成人右半肝活体肝移植21例分析

目的 探讨成人右半肝活体肝移植供受者处理的关键性技术问题。方法 回顾性分析2007年4月至2009年5月首都医科大学附属北京佑安医院肝胆外科完成21例成人右半肝活体肝移植的资料。 结果 供者术后无死亡,发生并发症23例次,按照Clavien系统分级：Ⅰ级15例次,Ⅱ级8例次。经积极非手术治疗后,所有供者均痊愈。受者术后发生胆道并发症7例,均经外科手术处理痊愈,术后1个月内死亡4例。移植物含肝中静脉4例,不含肝中静脉17例,两组受者1年存活率分别为75%与76%（χ2 = 1.000,P = 0.617）。 结论 右半肝活体肝移植是治疗终末期肝病尤其是各种原因导致的急性肝功能衰竭的重要手段。仔细术前评估,精细手术操作,合理地分配肝中静脉并保证移植物和残肝的功能性体积,术后密切监护、妥善处理并发症是供受者安全的重要保证。     

Adult Living Liver Donors have Excellent Long‐Term Medical Outcomes: The University of Toronto Liver Transplant Experience

Right lobe living donor liver transplantation is an effective treatment for selected individuals with end‐stage liver disease. Although 1 year donor morbidity and mortality have been reported, little is known about outcomes beyond 1 year. Our objective was to analyze the outcomes of the first 202 consecutive donors performed at our center with a minimum follow‐up of 12 months (range 12–96 months). All physical complications were prospectively recorded and categorized according to the modified Clavien classification system. Donors were seen by a dedicated family physician at 2 weeks, 1, 3 and 12 months postoperatively and yearly thereafter. The cohort included 108 males and 94 females (mean age 37.3 ± 11.5 years). Donor survival was 100%. A total of 39.6% of donors experienced a medical complication during the first year after surgery (21 Grade 1, 27 Grade 2, 32 Grade 3). After 1 year, three donors experienced a medical complication (1 Grade 1, 1 Grade 2, 1 Grade 3). All donors returned to predonation employment or studies although four donors (2%) experienced a psychiatric complication. This prospective study suggests that living liver donation can be performed safely without any serious late medical complications and suggests that long‐term follow‐up may contribute to favorable donor outcomes.     

采用不含肝中静脉的右半肝行成人间活体肝移植

目的探讨采用不含肝中静脉的右半肝行成人间活体肝移植的可行性及安全性。方法2002年1月至2005年8月,我院施行了16例成人间右半肝活体肝移植,术中采用了不含肝中静脉的右半肝移植物,同时进行了一系列改良的手术技术包括肝右静脉的重建,右肝下静脉的重建,肝中静脉分支的搭桥等改进。结果全组供者无严重并发症及死亡。前2例受者中,1例发生肝静脉吻合口狭窄,1例因发生小肝综合征,死于肝功进行性恶化。后14例受者中发生并发症5例:急性排斥反应,肝动脉栓塞,胆漏,左膈下脓肿及肺部感染各1例;1例再移植术后肺部感染死于MODS。14例中除肝右静脉与下腔静脉(IVC)直接吻合外,其中5例加行右肝下静脉重建,另5例采用自体大隐静脉搭桥行肝中静脉分支与IVC重建,保证了右肝的流出道通畅。移植物与受者重量比(GRWR)为0.72%~1.15%,11例<1.0%,其中2例<0.8%,无小肝综合征发生。结论采用了改进的手术技术,特别是肝静脉流出道的充分重建可有效的避免小肝综合征,从而使采用不含肝中静脉的活体右半肝移植成为安全可靠的手术方式。     

Technique of bile duct reconstruction and management of biliary complications in right lobe living donor liver transplantation

From December 1999 to January 2002, 50 right lobe living donor liver transplantations were performed. The donor operations included an intraoperative cholangiography to elicit variations in bile duct anatomy. The biliary reconstruction was done whenever possible as an end-to-end microanastomosis of the donor right hepatic duct with the recipient's bile duct. As a result of the early segmental branching of the donor biliary tree, two segment bile ducts had to be anastomosed in 20 patients and three segment bile ducts in three patients. In 12 patients, a Roux-en-Y hepaticojejunostomy was performed. All anastomoses were drained externally. We observed two leakages at the resection surface which could be treated successfully by an external drainage. Six leaks occurred at the site of end-to-end biliary anastomoses. Twice the problem could be conservatively solved placing a stent percutaneously. In two patients a hepaticojejunostomy was performed after a bile duct necrosis. In two patients with an anastomotic leak, occurring 3 d, respectively, 3 month after the original transplantation, the bile duct could be directly reconstructed over a T-tube. Two anastomotic stenoses were observed, one in combination with a leak treated by percutaneous stent implantation and the second, 3 month after transplantation which was treated surgically. Biliary reconstruction after living donor liver transplantation requires microsurgical techniques and can be performed as a direct end-to-end anastomosis in most cases. Biliary complications were treated by percutaneous drainage or surgical revision in all cases.     

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。     

Survival following right lobe split graft,living‐ and deceased‐donor liver transplantation in adult patients: a systematic review and network meta‐analysis

Graft and patient survival outcomes following split liver transplantation (SLT), living‐donor liver transplantation (LDLT) and deceased‐donor liver transplantation (DDLT) were estimated using Bayesian network meta‐analysis. Databases were searched for relevant articles over the previous 20 years (MEDLINE, Embase, Cochrane Library and Google Scholar). Systematic review, pairwise meta‐analysis and Bayesian network meta‐analysis were performed. Pairwise meta‐analysis demonstrated that there were no significant differences in graft and patient survival outcomes. Consequently, Bayesian network meta‐analysis demonstrated no significant differences in 1‐, 3‐ and 5‐year graft and patient survival between the three alternative liver transplantations. No discrepancies were demonstrated after comparisons of direct and indirect evidence of 1‐, 3‐ and 5‐year patient and graft survival of the three node‐split models namely SLT, LDLT and DDLT. The 1‐, 3‐ and 5‐year graft and patient survival of the SLT and LDLT cohorts compared to the DDLT cohort demonstrated no significant differences. The direct and indirect evidence of this study can serve as comparator for future studies.     

Living Donor Liver Transplantation Using Dual Grafts from Two Donors: A Feasible Option to Overcome Small‐for‐Size Graft Problems?

Living donor liver transplantation (LDLT) between adults inevitably implies two potential risks associated with a small-for-size graft for the recipient and small remnant liver for the donor. To overcome these problems, LDLT using dual grafts from two independent donors can be a solution, in which sufficient graft volume can be obtained while preserving donor safety. We present a case of LDLT that was managed successfully by using right and left lobe dual grafts from two donors. The recipient was a large-size male with hepatitis C cirrhosis complicated by multiple hepatocellular carcinomas (HCCs). The first donor donated a right lobe graft and the second donor donated a left lobe plus caudate lobe graft with the middle hepatic vein. Graft function was excellent throughout the course without evidence of small-for-size syndrome. In conclusion, LDLT using dual grafts can be justified in a selected case to avoid small-for-size graft problems without increasing independent donor risks.     

A retrospective analysis of re‐exploration after living donor right lobe liver transplantation: incidence,causes, outcomes,and risk factors

Despite technical difficulties, right lobe liver grafting is preferred in living donor liver transplantation because of the graft size. Re‐exploration after living donor right lobe liver transplantation (LRLT) has never been separately analyzed. We aimed to analyze the incidence, causes, outcomes, and risk factors of re‐exploration after LRLT. We reviewed medical records of 1016 LRLT recipients from October 2003 to July 2017 and identified recipients who underwent re‐exploration within hospital stay. Separate analyses were also performed according to cause of re‐exploration. The overall incidence of re‐exploration was 17.0% (173/1016). The most common cause of re‐exploration was bleeding (50%). Overall re‐exploration was associated with clinical outcome, but different results were shown on analyses according to cause of re‐exploration. Risk factors of re‐exploration were underlying hepatocellular carcinoma and operative duration [Odds ratio (OR), 1.49; 95% confidence interval (CI), 1.05–2.12; P = 0.03, and OR, 1.002; 95% CI, 1.001–1.004; P = 0.0023, respectively]. Re‐exploration after LRLT is relatively common, and is strongly associated with mortality and graft failure.     

成人右半肝活体肝移植胆道重建探讨

目的探讨成人右半肝活体肝移植胆道重建的技术问题.方法回顾性分析我院2007年4月至2009年5月完成的21例成人右半肝活体肝移植资料.供肝右肝管与受者肝总管单个吻合10例;供肝两支胆管开口分别与受者两支胆管吻合5例;供肝胆管整形成一个开口与受者胆管吻合5例,其中采用T管支撑2例,Y型管支撑1例;右肝管空肠Roux-en-Y吻合1例.结果4例受者术后1个月内死亡,1例因术后急性肝坏死行再次肝移植.其余受者存活至今,1年存活率为77.65%.受者术后发生胆道并发症7例,其中胆漏5例,胆道狭窄2例,均经外科手术处理痊愈.胆管与胆管单个吻合口组、胆管整形成一个开口与受者胆管吻合组和两支胆管开口分别与受者胆管吻合组比较,胆道并发症发生率差异无统计学意义(x2=0.659,P=0.719).结论根据供受者胆管情况,可以灵活采用单根胆管吻合、胆管整形、分别吻合和肝管空肠吻合等不同重建方式.后壁连续、前壁间断以及显微外科技术的采用可能有助于降低胆道并发症的发生率.     

活体肝移植供体手术及术后管理（附22例临床分析）

目的 探讨提高活体肝移植供体手术安全性和加强术后管理的措施。方法 回顾性分析北京大学人民医院2003年2月至2009年6月22例活体肝移植供体的临床资料,总结供体术前评估、手术技术、术后并发症及随访情况。结果 术前对供体进行三步法评估,术中采用超吸刀 （CUSA）进行肝脏实质分离,术后定期随访。供肝移植物包括肝左外叶2例、左半肝6例、扩大左半肝1例、右半肝5例和扩大右半肝8例。1例在术后早期出现腹腔内出血,1例合并胸水,1例枕后皮下血肿,其他供体未出现严重并发症,术后肝功能迅速恢复正常,随访至今无供体死亡。结论 活体肝移植供体手术复杂,严格术前评估,术中精细操作,术后加强随访是提高活体肝移植供体安全的重要保证。     

Protein S deficiency in a living liver donor

Protein S deficiency is a thrombophilia associated with increased risk of thromboembolic episodes in affected patients. Traditionally, protein S deficiency in a potential donor was considered an absolute contraindication to living donor liver transplantation, both due to the increased risk incurred by the thrombophilic donor as well as the risk of transmitting the thrombophilia to the liver recipient, as protein S is predominantly produced by the liver. We present the first successful case of living donor liver transplantation using a donor with asymptomatic protein S deficiency. Interestingly, whereas the donor continued to have protein S levels approximately 50% of normal, the recipient maintained normal levels of protein S post-transplant, potentially due to compensation by extra-hepatic protein S production. We discuss the prior literature of protein S deficiency acquired via liver transplantation, and we evaluate potential criteria by which the safety of transplants utilizing this pool of donors may be enhanced.     

Risks of donation and quality of donors'' life after living donor liver transplantation

The purpose is to clarify risks of donation and quality of the donor's life after living-related donor liver transplantation (LDLTx). Sixty-eight donors were classified into four groups: lateral segment group (n = 30); left lobe group (n = 18); left lobe with the middle hepatic vein group (n = 11); right lobe group (n = 9). We investigated (i) the risks of donation, and evaluated the following: blood loss, operation time, postoperative liver function and duration of hospitalization; (ii) quality of donors' life: donors were mailed a structured questionnaire and the Short-Form Health Survey (SF-36), a generic measure assessing quality of life using eight scales. The results were: (i) there were no differences in liver function and duration of hospitalization between four groups; (ii) 48 donors (71%) responded. All donors returned to normalcy. The donors did not regret their decision to donate except two cases whose recipients had died. The donors' life was almost guaranteed regardless of the lobe we used as the graft.     

Totally Laparoscopic Full Left Hepatectomy for Living Donor Liver Transplantation in Adolescents and Adults

In recent years different minimal access strategies have been designed in order to perform living donor liver surgery for adult recipients with less morbidity. Techniques involve shortening the length of the incision with or without previous laparoscopic mobilization of the liver. Herein we present two cases of totally laparoscopic living donor left hepatectomy, with and without removal of the middle hepatic vein, respectively. We describe in detail the anatomical and technical aspects of the procedure focusing on relevant points to enhance safety.     

儿童活体肝移植术后5年认知水平的调查研究

目的 分析儿童在活体肝移植术后5年的认知水平,同时研究影响儿童认知水平的相关因素,从而给儿童活体肝移植术的护理提供科学依据,加强儿童活体肝移植术后的认知水平.方法 本研究通过方便抽样调查某医院实施活体肝移植手术的37例儿童作为研究对象,通过人口社会学资料进行问卷调查设计,选择蒙特利尔认知评估量表来调查儿童活体肝移植术后...     

小儿活体肝移植伦理审查问题研究及探讨

目的 通过分析小儿活体肝移植伦理审查资料和审查过程,探讨小儿活体肝移植的伦理审查的要点和难点.方法 回顾性分析近5年我院小儿活体肝移植伦理审查材料937例.结果 937例中936例通过,1例未通过.结论 根据《人体器官移植条例》和《卫生部关于规范活体器官移植若干规定》要求,严格履行审查程序,充分评估和权衡手术风险,在挽...     

Living-donor liver transplantation in the new decade: perspective from the twentieth to the twenty-first century

Liver transplantation from living donors developed rapidly in the last decade of the twentieth century and is now an important option in the treatment of patients with end stage and/or irreversible liver diseases. Although the disadvantages of small-for-size grafts are being significantly mitigated by the repertoire of left lobe, while left liver, and right lobe grafts, the struggle for graft size matching has disclosed not a few problems, such as small grafts for advanced disease, anatomical variations in donor livers, and, above all, the increasing importance of donor safety. The range of donor candidates is also an important point of discussion in regard to the social significance of this treatment modality. Apart from the surgical aspects, many medical aspects, including the indications and timing of transplantation specific to this technique, the prevention of disease transmission in family members, and immunological aspects, including the risk of graft-versus-host disease, remain to be clarified. Social and economic questions, as well as surgical and medical issues, will be the theme in the second decade, and the new century, of this newborn treatment modality. Received: January 9, 2001 / Accepted: April 24, 2001     

Segmental regeneration in right-lobe liver grafts in adult living donor liver transplant

Chen H‐L, Tsang LL‐C, Concejero AM, Huang T‐L, Chen T‐Y, Ou H‐Y, Yu C‐Y, Chen C‐L, Cheng Y‐F. Segmental regeneration in right‐lobe liver grafts in adult living donor liver transplant. Abstract:  Our aim is to evaluate the relationship and impact of right‐lobe (RL) liver grafts procured with or without the middle hepatic vein (MHV) trunk and MHV tributary reconstruction on segmental regeneration of these grafts in adult living donor liver transplantation (ALDLT). Patients underwent primary ALDLT using a RL liver graft were divided into three groups according to graft type: with MHV tributary reconstruction (group I), without MHV tributary reconstruction (group II), and with inclusion of the MHV trunk (group III). The overall graft volume and the volumes of the anterior and posterior segments of the grafts six months post‐transplant, evaluated using computed tomography, were calculated as the regeneration indices. Optimal regeneration of the RL liver graft was achieved in the three groups of patients. There was no significant difference in the regeneration indices between groups I (149.4%) and III (143.6%). However, in group II (112.4%) without MHV or tributary reconstruction, the anterior regenerative index was lower than the other two groups and exhibited transient prolonged hyperbilirubinemia. Segmental graft regeneration is maximized by adequate venous drainage. Inclusion of the MHV trunk or MHV tributary reconstruction influences segmental liver regeneration and preclude transient hyperbilirubinemia in the early post‐liver transplant phase.     

Impact of Adult Living Donor Liver Transplantation on Waiting Time Survival in Candidates Listed for Liver Transplantation

Studies comparing adult living donor liver transplantation to deceased donor liver transplantation have focused on post-transplant survival. Our aim was to focus on the impact of living donor liver transplant on waiting time mortality and overall mortality. We analyzed the affect of living donor liver transplantation on waiting time mortality and overall mortality (from listing until last follow up) in a cohort of 116 transplant candidates. Fifty-eight candidates who had individuals present as potential living donors (volunteer group) were matched by MELD score to 58 liver transplant candidates who did not have individuals present as a potential living donor (no volunteer group). Twenty-seven percent of candidates in the no volunteer group and 62% of candidates in the volunteer group underwent liver transplantation, p = 0.0003. One-year waiting list mortality for the volunteer group and no volunteer group was 10% and 20%, respectively, p = 0.03. Patient survival from the time of listing to last follow up was similar between the two groups. In our study group, living donor liver transplantation is associated with a higher rate of liver transplantation and lower waiting time mortality. In the era of living donor liver transplantation, estimates of patient survival should incorporate waiting time mortality.     

Laparoscopic-Assisted Right Lobe Donor Hepatectomy

The major impediment to a wider application of living donor hepatectomy, particularly of the right lobe, is its associated morbidity. The recent interest in a minimally invasive approach to liver surgery has raised the possibility of applying these techniques to living donor right lobectomy. Herein, we report the first case of a laparoscopic, hand-assisted living donor right hepatic lobectomy. We describe the technical aspects of the procedure, and discuss the rationale for considering this option. We propose that the procedure, as described, did not increase the operative risks of the procedure; instead, it decreased potential morbidity. We caution that this procedure should only be considered for select donors, and that only surgical teams familiar with both living donor hepatectomy and laparoscopic liver surgery should entertain this possibility.     

活体肝移植右半供肝切取的临床经验总结（附157例报告）

目的总结活体右半供肝切取的经验。方法对2002年1月至2009年8月在四川大学华西医院肝脏移植中心施行活体右半肝供体手术的157例患者的资料进行回顾性分析。全部供者均自愿无偿捐肝,其捐赠行为均经医院伦理学委员会批准。了解术前计算机体层摄影术（CT）评估供肝体积的效果：术前应用CT测定供体的全肝体积、右半肝体积（不含肝中静脉）,从而计算残余左半肝体积比;术后测定切取的右半肝重量、应用华西严律南公式计算标准肝脏体积（standard liver volume,SLV）,计算残余左半肝体积重量比,比较术前供肝CT测定全肝体积与SLV的差异。供体均行不含肝中静脉的右半供肝切除术。静脉复合麻醉,取双侧（后期改进为右侧）肋缘下并延至剑突的切口,游离右侧肝脏,确定切肝线,不阻断入肝血流,用超声吸引刀离断肝组织直至整个右半肝游离,依次阻断并切断肝右动脉,门静脉右支及肝右静脉,将供肝移至后台进行灌注及修整。了解供者术中情况,包括供体取肝手术时间、术中失血量、术中有否发现不适合作为供体的病例及其原因。了解供者术后随访情况,术后并发症采用Clavien系统分级评价。结果供体的术前CT供肝体积测定结果：全肝体积（1301±174）ml,右半肝体积（724±137）ml,残余左半肝体积比（45．5±6．9）％。实测值：右半肝重量（558±77）g,SLV（1055±129）ml,残余左半肝重量比（46．7±6．2）％,其中30％～35％者10例（6％）,〉35％者147例（94％）。CT测定供体全肝体积比SLV平均大23％。供体术中平均失血量493ml,手术时间（431±68）min。术中探查发现不适合作为供体而未完成右半肝切除4例,包括肝总管进入肝圆韧带左纵沟内再发出肝右管1例、多支肝右管1例、中度脂肪肝（超过30％的肝组织大泡型脂肪变性）1例和肝硬化1例。术后共54例发生61例次并发症,其中发生ClavienⅢ级及以上并发症18例次,包括胸腔积液12例次、肝功能不全2例次、门静脉血栓形成1例次、胆漏1例次、腹腔内出血1例次、切口裂开1例次,经对症治疗后均痊愈。所有供体恢复良好,随访3年均健康存活。结论术前准确掌握CT测定供肝体积的准确性和偏差程度,应用经临床验证有效的评估公式进行验证,并按正确切线断肝,对完成手术计划,保证供、受体安全具有重要的临床意义。