背景:肝切除术后肝功能衰竭(PHLF)对肝脏手术后的发病率和死亡率有显著影响。术前肝功能的标准化评估对于识别有风险的患者至关重要。这些欧洲共识指南为术前患者评估提供了指导。
方法:采用改进的德尔菲法达成共识。专家小组由肝胆外科医生组成,放射科医生,核医学专家,和肝病学家。指南过程由方法学家监督,并由患者代表审查。在PubMed/MEDLINE进行了系统的文献检索,科克伦图书馆,和世界卫生组织国际临床试验注册。证据评估和陈述的发展遵循苏格兰校际指南网络方法。
结果:根据涵盖4个关键领域的271份出版物,产生了21个陈述(至少85%的同意)(证据的中位数水平为2至2)。仅确定了一些系统评价(2++)和一个RCT(1+)。复杂切除前应考虑术前肝功能评估,在怀疑或已知的潜在肝病患者中,或化疗相关或药物诱导的肝损伤。反映肝功能或门脉高压的临床评估和基于血液的评分(例如白蛋白/胆红素,血小板计数)有助于识别PHLF的风险。未来肝脏残存量的测定是评估的基础,根据当地的专业知识和可用性,可以与吲哚菁绿清除或LiMAx®结合使用。功能性MRI和肝脏闪烁显像是替代方案,在一次检查中结合FLR体积和功能。
结论:这些指南反映了评估术前肝功能和PHLF风险的既定方法,并发现了未来研究感兴趣的证据空白。
肝脏手术是治疗肝脏肿瘤的有效方法。肝功能衰竭是肝脏质量差或进行大型手术的患者的主要问题。肝衰竭的治疗选择有限,死亡率高。为了估计病人的风险,术前评估肝功能很重要。为此目的存在许多方法,包括功能,血,和成像测试。本指南总结了现有文献和专家意见,并帮助临床医生规划安全的肝脏手术。
Posthepatectomy liver failure (PHLF) contributes significantly to morbidity and mortality after liver surgery. Standardized assessment of preoperative liver function is crucial to identify patients at risk. These European
consensus guidelines provide guidance for preoperative patient assessment.
A modified Delphi approach was used to achieve
consensus. The expert panel consisted of hepatobiliary surgeons, radiologists, nuclear medicine specialists, and hepatologists. The
guideline process was supervised by a methodologist and reviewed by a patient representative. A systematic literature search was performed in PubMed/MEDLINE, the Cochrane library, and the WHO International Clinical Trials Registry. Evidence assessment and statement development followed Scottish Intercollegiate Guidelines Network methodology.
Based on 271 publications covering 4 key areas, 21 statements (at least 85 per cent agreement) were produced (median level of evidence 2- to 2+). Only a few systematic reviews (2++) and one RCT (1+) were identified. Preoperative liver function assessment should be considered before complex resections, and in patients with suspected or known underlying liver disease, or chemotherapy-associated or drug-induced liver injury. Clinical assessment and blood-based scores reflecting liver function or portal hypertension (for example albumin/bilirubin, platelet count) aid in identifying risk of PHLF. Volumetry of the future liver remnant represents the foundation for assessment, and can be combined with indocyanine green clearance or LiMAx® according to local expertise and availability. Functional MRI and liver scintigraphy are alternatives, combining FLR volume and function in one examination.
These
guidelines reflect established methods to assess preoperative liver function and PHLF risk, and have uncovered evidence gaps of interest for future research.
Liver surgery is an effective treatment for liver tumours. Liver failure is a major problem in patients with a poor liver quality or having large operations. The treatment options for liver failure are limited, with high death rates. To estimate patient risk, assessing liver function before surgery is important. Many methods exist for this purpose, including functional, blood, and imaging tests. This
guideline summarizes the available literature and expert opinions, and aids clinicians in planning safe liver surgery.