肝移植术后胆道并发症病因及预防

目的分析原位肝移植术后胆1道并发症的病因。方法回顾性分析307例尸体供肝和40例活体供肝原位肝移植的临床资料,总结术后胆道并发症的病因。结果40例活体肝移植受体术后胆道并发症的发生率5.0%,307例尸体供肝肝移植受体术后胆道并发症的发生率为18.9%;肝内胆道狭窄和胆道铸型结石形成等严重胆道并发症在活体肝移植和放置“T”管的尸肝移植未发生。结论缺血时间尤其热缺血时间是导致严重胆道并发症的最主要的原因,放置“T”管引流能降低胆道并发症的发生率。     

无心跳供肝发生胆道严重缺血性病变的危险因素分析

目的 探讨无心跳供肝发生严重胆道缺血性病变的危险因素.方法 北京朝阳医院2002年7月至2006年6月实施的同种异体原位肝移植病例中排除肝肾联合移植、二次肝移植、供受体ABO血型不符病例,统计人选病例131例,术后随访时间均>180 d.排除混杂因素后采用Logistic回归分析缺血再灌注相关性严重胆道并发症的危险因素.结果 无心跳供肝胆道二次热缺血时间>60 min是术后严重缺血性胆道并发症的独立危险因素.热缺血与冷保存协同作用于供肝,单独或同时延长热缺血、冷保存时间,术后严重缺血性胆道并发症发生率增高.结论 无心跳供肝热缺血或冷保存时间延长的协同作用以及胆道二次热缺血时间>60 min是肝移植术后严重缺血性胆道并发症的危险因素.将热缺血时间带入拟合直线回归方程可预知冷保存时间的相对"安全"时限.     

尿激酶灌注无心跳供肝预防肝内缺血型胆道病变的临床研究

目的 探讨降低无心跳尸体供体肝移植术后肝内缺血型胆道病变发生率的方法,进而减少再移植率,提高长期生存质量.方法 针对无心跳尸体供肝在热、冷缺血状态下胆道微循环中可能存在的微血栓形成,进行前瞻性临床研究.以2006年1月至2007年3月实施并存活超过1年的肝脏移植病人112例为实验组;以1999年7月至2005年12月完成并存活超过1年的肝脏移植220例为对照组.实验组在供肝切取冷灌注时及供肝修整完毕后两次应用尿激酶灌洗供肝动脉系统.比较两组肝内缺血型胆道病变的发生率.结果 对照组220例中13例受体术后发生肝内缺血型胆道病变,发生率5.9%,发生时间为术后3～11个月;实验组112例中2例分别在术后3、6个月发生肝内缺血型胆道病变,发生率1.8%.结论 (1)无心跳尸体供肝存在较高的肝内胆道缺血型病变发生率和再移植率.(2)对无心跳尸体供肝常规采用尿激酶两次灌洗方案能有效降低肝内缺血型胆道病变的发生率.     

尿激酶灌注无心跳供肝预防肝内缺血型胆道病变的临床研究

目的 探讨降低无心跳尸体供体肝移植术后肝内缺血型胆道病变发生率的方法,进而减少再移植率,提高长期生存质量.方法 针对无心跳尸体供肝在热、冷缺血状态下胆道微循环中可能存在的微血栓形成,进行前瞻性临床研究.以2006年1月至2007年3月实施并存活超过1年的肝脏移植病人112例为实验组;以1999年7月至2005年12月完成并存活超过1年的肝脏移植220例为对照组.实验组在供肝切取冷灌注时及供肝修整完毕后两次应用尿激酶灌洗供肝动脉系统.比较两组肝内缺血型胆道病变的发生率.结果 对照组220例中13例受体术后发生肝内缺血型胆道病变,发生率5.9%,发生时间为术后3～11个月;实验组112例中2例分别在术后3、6个月发生肝内缺血型胆道病变,发生率1.8%.结论 (1)无心跳尸体供肝存在较高的肝内胆道缺血型病变发生率和再移植率.(2)对无心跳尸体供肝常规采用尿激酶两次灌洗方案能有效降低肝内缺血型胆道病变的发生率.     

尿激酶灌注无心跳供肝预防肝内缺血型胆道病变的临床研究

目的 探讨降低无心跳尸体供体肝移植术后肝内缺血型胆道病变发生率的方法,进而减少再移植率,提高长期生存质量.方法 针对无心跳尸体供肝在热、冷缺血状态下胆道微循环中可能存在的微血栓形成,进行前瞻性临床研究.以2006年1月至2007年3月实施并存活超过1年的肝脏移植病人112例为实验组;以1999年7月至2005年12月完成并存活超过1年的肝脏移植220例为对照组.实验组在供肝切取冷灌注时及供肝修整完毕后两次应用尿激酶灌洗供肝动脉系统.比较两组肝内缺血型胆道病变的发生率.结果 对照组220例中13例受体术后发生肝内缺血型胆道病变,发生率5.9%,发生时间为术后3～11个月;实验组112例中2例分别在术后3、6个月发生肝内缺血型胆道病变,发生率1.8%.结论 (1)无心跳尸体供肝存在较高的肝内胆道缺血型病变发生率和再移植率.(2)对无心跳尸体供肝常规采用尿激酶两次灌洗方案能有效降低肝内缺血型胆道病变的发生率.     

尿激酶灌注无心跳供肝预防肝内缺血型胆道病变的临床研究

目的 探讨降低无心跳尸体供体肝移植术后肝内缺血型胆道病变发生率的方法,进而减少再移植率,提高长期生存质量.方法 针对无心跳尸体供肝在热、冷缺血状态下胆道微循环中可能存在的微血栓形成,进行前瞻性临床研究.以2006年1月至2007年3月实施并存活超过1年的肝脏移植病人112例为实验组;以1999年7月至2005年12月完成并存活超过1年的肝脏移植220例为对照组.实验组在供肝切取冷灌注时及供肝修整完毕后两次应用尿激酶灌洗供肝动脉系统.比较两组肝内缺血型胆道病变的发生率.结果 对照组220例中13例受体术后发生肝内缺血型胆道病变,发生率5.9%,发生时间为术后3～11个月;实验组112例中2例分别在术后3、6个月发生肝内缺血型胆道病变,发生率1.8%.结论 (1)无心跳尸体供肝存在较高的肝内胆道缺血型病变发生率和再移植率.(2)对无心跳尸体供肝常规采用尿激酶两次灌洗方案能有效降低肝内缺血型胆道病变的发生率.     

尿激酶灌注无心跳供肝预防肝内缺血型胆道病变的临床研究

目的 探讨降低无心跳尸体供体肝移植术后肝内缺血型胆道病变发生率的方法,进而减少再移植率,提高长期生存质量.方法 针对无心跳尸体供肝在热、冷缺血状态下胆道微循环中可能存在的微血栓形成,进行前瞻性临床研究.以2006年1月至2007年3月实施并存活超过1年的肝脏移植病人112例为实验组;以1999年7月至2005年12月完成并存活超过1年的肝脏移植220例为对照组.实验组在供肝切取冷灌注时及供肝修整完毕后两次应用尿激酶灌洗供肝动脉系统.比较两组肝内缺血型胆道病变的发生率.结果 对照组220例中13例受体术后发生肝内缺血型胆道病变,发生率5.9%,发生时间为术后3～11个月;实验组112例中2例分别在术后3、6个月发生肝内缺血型胆道病变,发生率1.8%.结论 (1)无心跳尸体供肝存在较高的肝内胆道缺血型病变发生率和再移植率.(2)对无心跳尸体供肝常规采用尿激酶两次灌洗方案能有效降低肝内缺血型胆道病变的发生率.     

尿激酶灌注无心跳供肝预防肝内缺血型胆道病变的临床研究

目的 探讨降低无心跳尸体供体肝移植术后肝内缺血型胆道病变发生率的方法,进而减少再移植率,提高长期生存质量.方法 针对无心跳尸体供肝在热、冷缺血状态下胆道微循环中可能存在的微血栓形成,进行前瞻性临床研究.以2006年1月至2007年3月实施并存活超过1年的肝脏移植病人112例为实验组;以1999年7月至2005年12月完成并存活超过1年的肝脏移植220例为对照组.实验组在供肝切取冷灌注时及供肝修整完毕后两次应用尿激酶灌洗供肝动脉系统.比较两组肝内缺血型胆道病变的发生率.结果 对照组220例中13例受体术后发生肝内缺血型胆道病变,发生率5.9%,发生时间为术后3～11个月;实验组112例中2例分别在术后3、6个月发生肝内缺血型胆道病变,发生率1.8%.结论 (1)无心跳尸体供肝存在较高的肝内胆道缺血型病变发生率和再移植率.(2)对无心跳尸体供肝常规采用尿激酶两次灌洗方案能有效降低肝内缺血型胆道病变的发生率.     

尿激酶灌注无心跳供肝预防肝内缺血型胆道病变的临床研究

目的 探讨降低无心跳尸体供体肝移植术后肝内缺血型胆道病变发生率的方法,进而减少再移植率,提高长期生存质量.方法 针对无心跳尸体供肝在热、冷缺血状态下胆道微循环中可能存在的微血栓形成,进行前瞻性临床研究.以2006年1月至2007年3月实施并存活超过1年的肝脏移植病人112例为实验组;以1999年7月至2005年12月完成并存活超过1年的肝脏移植220例为对照组.实验组在供肝切取冷灌注时及供肝修整完毕后两次应用尿激酶灌洗供肝动脉系统.比较两组肝内缺血型胆道病变的发生率.结果 对照组220例中13例受体术后发生肝内缺血型胆道病变,发生率5.9%,发生时间为术后3～11个月;实验组112例中2例分别在术后3、6个月发生肝内缺血型胆道病变,发生率1.8%.结论 (1)无心跳尸体供肝存在较高的肝内胆道缺血型病变发生率和再移植率.(2)对无心跳尸体供肝常规采用尿激酶两次灌洗方案能有效降低肝内缺血型胆道病变的发生率.     

尿激酶灌注无心跳供肝预防肝内缺血型胆道病变的临床研究

目的 探讨降低无心跳尸体供体肝移植术后肝内缺血型胆道病变发生率的方法,进而减少再移植率,提高长期生存质量.方法 针对无心跳尸体供肝在热、冷缺血状态下胆道微循环中可能存在的微血栓形成,进行前瞻性临床研究.以2006年1月至2007年3月实施并存活超过1年的肝脏移植病人112例为实验组;以1999年7月至2005年12月完成并存活超过1年的肝脏移植220例为对照组.实验组在供肝切取冷灌注时及供肝修整完毕后两次应用尿激酶灌洗供肝动脉系统.比较两组肝内缺血型胆道病变的发生率.结果 对照组220例中13例受体术后发生肝内缺血型胆道病变,发生率5.9%,发生时间为术后3～11个月;实验组112例中2例分别在术后3、6个月发生肝内缺血型胆道病变,发生率1.8%.结论 (1)无心跳尸体供肝存在较高的肝内胆道缺血型病变发生率和再移植率.(2)对无心跳尸体供肝常规采用尿激酶两次灌洗方案能有效降低肝内缺血型胆道病变的发生率.     

Living-donor liver transplantation: results of a single center

In the absence of cadaveric donor liver transplantation, living-donor liver transplantation (LDLT) is an alternative option for patients with end-stage liver disease. The objective of this study was to evaluate the outcome of LDLT at a single medical center in Turkey. We retrospectively analyzed the results of 101 LDLTs in 99 recipients with end-stage liver disease. We transplanted 49 right liver lobes, 16 left lobes, and 36 hepatic segments II and III. Most donors (46%) were parents of the recipients. Seventeen recipients had concomitant hepatocellular carcinoma and cirrhosis. Retransplantation was performed in two recipients. Ten hepatic arterial thromboses, 1 hepatic arterial bleeding, and 12 biliary leaks occurred in the early postoperative period. Most complications were treated with interventional techniques. Three hepatic vein stenoses, three portal vein stenoses, one hepatic arterial stenosis, and six biliary stenoses developed during the late postoperative period. Recipients with those complications were treated with interventional techniques. Mean follow-up was 14.2 +/- 10.9 months. During that time, no tumor recurrence was detected in any recipient with hepatocellular carcinoma. Twenty-two recipients died during the follow-up. At this time, the remaining 77 recipients (77%) are alive, exhibiting good graft function. In general, complication rates are slightly higher after LDLT than after cadaveric liver transplantation. However, most complications can be treated with interventional techniques. LDLT continues to be a life-saving option in countries without satisfactory cadaveric donation rates.     

Incidence and management of biliary complications after adult‐to‐adult living donor liver transplantation

Kyoden Y, Tamura S, Sugawara Y, Matsui Y, Togashi J, Kaneko J, Kokudo N, Makuuchi M. Incidence and management of biliary complications after adult‐to‐adult living donor liver transplantation.
Clin Transplant 2010: 24: 535–542.
© 2009 John Wiley & Sons A/S. Abstract: Background: There are few detailed reports of biliary complications in a large adult living donor liver transplantation (LDLT) series. Patient and methods: Biliary complications, treatment modalities, and outcomes in these patients were retrospectively analyzed in 310 adult LDLT. Results: One patient underwent retransplantation. Duct‐to‐duct anastomosis was primarily performed in 223 patients (72%). During the observation period (median 43 months), biliary complications were observed in 111 patients (36%); 53 patients (17%) had bile leakage, 70 patients (23%) had bile duct stenosis, and 12 patients (4%) had bile leakage followed by stenosis. A biliary anastomotic stent tube was placed in 266 patients (86%) at the time of transplantation. Univariate analysis of various clinical factors revealed duct‐to‐duct anastomosis as the single significant risk factor (p = 0.009) for biliary complications. The three‐yr and five‐yr overall patient survival rates were 88% and 85% in those with biliary complications, and 85% and 83%, respectively, in those without biliary complications (p = 0.59). Conclusion: Biliary complications are a major cause of morbidity following LDLT. Duct‐to‐duct anastomosis carried a higher risk for bile duct stenosis. With appropriate management, however, there was little influence on overall survival.     

Hepatocellular carcinoma: A prime indication for living donor liver transplantation

Cadaveric liver transplantation for hepatocellular carcinoma (HCC) is limited by donor organ availability. This report reviews our initial experience with living donor liver transplantation (LDLT) for HCC. Since August 1998, a total of 71 adults have undergone LDLT; 27 (38%) for HCC. Underlying diagnoses included hepatitis C in 17, hepatitis B in eight, cryptogenic cirrhosis in one, and primary biliary cirrhosis in one. Four patients had recurrent HCC after resection. Patients with tumors measuring 5 cm or larger received a single dose of intravenous doxorubicin intraoperatively and six cycles of doxorubicin at 3-week intervals beginning 6 weeks postoperatively. All HCC patients are followed with CT scans and alpha-fetoprotein measurements every 3 months during the first 2 years after transplant. Mean waiting time to transplant for patients with HCC was 83 days, compared to 414 (P = 0.001) days for 50 patients with HCC who were transplanted with cadaveric organs during this period. At median follow-up of 236 days, there have been four deaths due to non-tumor-related causes and one death from recurrence; recurrence has been observed in one other patient. LDLT permits expeditious transplantation in patients with early HCC, and provides access to transplantation for patients with HCC exceeding the United Network of Organ Sharing criteria for prioritization who are, in effect, barred from receiving cadaveric organs. Presented at the Third Americas Congress of the American Hepatopancreatobiliary Association, Miami, Fla., Feb. 22–25, 2001.     

Technical implications of living donor liver transplantation: a single-center experience

Liver transplantation for end-stage liver disease is the treatment of choice in current surgical practice. However, the shortage of cadaveric organs has limited this treatment option for many years. Living donor liver transplantation (LDLT) may be an option to overcome the organ shortage. In the present series we report a single-center experience with 39 LDLT performed from March 2000 to June 2003. The main indications for LDLT was hepatitis B cirrhosis (11 patients). The recipient hepatectomy was performed with caval preservation. The hepatic vein anastomosis was performed either to recipient hepatic vein or inferior vena cava. The portal vein anastomosis was performed either to the recipient's main or right portal branch. Biliary diversion was performed to the recipient biliary ducts if possible, otherwise to a jejunal loop in Roux-en-Y fashion. The survival rate at the end of one year was 71%. The leading cause of mortality was sepsis in five patients. Biliary complications developed in 20% of the recipients. All bile leaks were from the Roux-en-Y hepaticojejunostomy. Hepatic artery thrombosis was diagnosed in four patients by loss of hepatic blood flow on Doppler ultrasound. LDLT is a major surgical option for end-stage liver disease, particularly for countries with low rates of organ donation. However, there are technical challenges to be overcome such as small vessels from segmental grafts and multiple small bile ducts.     

成人间双供体活体肝脏移植成功2例报告

目的供肝短缺是影响肝脏移植发展的主要因素之一，活体供肝是解决这一矛盾的重要措施，供者提供足够的肝脏是影响活体肝脏移植的重要因素。方法施行成人间双供体活体肝移植2例，1例由受者的两位姐姐分别提供左半肝作为供肝，另1例由受者母亲提供右半肝，由无心跳供者提供左半肝(采用劈裂方式，其另一部分肝脏同时为另一成人受者实施肝脏移植)作为供肝。结果术后供、受者肝功能均恢复良好。结论成人问双供肝活体肝脏移植可以为受者提供更大重量的肝脏，又可减少供者提供较多肝脏所带来的风险；双供肝一受者肝脏移植手术操作复杂。     

The influence of portoenterostomy on transplantation for biliary atresia.

After portoenterostomy (PE) for biliary atresia (BA), many patients suffer progressive deterioration of liver function and ultimately require liver transplantation. We retrospectively reviewed a single center's experience with pediatric liver transplantation for BA from 1988 to 2002. Sixty-six patients underwent 69 liver transplants for BA. Forty-two (63%) patients had previously undergone Kasai PE, 11 (17%) biliary appendicoduodenostomy (BAD), and 13 (20%) had no prior biliary drainage (NBD). The BAD procedure offered only short-term biliary drainage--the mean interval between PE and transplant was more than twice that for Kasai patients than for BAD patients (132 versus 49 weeks). The transplants included 11 cadaveric partial, 27 cadaveric whole, and 31 living related transplants. Three patients required retransplant. Prior PE did not increase the incidence of major perioperative complications or unplanned reexploration. After transplant, the 1-, 5-, and 10-year actuarial graft survival rates were 87%, 86%, and 80%, respectively. The 1-, 5-, and 10-year actuarial patient survival rates were 91%, 89%, and 83%. PE remains an important bridge to transplant. In conclusion, transplantation for BA offers excellent long-term graft and patient survival.     

Biliary Complications Following Deceased and Living Donor Liver Transplantation: A Review

Introduction

Biliary complications are the most important source of complications after liver transplantation, and an important cause of morbidity and mortality. With the evolution of surgical transplantation techniques, including living donor and split-liver transplants, the complexity of these problems is increasing. Many studies have shown a higher incidence of biliary tract complications in living donor liver transplantation (LDLT) compared with deceased donor liver transplantation (DDLT). This article reviews biliary complications after liver transplantation and correlations with LDLT and DDLT.

Objective

Provide an overview of biliary complications among LDLT and DDLT.

Results

The incidence of biliary complications is higher among LDLT (28.7%) when compared with DDLT (15.5%). Bile leaks were the most common complication due to LDLT (17.1%); however, stricture was the most common complication due to DDLT (7.5%).     

Outcome of pediatric live-donor liver transplantation-the Toronto experience

Background/Purpose: Live-donor liver transplantation (LDLT) has developed to address the critical shortage of cadaveric organs that accounts for 20% of children who die while awaiting for a liver transplant in Ontario each year. This report reviews the outcome of the pediatric recipients of LDLT at the authors[apos ] center. Methods: The charts of all children who received a LDLT between June 1996 and March 2002 were reviewed retrospectively. Results: Thirteen children (mean age, 3.6 years) underwent LDLT. All donors were parents except for one cousin. Ten grafts were left-lateral segments, 2 were right lobes, and 1 was a left lobe. Three patients required a SILASTIC^{[reg ]} (Dow Corning, Midland, MI) patch for delayed abdominal wall closure. Patient and graft survival rate was 100% with a median follow-up of 376 days. Major postoperative complications included biliary leaks (n [equals] 2), biliary strictures (n [equals] 1), portal vein thrombosis (n [equals] 1), and hepatic venous complications (n [equals] 1). There were no cases of hepatic artery thrombosis. Ten of 12 children became Positive for Epstein-Barr virus (EBV), and 3 of these patients had readily treatable post-transplant lymphoproliferative disorder. Conclusions: LDLT is an acceptable alternative to cadaveric transplantation for children with end-stage liver disease. J Pediatr Surg 38:668-671. [copy ] 2003 Elsevier Inc. All rights reserved.     

Living donor versus deceased donor liver transplantation: a surgeon‐matched comparison of recipient morbidity and outcomes

Informed consent for living donor liver transplantation (LDLT) requires that patients are provided with accurate information on the relative benefits and risks of this procedure compared with deceased donor liver transplantation (DDLT). There is strong evidence to suggest that LDLT facilitates timely transplantation to patients; however, information on the relative morbidity and death risks after LDLT as compared with DDLT is limited. A matched cohort comparison was performed matching recipients for age, MELD, date of transplant, gender, primary diagnosis, and recipient surgeon. A total of 145 LDLT were matched with 145 DDLT. LDLT had a higher overall rate of perioperative surgical complications (P = 0.009). Most of this difference was caused by a higher rate of biliary complications. However, the complications that occurred in the DDLT group tended to be more serious (P = 0.037), and these complications were strongly associated with graft loss in multivariate analysis. The 3‐ and 5‐year graft and patient survivals were similar. In conclusion, DDLT and LDLT have different complication profiles, but comparable hospital stays and survival rates. In areas of deceased donor organ shortages, LDLT offers an excellent alternative to DDLT because it facilitates access to a liver transplant without compromising short‐ or medium‐term recipient outcomes.