慢性丙肝肝硬化患者肝移植术前后抗病毒治疗研究进展

有20％～30％的慢性丙型肝炎（丙肝）患者发展为肝硬化。目前肝移植是肝硬化最有效的治疗手段。丙肝肝硬化患者肝移植术后普遍存在丙肝复发的问题，而且术后丙肝进程加速。所以肝移植术前后丙肝的治疗应给予高度重视。目前所采用的治疗方案主要是利用干扰素和利巴韦林进行抗病毒治疗。但治疗开始时间、治疗剂量、治疗持续时间均处于研究之中。现将有关研究进展情况简述如下。     

切取肝中静脉对活体肝移植供者早期残肝淤血和再生的影响

目的 探讨肝中静脉的切取对活体右半肝移植供者残肝淤血和再生的影响.方法 本中心2008年8月至2009年8月实施的活体右半肝移植供者28例,其中不带肝中静脉右半肝切取的供体11例(A组),带肝中静脉右半肝切取的供体17例(B组).术后2周行CT检查测量残肝的体积.比较两组供者Ⅳ段肝静脉与不同分型的术后早期残肝淤血和再生情况.结果 本组供体有10例发现Ⅳ段淤血,均为残肝不含肝中静脉者(B组),其中7例为完全或大部分淤血,A组供者无1例出现肝脏淤血;两组相比差异有统计学意义(P =0.006).B组供者中Ⅳ段肝静脉分型为Ⅰ型者共有6例,Ⅳ段全部出现淤血且为完全淤血;而Ⅱ型中共有4例患者发生淤血,其中完全淤血1例,两型相比差异有统计学意义(P=0.035).术后两周B组Ⅳ段体积为(186±72) ml,A组Ⅳ段体积为(302±85) ml,B组显著小于A组(P =0.005).B组Ⅳ段再生比例显著小于A组(P =0.007);Ⅰ～Ⅲ段的再生比例B组显著大于A组(P =0.008);而A、B组残肝再生差异无统计学意义(P=0.63).结论 带肝中静脉右半肝切除没有明显损害供体早期肝功能.残肝Ⅳ段有淤血发生,导致再生受到不利影响,但可通过Ⅱ、Ⅲ段再生代偿,整体残肝再生不受影响.     

小剂量HBIg联合核苷类似物预防肝移植术后乙肝复发1506例回顾性分析

目的 确定小剂量乙肝免疫球蛋白(HBIg)联合核苷类似物预防肝移植术后乙肝复发的效果.方法 对我院1998年12月至2009年11月间因乙肝相关性终末期肝病行肝移植手术并接受核苷类似物联合小剂量HBIg预防乙肝复发病例进行回顾性分析,调查其术前、术后乙肝相关检查、乙肝复发情况以及患者的生存情况.结果 在移植术后存活>30 d且获得随访(中位随访时间为27.8个月)的1506例患者中,术后出现乙肝复发者37例.术后1、2、3、4、5、6年累计复发率分别为1.3%、2.4%、2.7%、2.9%、3.7%、4.6%;术后乙肝复发时间为0.3～66.6个月(中位值为12.8个月).在37例乙肝复发患者中,9例检测出病毒变异,其中YMDD变异4例,YMDD+YIDD变异2例,YMDD+YVDD变异、YVDD变异、YIDD变异各1例.结论 肝脏移植为治疗乙肝相关性肝病的重要手段,术后采用核苷类似物联合小剂量HBIg可有效预防乙肝复发,乙肝复发患者及时采取挽救治疗可控制疾病,改善预后.

Abstract：

Objective To evaluate the preventive effect of combination of low-dose HBIg and Nucleoside analogues on recurrence of hepatitis B after liver transplantation. Methods Retrospectively analyzed HBV status and recurrence in patients accepting Nucleoside analogues plus low-dose HBIg as prophylaxis treatment after liver transplantation for HBV-related end-stage liver disease from December 1998 to Octomber 2009 in our center. Results In all the 1506 patients whose survival time >30 d after liver transplantation, 37 patients showed HBV recurrence, the HBV cumulative-recurrence rate of 1, 2, 3, 4, 5 and 6y was 1.3%,2. 4%,2. 7%,2. 9%,3. 7% and 4.6% respectively. The time of recurrence varied from 0. 3 to 66. 6 months (median 12. 8 months) after transplantation. Virus mutation could be tested in 9 cases of the 37 recurrence patients, including 4 YMDD cases, 2 YMDD + YIDD cases, 1 YMDD+YVDD cases, 1 YVDD case,and 1 YIDD case. Conclusions Liver transplantation is the principal therapeutic method for the patient with end-stage liver diseases related to HBV, with the effectively prophylaxis treatment to aim directly at HBV recurrence. If the patients who got HBV recurrence received targeted treatments, the situation can be controlled satisfactorily.     

活体肝移植术后Ⅴ、Ⅷ段肝静脉淤血的临床及影像学观察

目的 评价活体肝移植(living donorlivertransplantation,LDLT)术后Ⅴ、Ⅷ段肝静脉淤血(hepatic venous congestion,HVC)的MSCT表现及其对患者术后肝功能恢复的影响.方法83例在天津市第一中心医院移植外科施行活体右半肝移植的患者纳入本研究,所有患者均于术后早期(≤1个月)和术后中晚期(≥3个月)进行MSCT平扫和增强检查,记录淤血区的MSCT表现和患者术后1～7 d丙氨酸转氨酶(ALT)、天冬氨酸转氨酶(AST)、总胆红素(TB)及凝血酶原时间(PT).比较淤血组和无淤血组上述指标之间的差异.结果 20例患者(24.10%)LDLT术后1个月内出现Ⅴ、Ⅷ段HVC,淤血区体积和淤血率分别为(218.25±130.29)cm3和16.68%±8.81%.淤血区于MSCT平扫及动脉期多呈低密度,门静脉期多呈混杂密度或高密度,增强后动脉期及门静脉期呈持续低密度者预后不良.淤血组与无淤血组患者术后1～7 d各项肝功能化验指标差异均无统计学意义(均P＞0.05).结论 MSCT是评价LDLT术后Ⅴ、Ⅷ段HVC的有效方法,多数HVC对LDLT术后患者肝功能恢复没有影响.

Abstract：

Objective To evaluate MSCT appearance and impaction of Ⅴ, Ⅷ segments' hepatic venous congestion ( HVC ) on hepatic functional recovery in living donor liver transplantation (LDLT).Methods In this study, 83 patients undergoing LDLT in our hospital were included, all subjects received plain and contrast MSCT examinations at early stage (within 1 month) and later stage (3 months later) after LDLT. MSCT appearance of HVC was recorded, at the same time, gutamic pyruvic transaminase ( ALT),glutamic oxalacetic transaminase (AST), total bilirubin (TB) and prothrombin time (PT) of 1 to 7 days after LDLT between congestion group and non-congestion group were recorded and compared.Results Segments Ⅴ and Ⅷ congestion was identified by after LDLT CT scanning in 20 patients (24. 10% ). Congestion volume and congestion ratio was (218. 25 ± 130. 29) cm3 and 16. 68% ±8. 81%,respectively. HVC often appear as hypoattenuation on plain CT scan and arterial phase, mixed or hyperattenuation on portal vein phase. There was no significant difference of ALT, AST, TB and PT after LDLT between congestion group and non-congestion group (P ＞ 0. 05). Conclusions MSCT is a valuable method to evaluate Ⅴ, Ⅷ segments' HVC after LDLT, most HVC has no impaction on hepatic functional recovery in LDLT patients.     

胆道数字成像技术在活体肝移植肝内胆道解剖分型及胆道切面确定中的应用

目的 评价术中胆道数字成像技术在活体肝移植(living donor liver transplantation,LDLT)肝内胆道解剖分型和胆道切面确定中的作用及临床价值.方法 66例LDLT供者,通过术中胆道数字减影了解胆道分型及变异,结合金属标志物准确选择胆道离断位置,与手术结果比较,分析其在LDLT供者术中胆道解剖描述及切面确定中的作用.结果 所有供者均采用胆道数字成像技术对肝内胆道解剖进行分型,Ⅰ型(经典型)45例(68.2%),Ⅱ型(三叉型,胆总管由右前肝管、右后肝管、左肝管汇合而成)7例(10.6%),Ⅲ型(无右肝管主干,右后肝管汇入肝总管)13例(19.7%),Ⅳ型(无右肝管主干,右后肝管汇入左肝管)1例(1.5%),Ⅴ型(复杂分型)0例(0%).Ⅰ型所有供者均形成单一吻合口;Ⅱ型7例供者中4例形成2个吻合口,3例经成形或非成形后形成1个吻合口;Ⅲ型13例供者中9例形成2个吻合口,4例经成形后形成1个吻合口;Ⅳ型1例供者,2个胆道吻合口.所有供者都完成活体右半肝切取术.结论 术中胆道数字减影结合金属标志物可以精确显示肝内胆道解剖及变异并准确定位肝管切面,减少胆道吻合口数目,有助于供肝的安全获取和移植.

Abstract：

Objective To evaluate biliary digital imaging technology in determining the type of the intrahepatic bile duct anatomy and the transection plane of the duct in right lobe living donor liver transplantation(LDLT). Methods Mobile digital subtraction angiography was performed to show the intrahepatic bile duct anatomy of 66 liver transplant donor candidates. Combined with metal markers, the bile duct transection plane was defined. Comparing with the actual results, the effect of digital imaging technology in determining the intrahepatic anatomical variations and transection plane of the duct in LDLT was evaluated. Results Intrahepatic bile duct anatomical variations were showed in all donors by using digital imaging technology. type Ⅰ (classical type) was identified in45 cases (68.2%), type Ⅱ (with triple confluence, the simultaneous emptying of the right anterior segmental duct, right posterior segmental duct and left hepatic duct into the common hepatic duct) in 7 cases ( 10.6% ), type Ⅲ (no right hepatic duct stem, right posterior segmental duct draining into common hepatic duct) in 13 cases ( 19. 7% ), type Ⅳ (no right hepatic duct stem, right posterior segmental duct draining into left hepatic duct) in 1 case (1.5%), and type Ⅴ (complex variation ) in no case (0%). As a result, cases of type Ⅰ form a single anastomosis. In type Ⅱ, four cases formed double anastomoses, three cases formed single anastomosis with or without ductoplasty. In type Ⅲ, two anastomoses were formed in 9 cases, single anastomosis in 4 cases with ductoplasty. The case of type Ⅳ had double anastomoses. In all cases right lobe liver were harvested.Conclusions Biliary digital subtraction image combined with metal markers accurately defines intrahepatic bile duct anatomy and the transection plane, helping to reduce number of bile duct anastomosis, and contributes to safe graft harvesting.     

肝移植术后缺血型胆道狭窄非手术治疗的长期疗效分析

目的 评估肝脏移植术后缺血型胆道狭窄(ischemic biliary lesions)非手术治疗的效果.方法 该研究回顾分析了2000年9月至2002年6月在天津市第一中心医院行原位肝移植术的253例病例中术后发生缺血型胆道狭窄35例,给予病人首先使用球囊扩张和支架支撑(或导管引流1～6个月)等非手术治疗手段来治疗,全部病例随访5年以上,收集病例资料分析治疗效果.结果 35例缺血型胆道狭窄中24例非手术治疗后有效(9例临床治愈).治疗有效者中后来有8例出现再次狭窄,2例再次非手术治疗有效,6例无效接受再次肝移植手术.在随访8～80个月(中位数为54个月)过程中18例病人胆道情况良好.结论 非手术治疗手段对于肝移植术后缺血型胆道狭窄的治疗是有效的应该作为首选.     

门静脉血栓的肝移植术中处理

目的 探讨门静脉血栓(PVT)的肝移植术中外科处理方法及其效果.方法 肝移植患者2508例,共行肝移植2614次,其中253例术前并发PVT.并发PVT者的Yerdel分级为,Ⅰ级者104例,Ⅱ级者114例,Ⅲ级者29例,Ⅳ级者6例.根据具体情况对并发Ⅰ、Ⅱ级PVT者施行静脉血栓切除术、外翻血栓切除术或外翻式门静脉内膜剥脱切除术;并发Ⅲ级PVT者,18例行外翻式门静脉内膜剥脱切除术,11例行外翻血栓切除术;并发Ⅳ级PVT者行外翻式门静脉内膜剥脱切除术.结果 218例并发Ⅰ、Ⅱ级PVT者中,32例行静脉血栓切除术,52例行外翻血栓切除术,134例行外翻式门静脉内膜剥脱切除术,均获得成功.29例并发Ⅲ级PVT者中,18例行外翻式门静脉内膜剥脱切除术,均获得成功;11例行外翻血栓切除术,其中5例获得成功,6例失败.6例并发Ⅳ级PVT者中,3例行外翻式门静脉内膜剥脱切除术,获得成功,3例取栓失败.253例并发PVT者肝移植术后6个月的存活率为93.7%,与同期无PVT的肝移植患者相比较(94.4%),差异无统计学意义(P>0.05).结论 并发PVT者可接受肝移植,术中应根据PVT的Yerdel分级情况,采取适合的外科处理方式.     

Reconstruction of Ⅴ and Ⅷ bepatic veins in right lobe (without middle hepatic vein) living donor liver transplantation

Objective To summarize the experience of reconstruction of Ⅴ and Ⅷ hepatic veins in right lobe (without middle hepatic vein) living donor liver transplantation. Methods The clinical data of 55 cases of living donor liver transplantation of right lobe without middle hepatic vein were analyzed, and Ⅴ and Ⅷ hepatic veins were reconstructed. All donors underwent evaluation on the basis of vascular anatomy, GRWR and graft volume/ESLV. Fifty-one grafts underwent reconstruction of Ⅴ and Ⅷ hepatic veins with cold-storage cadaveric iliac veins. Great saphenous vein, varicose umbilical veins, recipient intrahepatic portal veins and recipient intrahepatic veins were used respectively in the remaining 4 cases. Results One recipient died of obstruction of out-flow on the postoperative day 43. One recipient was converted to cadaver donor liver transplantation at the 7th day after operation, because of acute liver function failure. The remaining 53 cases recovered successfully. Conclusion Reconstruction of Ⅴ and Ⅷ hepatic veins with proper materials in right lobe (without middle hepatic vein) living donor liver transplantation is feasible, and the effect is satisfactory.     

肝移植治疗混合细胞型肝癌21例临床分析

目的 探讨肝移植治疗混合细胞型肝癌的疗效以及影响预后的因素.方法 回顾性分析原位肝移植治疗的21例混合细胞型肝癌患者以及非肝移植治疗的8例临床及病理资料,采用Kaplan-Meier法计算肝移植术后患者累积生存率和无瘤生存率,Log-Rank检验行单因素分析,COX回归多因素分析预测影响预后的临床因素.结果 肝移植组21例患者术后围手术期生存率100％.术后生存时间1～ 103个月,中位生存时间23个月.术后无瘤生存时间3～ 103个月,中位无瘤生存时间15个月.1年、2年、3年、5年总体累积生存率分别为69％、58％、38％和38％,累积无瘤生存率分别为63％、52％、38％和38％.非肝移植组生存时间1～11个月,中位生存时间6个月,6个月生存率为50％,1年生存率为0.单因素分析显示,术前伴有肝硬化、肿瘤直径、淋巴结转移、门静脉肉眼癌栓及Allen分型为混杂型可能是预后不良的影响因素(P＜0.05).多因素分析提示,淋巴结转移、门静脉肉眼癌栓为影响预后的独立因素(P＜0.05).结论 肝移植是治疗混合细胞型肝癌的一种有效方法,严格筛选适应证可有效降低肿瘤复发转移的风险并延长生存期.     

预防活体肝移植后肝小体积综合征的综合措施

目的 通过术前选择合适的供肝、术中建立充分的流出道及术后调整门静脉压等综合措施预防活体肝移植术后肝小体积综合征.方法 总结2007年12月至2009年11月的113例活体肝移植的临床资料,术前通过影像系统评估供肝体积,测算供肝体积与受者体重比(GRWR),根据供肝解剖及GRWR确定采用的供体类型(含肝中静脉右半肝,不含肝中静脉右半肝,含肝中静脉左半肝等),术中通过建立充分的流出道,根据GRWR、术前脾功能亢进情况、肝动脉开放后门静脉血流量及门静脉压力,确定是否采用脾动脉结扎等方法将门静脉压力控制在＜20 mm Hg(2.67 kPa),门静脉血流量控制在＜250 ml·min-1·100 g-1,观察采取上述措施后肝小体积综合征的发生情况.结果 75例受者接受含肝中静脉的右半肝,37例接受不含肝中静脉的右半肝,1例接受含肝中静脉左半肝.随访6个月,所有受者均未出现持续黄疸、败血症等严重的肝小体积综合征表现,1例受者于术后42 d死于脑卒中及呼吸衰竭,受者术后6个月存活率为99.1％(112/113).结论 术前根据供肝血管解剖及GRWR选择适当的供肝类型,术中建立充分的流出道,通过脾动脉结扎等方式调整门静脉血流及压力的综合方法可有效预防肝小体积综合征.