• 四川大學(xué)華西醫(yī)院膽道外科(成都610041);

目的 　探討惡性梗阻性黃疸根治性切除術(shù)圍手術(shù)期腎功能的保護(hù)及急性腎功能衰竭(ARF)的預(yù)防。
方法 　為降低ARF的發(fā)生率，從2004年起本治療小組在ARF的預(yù)防方面采取了一系列措施，包括預(yù)防內(nèi)毒素血癥，術(shù)前減黃，充分?jǐn)U容，營養(yǎng)支持，甘露醇、速尿的使用，預(yù)防彌散性血管內(nèi)凝血等。分2個(gè)階段回顧性分析從2000～2007年8年間（第1階段： 2000年1月至2003年12月； 第2階段： 2004年1月至2007年12月）本治療小組行根治性切除術(shù)的惡性梗阻性黃疸患者206例圍手術(shù)期ARF的發(fā)生率，并引入了最新的ARF分級標(biāo)準(zhǔn)(RIFLE標(biāo)準(zhǔn))對ARF進(jìn)行分級。
結(jié)果 　第2階段惡性梗阻性黃疸的根治性切除率從第1階段的44.8%提高到57.1%（P＜0.05），圍手術(shù)期ARF的發(fā)生率從15.1%下降至6.7%（P＜0.05），其中ARF危險(xiǎn)及損害階段的發(fā)生率在第1階段與第2階段比較差異無統(tǒng)計(jì)學(xué)意義(P gt;0.05)，而ARF衰竭階段發(fā)生率則由10.5%降至2.5%（P＜0.05），因此ARF發(fā)生率的降低主要是通過將急性腎功能損害控制在早期階段而避免其向衰竭階段發(fā)展，從而使圍手術(shù)期的死亡率從16.3%降至5.8%（P＜0.05）。
結(jié)論 　通過最新的RIFLE標(biāo)準(zhǔn)對ARF進(jìn)行分級統(tǒng)計(jì)，說明我們在圍手術(shù)期所采取的預(yù)防措施有效地控制了惡性梗阻性黃疸患者圍手術(shù)期ARF的發(fā)生和發(fā)展。

引用本文： 羊曉勤,周勇. 惡性梗阻性黃疸根治性切除術(shù)后急性腎功能衰竭的預(yù)防. 中國普外基礎(chǔ)與臨床雜志, 2008, 15(10): 761-764. doi: 復(fù)制

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2. 　Pain JA, Cahill CJ, Bailey ME. Perioperative complications in obstructive jaundice: therapeutic considerations [Ｊ]. Br J Surg, 1985; 72(12)∶942.
3. 　Kellum JA, Levin N, Bouman C, et al. Developing a consensus classification system for acute renal failure [Ｊ]. Curr Opin Crit Care, 2002; 8(6)∶509.
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10. 　Papakostas C, Bezirtzoglou E, Pitiakoudis M, et al. Endotoxinemia in the portal and the systemic circulation in obstructive jaundice [Ｊ]. Clin Exp Med, 2003； 3(2)∶124.
11. 　Sakrak O, Akpinar M, Bedirli A, et al. Short and long-term effects of bacterial translocation due to obstructive jaundice on liver damage [Ｊ]. Hepatogastroenterology, 2003; 50(53)∶1542.
12. 　黃志強(qiáng)主編. 黃志強(qiáng)膽道外科學(xué) [M]. 濟(jì)南: 山東科學(xué)技術(shù)出版社，1998∶ 169~171.
13. 　Dawson JL. Postoperative renal failure in obstructive jaundice: effect of mannitol diuresis [Ｊ]. Br Med J, 1965； 5427(1)∶82.
14. 　Gubern JM, Martínez-Ródenas F, Sitges-Serra A. Use of mannitol as a measure to prevent postoperative renal failure in patients with obstructive jaundice [Ｊ]. Am J Surg, 1990; 159(4)∶444.
15. 　Wahbah AM, el-Hefny MO, Wafa EM, et al. Perioperative renal protection in patients with obstructive jaundice using drug combinations [Ｊ]. Hepatogastroenterology, 2000; 47(36)∶1691.
16. 　Pugaev AV, Lidov PI, Achkasov EE, et al. Enteral nutrition in the complex treatment of patients with mechanical jaundice in gallstone disease [Ｊ]. Klin Med, 2008; 86(1)∶51.
17. 　O’Brien DP, Shearer MJ, Waldron RP, et al. The extent of vitamin K deficiency in patients with cholestatic jaundice: a preliminary communication [Ｊ]. J R Soc Med， 1994; 87(6)∶320.
18. 　Venkataraman R, Kellum JA. Defining acute renal failure: the RIFLE criteria [Ｊ]. J Intensive Care Med， 2007; 22(4)∶187.
19. 　Ricci Z, Cruz D, Ronco C. The RIFLE criteria and mortality in acute kidney injury: A systematic review [Ｊ]. Kidney Int，2008； 73(5)∶538.
20. 　Perez-Valdivieso JR, Bes-Rastrollo M, Monedero P, et al. Pro-gnosis and serum creatinine levels in acute renal failure at the time of nephrology consultation: an observational cohort study [Ｊ]. BMC Nephrol， 2007； 8∶14.
  1. 1. 　Wait RB, Kahng KU. Renal failure complicating obstructive jaundice [Ｊ]. Am J Surg, 1989; 157(2)∶256.
  2. 2. 　Pain JA, Cahill CJ, Bailey ME. Perioperative complications in obstructive jaundice: therapeutic considerations [Ｊ]. Br J Surg, 1985; 72(12)∶942.
  3. 3. 　Kellum JA, Levin N, Bouman C, et al. Developing a consensus classification system for acute renal failure [Ｊ]. Curr Opin Crit Care, 2002; 8(6)∶509.
  4. 4. 　Clarke DL, Pillay Y, Anderson F, et al. The current standard of care in the periprocedural management of the patient with obstructive jaundice [Ｊ]. Ann R Coll Surg Engl, 2006; 88(7)∶610.
  5. 5. 　吳言濤. 梗阻性黃疸的圍手術(shù)期處理 [Ｊ]. 中國普外基礎(chǔ)與臨床雜志， 2003； 10(3)∶183.
  6. 6. 　崔平， 楊世昆. 惡性梗阻性黃疸患者圍手術(shù)期處理92例體會 [Ｊ]. 中國普外基礎(chǔ)與臨床雜志， 1998； 5（5）∶308.
  7. 7. 　楊林， 謝曉東， 王朝華， 等. 經(jīng)皮肝穿膽道引流術(shù)治療惡性梗阻性黃疸 [Ｊ]. 中國普外基礎(chǔ)與臨床雜志, 2004; 11(4)∶299.
  8. 8. 　Uslu A, Cayci M, Nart A, et al. Renal failure in obstructive jaundice [Ｊ]. Hepatogastroenterology, 2005； 52(61)∶52.
  9. 9. 　黃志強(qiáng)主編. 黃志強(qiáng)膽道外科學(xué) [M]. 濟(jì)南: 山東科學(xué)技術(shù)出版社， 1998∶ 168~169.
  10. 10. 　Papakostas C, Bezirtzoglou E, Pitiakoudis M, et al. Endotoxinemia in the portal and the systemic circulation in obstructive jaundice [Ｊ]. Clin Exp Med, 2003； 3(2)∶124.
  11. 11. 　Sakrak O, Akpinar M, Bedirli A, et al. Short and long-term effects of bacterial translocation due to obstructive jaundice on liver damage [Ｊ]. Hepatogastroenterology, 2003; 50(53)∶1542.
  12. 12. 　黃志強(qiáng)主編. 黃志強(qiáng)膽道外科學(xué) [M]. 濟(jì)南: 山東科學(xué)技術(shù)出版社，1998∶ 169~171.
  13. 13. 　Dawson JL. Postoperative renal failure in obstructive jaundice: effect of mannitol diuresis [Ｊ]. Br Med J, 1965； 5427(1)∶82.
  14. 14. 　Gubern JM, Martínez-Ródenas F, Sitges-Serra A. Use of mannitol as a measure to prevent postoperative renal failure in patients with obstructive jaundice [Ｊ]. Am J Surg, 1990; 159(4)∶444.
  15. 15. 　Wahbah AM, el-Hefny MO, Wafa EM, et al. Perioperative renal protection in patients with obstructive jaundice using drug combinations [Ｊ]. Hepatogastroenterology, 2000; 47(36)∶1691.
  16. 16. 　Pugaev AV, Lidov PI, Achkasov EE, et al. Enteral nutrition in the complex treatment of patients with mechanical jaundice in gallstone disease [Ｊ]. Klin Med, 2008; 86(1)∶51.
  17. 17. 　O’Brien DP, Shearer MJ, Waldron RP, et al. The extent of vitamin K deficiency in patients with cholestatic jaundice: a preliminary communication [Ｊ]. J R Soc Med， 1994; 87(6)∶320.
  18. 18. 　Venkataraman R, Kellum JA. Defining acute renal failure: the RIFLE criteria [Ｊ]. J Intensive Care Med， 2007; 22(4)∶187.
  19. 19. 　Ricci Z, Cruz D, Ronco C. The RIFLE criteria and mortality in acute kidney injury: A systematic review [Ｊ]. Kidney Int，2008； 73(5)∶538.
  20. 20. 　Perez-Valdivieso JR, Bes-Rastrollo M, Monedero P, et al. Pro-gnosis and serum creatinine levels in acute renal failure at the time of nephrology consultation: an observational cohort study [Ｊ]. BMC Nephrol， 2007； 8∶14.