간질환환자에서의 수술위험도평가및 흔히접하는타과협진의뢰 강성희 연세대원주의대
수술위험도평가
수술및마취가간에미치는영향 생화학적간기능검사이상 전신혹은척추마취 ( 경막외마취포함 ) 하의대부분수술적처치후간기능이상발생 이전에간질환이없는정상인에게서경도의간효소치의변화 : 임상적의미적고, 대부분자연회복 기존에심한간손상이동반된간경변환자 : 경도의간기능손상도치명적!
수술및마취가간에미치는영향 혈역학적변화및저산소증 간경변증, 문맥압항진증 : 간으로의혈류가정상에비해서감소상태 수술로간내저혈압및저산소증이쉽게유발
수술및마취가간에미치는영향 약물대사 마취약제의작용시간이정상인보다연장 : 간경변 - 약물분포영역이증가, 저알부민혈증, 간기능장애에의한약물대사의변화 : Propofol - 약제반감기가간경변증환자에서도짧아안전 ( 수면내시경검사시이용 ) : 간에서대사가되지않는마취제로대체 (Isoflurane, desflurane, sevoflurane) : 마약성혹은 benzodiazepine 계통의약제사용은피하기 (remifentanil로대체가능 )
간질환의종류 수술위험도 간질환의정도 수술의종류
간기능수치의이상을보이는무증상환자 현병력 투약력, 보완대체요법이력 간기능검사 무증상, 경한 ALT상승 : 수술진행가능 원인불명, ALT 3배 : 수술연기및원인감별 Gilbert syndrome 같은비포합고빌리루빈혈증 : 수술후이환율이나사망률이정상인과같다
1. 기저간질환종류에따른영향 급성간염 수술위험과수술후사망률이높아선택적수술은금기!! 간기능회복후시행 만성간염 수술위험도는원인과는상관없고임상적, 생화학적, 조직학적중증도와관련 만성 B 형, C 형간염환자는 AST/ALT 가정상이고간기능이보존되어있을경우수술후합병증의위험이정상인보다높지않다
1. 기저간질환종류에따른영향 알코올성간염 선택적수술은금기 약 3개월이상금주를하면간기능이많이호전 선택적수술의경우, 3개월이상의금주후에다시잔존간기능을평가한뒤수술을결정 폐쇄성황달 수술후사망률증가 Hct < 30%, T. bil 11 mg/dl, 악성종양, Cr 1.4 mg/dl 이상, Alb 3.0 g/dl, 65 세이상
1. 기저간질환종류에따른영향 지방간 선택적수술은금기가아니다 자가면역성간염 간기능이유지되는경우선택적수술엔문제가없다
2. 간질환환자의중증도평가 - 간경변증 Child-Turcotte-Pugh (CTP) 점수 점수체계와수술후이환율및사망률간에상관관계가뚜렷함 수술후 30일사망률 ( 복부수술 ): CTP A: 10%, CTP B: 17~30%, CTP C: 63~82% 단, CTP A 등급이라도문맥압항진증이있는경우간절제술후합병증의위험
2. 간질환환자의중증도평가 - 간경변증 Child-Turcotte-Pugh (CTP) 점수의실제적용 CTP A: 수술가능 CTP B: 준비후수술가능 ( 심한간절제 or 고위험의심장수술제외 ) CTP C: 수술불가
2. 간질환환자의중증도평가 - 간경변증 Child-Turcotte-Pugh (CTP) 점수의한계 주관적인요소 - 복수와간성혼수 모든요소들이가중치없이동일하게평가 같은등급내의환자들이균일하지않아서로다른예후를보일수있다는점
2. 간질환환자의중증도평가 - 간경변증 Model for End-stage Liver Disease (MELD) 점수 객관적변수 : serum creatinine, total bilirubin, prothrombin time (INR) 1 주, 3 개월및 1 년사망률예측 >> CTP 점수 중요도에따라서변수들에가중치 임의적인 cut-off 를사용하지않고연속적, MELD 점수가 1 점만올라도위험성이비례하여증가 MELD 7 (5.7%), MELD 8-11 (10.3%), MELD 12-15 (25.4%) ** 특히, MELD 8 -> Linear correlation
2. 간질환환자의중증도평가 - 간경변증 Mayo clinic model (http://www.mayoclinic.org/meld/mayomodel9.html) : MELD + Age + ASA
MAYO CLINIC MODEL (POST-OPERATIVE MORTALITY IN CIRRHOSIS)
3. 수술의종류에따른평가
Hanje et al. Nat Clin Pract Gastroenterol Hepatol. 2007
흔히접하는타과협진
CASE 1. 56/F, MILD LFT ELEVATION Exam Result Unit Normal Total protein 7.1 g/dl (6.2~8.1) Albumin 4.1 g/dl (3.2~5.5) Total cholesterol 178 mg/dl (~<200) TG 169 mg/dl (~<200) AST(SGOT) 78 U/L (~<40) ALT(SGPT) 85 U/L (~<40) ALP 245 U/L (~<140) r-gt 178 U/L (~<60) Total Bilirubin 1.1 mg/dl (~<1.3) Direct Bilirubin 0.5 mg/dl (~<0.4) BMI: 20.1 (161cm, 52Kg) Alcohol: none Drug Hx.: 정형외과허리수술후입원치료중항생제및진통제투약 HBsAg/anti-HBs (-/+), anti-hcv (-) ANA(-), AMA(-) Glucose 104 mg/dl
CASE 1. 56/F, MILD LFT ELEVATION Clinical impression? > R/O Drug Induced Liver Injury (DILI)
Drug Induced Liver Injury (DILI) Determined by ALT and ALP Hepatocellular type > ALT > 3X UNL or ALT/ALP ratio 5 Cholestatic type > ALP > 2X UNL or ALT/ALP ratio 2 > Rarely result in death > But, more prone to chronicity > Prolonged cholestasis > Vanish bile duct syndrome: for months or years > Cardiovascular and CNS drugs Mixed type > 5 >ALT/ALP ratio > 2 Fundam Clin Pharmaco 2008
DRUG INDUCED LIVER INJURY (DILI) Chang CY. AP&T 2006
DIAGNOSTIC APPROACH OF DILI
CASE 2. 56/M, LFT ELEVATION Exam 수술전 Result Post op #4 Result Unit Normal Total protein 5.6 3.8 g/dl (6.2~8.1) Albumin 3.4 2.3 g/dl (3.2~5.5) Total cholesterol 180 185 mg/dl (~<200) TG 250 300 mg/dl (~<200) AST(SGOT) 47 1510 U/L (~<40) ALT(SGPT) 14 2000 U/L (~<40) ALP 89 139 U/L (~<140) r-gt 261 350 U/L (~<60) Total Bilirubin 1.74 2.50 mg/dl (~<1.3) Direct Bilirubin 0.8 1.3 mg/dl (~<0.4) Alcohol: 소주 1 병 /day Drug Hx.: CCB 혈압약 HBsAg/anti-HBs (-/+), anti-hcv (-) ANA(-), AMA(-) ASD 로흉부외과에서 ASD patch repair 후간기능악화로의뢰 수술후 ICU care 및 Intubation, CRRT apply
CASE 2. 56/M, LFT ELEVATION
CASE 2. 56/F, LFT ELEVATION Clinical impression? > Liver cirrhosis > R/O Ischemic hepatitis
ISCHEMIC HEPATITIS 발병율 흔함 발병시기 24시간이내 원인 심혈관질환 (70%) 호흡부전 (15%) 패혈증 (15%) LFT ALT > x 200 UNL or >3000 IU/L, LDH상승 (ALT to LDH ratio <1.5) Jaundice 드물다. 조직학적소견 Coagulative necrosis, Sinosuidal congestion 사망률 진단에따라다양함 회복기간 보통 10-12일이내회복 위험요인 나이, 성별, 체중과무관 50% 이상에서저혈압동반
CASE 3. 72/F, RECURRENT CHOLESTATIC LFT ABNORMALITY Exam Result Unit Normal Total protein 7.5 g/dl (6.2~8.1) Albumin 4.1 g/dl (3.2~5.5) Total cholesterol 247 mg/dl (~<200) TG 169 mg/dl (~<200) AST(SGOT) 301 U/L (~<40) ALT(SGPT) 291 U/L (~<40) ALP 556 U/L (~<140) r-gt 663 U/L (~<60) Total Bilirubin 3.7 mg/dl (~<1.3) Direct Bilirubin 2.0 mg/dl (~<0.4) h/o Acute hepatitis ( 17.6.) - R/O Toxic hepatitis ( 한약환 ) +/- passed CBD stone s/p Cholecystectomy ( 17.8.) Fever/chill (-/-) Dark urine (+) RUQ pain (+-) HBsAg/Ab (-/+) HCV Ab (-), HAV Ab IgM (-) AMA (-) FANA (-) SMA (-) LKM Ab (-) IgG/A/M: 1011 / 180 / 64
CASE 3. 72/F, RECURRENT CHOLESTATIC LFT ABNORMALITY Clinical impression? > Biliary obstruction Next diagnostic approach? > Liver imaging
Liver CT:
CASE 3. 72/F, RECURRENT CHOLESTATIC LFT ABNORMALITY Final diagnosis > Distal CBD stone Therapeutic plan > ERCP and stone removal
CASE 4. 65/F, LFT ABNORMALITY AND ABDOMINAL DISTENSION Exam Result Unit Normal Total protein 6.5 g/dl (6.2~8.1) Albumin 3.3 g/dl (3.2~5.5) Total cholesterol 247 mg/dl (~<200) TG 169 mg/dl (~<200) AST(SGOT) 433 U/L (~<40) ALT(SGPT) 578 U/L (~<40) ALP 110 U/L (~<140) r-gt 86 U/L (~<60) Total Bilirubin 1.0 mg/dl (~<1.3) Direct Bilirubin 0.2 mg/dl (~<0.4) PT 70 % (80-100) AML - s/p Bu-Flu-ATG conditioning - s/p allo-pbsct ( 17.6.2.) Abdominal distension (+) Dyspnea (+) HBsAg/Ab (-/+) HCV Ab (-), HAV Ab IgM (-) AMA (-) FANA (-) SMA (-) LKM Ab (-) IgG/A/M: 1011 / 180 / 64
CASE 3. 65/F, LFT ABNORMALITY AND ABDOMINAL DISTENSION
CASE 3. 65/F, LFT ABNORMALITY AND ABDOMINAL DISTENSION Clinical impression? > R/O SOS (sinusoidal obstruction syndrome) > R/O CMV hepatitis > R/O GVHD, less likely Next diagnostic approach? > Liver biopsy to DDx. of CMV hepatitis
Diffuse sinusoidal dilatation with perivenular hepatocytes necrosis
CASE 3. 65/F, LFT ABNORMALITY AND ABDOMINAL DISTENSION 1. Diffuse sinusoidal dilatation with perivenular hepatocytes necrosis 2. Diffuse hemosiderin pigmentation in hepatocytes 3. Extramedullary hematopoiesis 4. No bile duct damage consistent with veno-occlusive disease
CASE 3. 65/F, LFT ABNORMALITY AND ABDOMINAL DISTENSION Final diagnosis > SOS Therapeutic plan > Experimental treatment
Thank you for your attention!!