摘要：
目的 探讨转移性肝肿瘤在TACE后肝脓肿形成的临床特征、相关危险因素、临床治疗措施的有效性及安全性.方法 采用回顾性研究方法,在1 812例转移性肝肿瘤TACE治疗后发生肝脓肿患者23例中,分析其临床特征及脓肿形成的危险因素,并对经皮穿刺引流(PCD)或结合经皮穿肝胆管引流(PTCD)治疗方法进行疗效和安全性分析.结果 收集转移性肝肿瘤在TACE后肝脓肿的发病率为1.3％(23/1812),术后高热、寒战、白细胞升高及中性粒细胞比例升高为脓肿主要表现,肝脓肿确诊时间平均为介入术后(11.3±3.7)d.消化道来源的恶性肿瘤患者占73.9％.有胃肠道手术史患者18例(78.3％);有糖尿病史者12例(52.2％);患者肝内转移灶数目大于3个者19例(82.6％);在脓肿发生后均有肝功能变差(P=0.024);19例(78.3％)患者动脉造影显示肿瘤为乏血供.患者血培养及脓液培养显示大肠埃希菌是肝脓肿主要的病原菌.肝脓肿液化前使用抗感染药物的平均天数为(10.4±3.3)d,脓肿液化的时间平均为(15.9±3.7)d.最大脓肿直径的平均为(9.2±2.0) cm.所有患者均行肝脓肿穿刺引流术(PCD),平均PCD的次数为(3.7±1.7)次.有7例患者存在胆汁瘤合并梗阻性黄疸行PCD后再行PTCD.平均肝脓肿引流时间为(3.1±1.7)个月.PCD和PTCD后均未出现感染性腹膜炎及肿瘤破裂,未发现有脓肿穿刺点肿瘤种植等并发症.所有患者肝脓肿后的中位生存期(8.0±0.7)个月.单纯行PCD的患者肝脓肿后的中位生存期为(9.0±1.0)个月,而PCD+PTCD组患者平均生存期为(5.0±0.7)个月,两者的中位生存期存在明显统计学差异(P=0.041).结论 转移性肝肿瘤TACE后发生肝脓肿的危险因素与原发肿瘤的部位、消化道手术有关,糖尿病可能是危险因素之一.其临床特征为病灶多发,易发于乏血供伴中央坏死病灶,主要感染细菌为消化道来源,易发胆汁瘤.积极有效的抗生素治疗,脓腔穿刺引流或结合PTCD是此类肝脓肿的有效治疗方法.%Objective To investigate the clinical features,related risk factors,the efficacy and safety of clinical management about liver abscess formation occurring after transcatheter arterial chemoembolization (TACE) for metastatic liver cancer.Methods Among 1812 patients with metastatic liver tumors who were receiving TACE,23 patients developed liver abscess.The clinical features and risk factors for abscess formation were retrospectively analyzed.The curative effects and safety of percutaneous puncture cavity drainage (PCD),or combined with percutaneous transhepatic cholangiography and drainage (PTCD) were analyzed.Results The incidence of liver abscess after TACE for metastatic liver tumors was 1.3％ (23/1812).Postoperative high fever,chill,elevated white blood cell count and increased neutrophil proportion were the main clinical features of liver abscess.The mean time before the diagnosis of liver abscess was confirmed was (11.3±3.7) days after TACE.The hepatic metastatic malignancy originated from the malignant tumor of digestive tract was seen in 73.9％ of patients,18 patients (78.3％) had a history of gastroenteric surgery,and 12 patients (52.2％) had a history of diabetes mellitus.The number of hepatic metastatic lesions was more than 3 in 19 patients (82.6％).After the formation of liver abscess,the liver functions became worse in all patients (P=0.024).In 19 patients (82.6％),angiography showed that the metastases were hypovascular lesions.Blood and pus cultures revealed that E.coli was the main infectious bacteria of liver abscess.The mean time of using anti-infective drugs before hepatic abscess developed liquefaction was (10.4±3.3) days,and the mean time of abscess liquefaction was (15.9±3.7) days.The mean value of the maximum diameters of abscesses was (9.2±2.0) cm.PCD was employed in all patients,the average times of PCD procedure was (3.7±1.7) times.PCD followed by PTCD was performed in 7 patients as they had biloma associated with obstructive jaundice.The average drainage time for liver abscess was (3.1 ±1.7) months.No infectious peritonitis,tumor rupture,or tumor implantation at puncture point was observed.The median survival time of 23 patients with liver abscess was (8.0±0.7) months.The median survival time in patients who received PCD procedure only was (9.0±1.0) months,while it was (5.0±0.7) months in patients who received PCD together with PTCD,and statistically significant difference in the median survival time existed between the above two groups (P=0.041).Conclusion The risk factors of liver abscess formation after TACE in patients with metastatic liver tumors include the site of primary tumor and gastrointestinal surgery.Diabetes may be one of the risk factors.Clinically,the lesions of liver abscess are usually multiple and they often occur in hypovascular lesions with central necrosis,The nain infectious bacteria are from digestive tract,and biloma is easy to develop.Active and effective antibiotic treatment plus puncture drainage of abscess cavity,or combined with PTCD,are effective treatment measures for this kind of liver abscess.
