活體肝臟移植受贈者手術前後生活品質及其心理社會相關因子之縱貫性研究

Abstract

研究背景：台灣於1984年成功完成亞洲首例肝臟移植手術，由於手術技術進步、免疫抑制劑的研發及照護品質的提升，肝臟移植已成為末期肝臟疾病病患延續生命的有效方法。然而，過去多數與本主題相關的研究多為橫斷性研究，在國內尚無縱貫性研究；另外，過去研究多是移植前或移植後的單一層面探討，未有同時探討肝臟移植病患生活品質、心理困擾及壓力因應的影響，因此，本研究將深入了解肝臟移植病患手術前後不同時間點之心理困擾、壓力因應及生活品質變化。研究目的：本研究旨在探討活體肝臟移植手術前後不同時間點，病患之心理困擾、壓力因應及生活品質之變化。確認活體肝臟移植病患在手術前至手術後六個月，各階段的照護需求。研究方法：採縱貫性研究，於2018年6月至2019年7月，經研究機構同意後，於台灣北部兩家醫學中心（臺大醫院及臺北榮總）肝臟移植病房及門診進行收案，每位個案分別於手術前兩天（T0）、手術後兩週（T1）、手術後六週（T2）、手術後三個月（T3）及手術後六個月（T4）進行共五次收案。以結構式問卷方式進行資料收集，問卷內容包含患者基本屬性（Social Demography）、簡式性格量表（Maudsley Personality Inventory, MPI）、臨床資料 （Clinical information）、家庭功能評估量表（Family function, APGAR）、疾病壓力因應量表（Stress Coping Strategies）、簡式症狀量表（The 5-item Brief Symptom Rating Scale, BSRS-5）、生活品質健康量表（中文版12-item Short-Form Health Survey, SF-12）。使用 SPSS 統計工具分析各變項之現況與變化。研究結果：共有22位受試者，72.7%為男性，年齡介於21~72歲，平均年齡53.3歲，45.5%退休或沒有在工作，59.1%照顧者為配偶，術前診斷有45.5%為酒精性肝硬化，36.4%為肝腫瘤，B或C型肝炎佔72.7%。受試者人格特質有較高之外向性，較低之神經質。家庭功能方面：平均分數為8.7±2.6~9.4±1.3，大多屬於高功能家庭。壓力因應方面：平均分數為14.1±5.2~18.4±5.3，手術前後五個時間點的平均分數變化為T4>T3=T2>T1>T0，趨勢有顯著差異（p=0.008）。心理困擾方面：平均分數為1.9±1.9~4.6±4.8，手術前後五個時間點的平均分數變化為T1>T0>T3>T2>T4，趨勢有顯著差異（p=0.01），失眠、焦慮、易怒及憂鬱等困擾症狀大多可隨時間逐漸改善，但低自尊這個面向在術後三個月分數逐漸上升，直至術後六個月。在術後前六週，良好的家庭功能與較低的心理困擾呈顯著相關。生活品質方面：平均分數為96.6±8.8~100.7±11.6，手術前後四個時間點的平均分數變化為T4>T3>T2>T0，生理功能面向平均分數變化為T4>T3>T0>T2，心理功能面向則是T2>T4>T3>T0。與生活品質相關的影響因子包含性別（女性）、人格（神經質）、主要照顧者（子女）、術前診斷（原發性膽道肝硬化）。結論與建議：術後第2週的心理困擾程度最高，照護者及醫護團隊成員須特別注意此階段患者的心理健康，尤其在失眠、焦慮及易怒方面。手術後6週時，由於患者的生理功能尚未恢復完全，仍需要家庭的支持及協助。良好的家庭功能可使患者增加使用正向壓力因應策略，降低術前的心理困擾。術後三個月至六個月階段，照護者須持續給予患者關注及社會支持以減輕其自卑程度。護理則是從肝移植前就開始有著關鍵作用。建議在手術前的衛教影片中，能納入以上結論，給病人及家屬一個預防針，以期能夠更好的因應術後身心變化，增進生活品質。由於樣本數的限制，建議未來的研究可增加收案機構，追蹤時間延長至一年以上，以增加樣本數，更加完整地了解患者在整個移植歷程的身心健康變化。

Background: Physical and psychological changes in living donor liver transplant recipients were rarely followed and studied. Purposes: The purpose of this study was to investigate changes in patients' psychological distress, stress coping, and quality of life at different time periods before and after transplantation. Methods: A longitudinal study was conducted from June 2018 to July 2019, 22 patients were admitted to the liver transplant wards of two medical centers in Taiwan (National Taiwan University Hospital and Taipei Veterans General Hospital) and follow up at out patient department. Five time points were arranged for patient follow ups: two days before surgery (T0), two weeks after surgery (T1), six weeks after surgery (T2), three months after surgery (T3), and six months after surgery (T4). Measurements in the structured questionnaire included sociodemographic and clinical information, the Maudsley Personality Inventory (MPI), the Family function (APGAR), coping strategies (Chinese version), The 5-item Brief Symptom Rating Scale (BSRS-5), Quality of Life Health Survey (Chinese version 12-item Short-Form Health Survey, SF-12). SPSS statistical software 22.0 was used to analyze the status and changes of various variables. Results: 72.7% were male, aged between 21 and 72 years, average age of 53.3 years; 45.5% were retired or not working, 59.1% of caregivers were spouses, 45.5% were preoperatively diagnosed with alcoholic cirrhosis, 36.4% were liver tumors, and hepatitis B or C accounted for 72.7%. These patients had higher extroveanthanity and lower neuroticism. Family function: average scored 8.7±2.6~9.4±1.3, mostly in highly functioning families. Stress coping: average scored 14.1±5.2~18.4±5.3, average score changes of the five time periods before and after surgery were T4>T3=T2>T1>T0, and the trend appeared a significantly difference (p=0.008). Psychological distress: average score were 1.9±1.9~4.6±4.8, the average score changes of the five time periods before and after surgery were T1>T0>T3>T2>T4, and the trend appeared a significantly difference (p=0.01), insomnia, anxiety, irritability and depression and other distress symptoms can gradually improve over time, but low self-esteem gradually increases at the third months after surgery, and the score gradually increased until six months. In the first six weeks after surgery, good family function was significantly correlated with lower psychological distress. Quality of life: average scores were 96.6±8.8~100.7±11.6, the average score change of the four time periods before and after surgery is T4>T3>T2>T0. The physiological function average score change were T4>T3>T0>T2 , and the psychological function average score change were T2>T4>T3>T0. Factors related to quality of life included gender (female), personality (neurotic), primary caregiver (children), preoperative diagnosis (primary bile duct cirrhosis). Conclusion implications: The second week after surgery had the highest level of psychological distress. Caregivers and health care team members should pay extra attention to the mental health of the patient at this stage, especially in the areas of insomnia, anxiety and irritability. Six weeks after surgery, the patient's physical function had not yet been fully restored and would still require family support and assistance. Good family function would prompt patients to implement positive stress coping strategies, and reduce preoperative psychological distress. Between three to six months after surgery, caregivers are required to provide continuous attention and social support to ease patient’s low self-esteem. Nursing care plays a key role before the liver transplantation. It is suggested that in the pre-surgery health care film, the above conclusions can be included, in order to have the patients and their families prepared, to better respond to postoperative physical and mental changes, to improve the quality of life.