic cardiac death or brain-dead donor liver. If the merger of one or more of the risk factors, clinicians recommend liver biopsy before biopsy, combined with clinical data to make a comprehensive assessment, select the appropriate donor liver, to protect the transplant effect.