成人间右半肝活体肝移植肝中静脉的处理

目的 总结成人间右半肝活体肝移植肝中静脉的处理经验。方法 回顾性分析两例成人间右半肝活体肝移植肝中静脉的处理方法，1例采取含肝中静脉的右半肝活体肝移植，肝中静脉移植供肝和剩余肝脏各保留一半，既有利于保证供体左肝内叶静脉回流，同时供肝右前叶静脉回流也不受到影响；另1例则采取不含肝中静脉的右半肝活体肝移植，术中重建供肝右前叶肝静脉回流通道，使供肝前叶淤血明显改善。结果 两例供体均存活，术后顺利出院，无并发症；受体1例存活，1例术后20d死于急性重度排斥反应。结论 成人间右半肝活体肝移植肝中静脉的处理十分关键，要注意保持供受体肝流出道的通畅，既要保证供体的绝对安全，又要尽量为受体提供足够的肝容量。     

成人-成人活体右半肝移植16例报告

目的　报道东京大学 16例成人终末期肝病患者进行活体右半肝移植的经验。方法　统计自 2 0 0 0年 10月到 2 0 0 1年 4月 ,对 16例成人终末期肝病患者进行了活体右半肝移植。供体和受体的平均体重分别为 5 5kg(42 - 78kg)和 5 7kg(41- 81kg)。结果　供体手术的平均失血量为 80 0ml(30 0 - 16 0 0ml) ,供体的平均住院时间为 12d(6 - 38d)。 14例供体未输血。 1例供体术后发生并发症。移植肝的平均重量为 719g(45 0 - 10 5 0g) ,所有移植肝均立即恢复功能 ,病人精神状态康复 ,凝血酶原时间恢复正常。 2例受体需要再次手术探查。 2例患者死亡 (1例在术后 16d死于全身性念珠菌感染 ,另 1例在术后 2 6d死于门静脉栓塞 )。结论　认为采用右半肝的活体肝移植可以提供足够体积和功能的肝脏达到较好的结果 ,为成年患者的肝移植提供了新的选择     

活体肝移植的几点关键外科技术

目的：探讨活体肝移植的几点关键外科技术。方法：2001年1月至2002年3月底,实施活体肝移植11例,其中左半肝8例,左外叶1例,成人右半肝2例;根据术前CT、血管造影和术中B超确定肝切除线,超声电刀离断肝实质,经门静脉灌注原位获取。受体手术采用保留腔静脉的全肝切除。移植肝原位植入,肝静脉重建采用扩大成型吻合技术,显微技术吻合肝动脉,胆道重建采用端端吻合,置“T“管引流。结果：11例供体术后顺利康复出院,未发生严重并发症。11例受体中,1例发生肝动脉血栓形成需再次肝移植,1例因不可逆转的严重排斥反应,于术后72d死亡。10例受体康复出院,肝功能、铜氧化酶恢复正常。结论：活体肝移植对供体是相对安全的。管道重建技术是活体肝移植的重要环节。术前、术中了解供体的解剖变异并正确处理,可降低并发症发生率。     

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目的 探讨和总结临床活估肝移植的手术经验。方法 对12例活体肝移植（13次手术，包括第一次减体积再次肝移植手术）的手术情况进行回顾性分析。结果 13次活体肝移植手术均获成功；所有供体手术后顺利康复，未出现任何严重并发症，并全部纳入术后长期随访中。1例晚期肝癌病人移植后死于胆瘘及继发多器官功能不全；9例Wilson病受体获得长期存活，术后神经系统症状显著改善，复查肝功能、铜氧化酶水平全部在正常范围；1例Wilson瘤，受体于术后72天死于不可递转的排异反应；1例乙型肝炎肝硬化伴亚急性戊型肝炎、肝功能衰竭、Ⅳ期肝性脑病的病人，行急诊成人右叶供肝活体肝移植，术后恢复顺利，现为术后第11周，未出现严重并发症，已恢复正常生活。结论 精湛细致的手术技术是活体肝移植成功的关键，活体肝移植适合我国国情，是解决当前全球性供肝来源匮乏问题的有效途径。     

成人—成人活体右半肝移植16例报告

目的：报道东京大学16例成人终末期肝病患进行活体右半肝移植的经验。方法：统计自2000年10月到2001年4月，对16例成人终末期肝病患进行了活体右半肝移植。供体和受体的平均体重分别为55kg(42-78kg)和57kg(41-81kg)。结果：供体手术的平均失血量为80ml(300-1600ml)，供体的平均住院时间为12d(6-38d)，14例供体未输血，1例供体术后发生并发症。移植肝的平均重量为719g(450-1050g)，所有移植肝均立即恢复功能，病人精神状康复，凝血酶原时间恢复正常。2例受体需要再次手术探查，2例患死亡（1例在术后16d死于全身性念珠菌感染，另1例在术后26d死于门静脉栓塞）。结论：认为采用右半肝的活体肝移植可以提供足够体积和功能的肝脏达到较好的结果。为成年患的肝移植提供了新的选择。     

成人-儿童间双供体活体肝脏移植一例报告

在活体肝移植中,供肝移植物达到受体标准肝体积的50%是满足受体正常肝功能的必要条件[1],主要的解决方法是切取供体占全肝60%～70%的右半肝、采用辅助式原位肝移植或给一个受体植入2个移植物.既往文献报道中,双供体活体肝移植都用于成人间[2-5],而成人-儿童间的双供体活体肝移植尚未见报道.     

使用活体右叶供肝肝移植的供体安全性

现有人提出对不能及时获得尸体供肝移植的成年患者采用活体的扩大右叶供肝肝移植 ,但由于供体的肝切除术复杂、费时 ,并要切除供体肝体积的近 60 %～ 70 % ,其供体安全性仍是一个主要问题。作者分析了2 2例采用成人对成人活体供体的右叶供肝肝移植资料以确定供体的选择标准。标准和方法　 1996年 3月～ 1999年 6月共施行2 2例成人对成人的活体右叶供肝移植术 ,供体年龄为18～ 51岁 (平均 35.5岁 ) ,与受体的关系为 :父亲 2例 ,配偶 8例 ,子女 4例 ,兄弟姐妹 4例以及叔、婶、侄子和姐夫各 1例。所有供体术前接受心理咨询 ,进行包括全血细胞计…     

成人间活体肝移植右半肝移植物切取的临床分析

目的：探讨成人间活体肝移植供体右半肝切取的技术。方法：8例成人间活体肝移植行供体右半肝切取，供肝切取范围：右半肝5例、扩大右半肝3例。供肝保留直径0.8cm以上的副右肝静脉。右半肝切除线在中肝静脉的右侧0.5~1.0cm处，扩大右半肝切除线在中肝静脉左侧0.5~1.0cm处。行术中胆道造影，在切取过程中不阻断入肝血流。结果：供体平均手术时间为448（353~510）min。供体手术平均失血量为384 （170 ~900 ）ml。切取的移植物平均重669.4（445~900）g，其中右半肝移植物平均重667.0g，扩大右半肝移植物平均重673.3g。移植物与受体体重之比平均为1.16%（0.76%~1.50%）。供体术后发生胆漏、肝肾功能不全各1例，经治疗后均痊愈。全组无手术死亡，均于3周内恢复出院。8例移植物和8例受体的1年生存率均为100%。结论：熟练掌握精良的供肝切取技术，成人活体肝移植中右半肝和扩大右半肝的切取对供体来说是安全的。     

右半肝活体肝移植验证标准肝体积公式

目的 分析216例活体肝移植患者的临床资料,探讨适合中国成人活体肝移植肝体积评估标准.方法 华西医院移植中心2001年7月至今共实施216例活体肝移植,选取符合标准的成人间活体右半肝(不含肝中静脉)179例肝移植供体,将供体的术中实测右半肝体积与CT测量右半肝体积以及各公式计算的标准右半肝体积进行比较,评估哪种公式更适合中国成人.结果 CT测量右半肝体积大于实际右半肝体积(P＜0.01).德国Heinemann、美国Yoshizumi、日本Urata、美国Vauthey、韩国Lee公式计算的右半肝体积结果显著大于实际肝脏体积(P＜0.01).香港Sheung Tat 公式计算的右半肝体积结果小于实际肝脏体积,差异有统计学意义(P＜0.05).华西Lünan-yan公式计算的右半肝体积结果与实际肝脏体积比较差异无统计学意义(P＞0.05).结论 华西Lünan-yan 标准肝体积公式适合中国成人活体肝移植标准肝体积评估.     

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目的：分析10例活体肝移植术中的血管变异，总结其外科处理经验，进一步提高手术成功率，减少并发症。方法：2001年1月至12月，行活体肝移植10例，其中左半肝8例，左外叶1例，右半肝1例，供肝者均为其母，经术中B超及胆管造影以确定肝切线。供体单支肝动脉分支与受体肝动脉吻合，两支肝动脉分别与受体肝左、右动脉吻合。门静脉分支与受体门静脉主干吻合。供体肝静脉与受体下腔静脉行端侧吻合。胆管重建均采用肝管分支与受体胆总管端端吻合，置T管引流。结果：10例活体肝移植，1例因肝动脉血栓形成，术后5天需次肝移植；1例发生排斥；其余8例均康复出院，5例已上学。结论：活体肝移植术中血管重建技术是其重要环节，术前和术中了解供受体解剖变异并正确处理，可减少术后血管和胆道的并发症。     

活体肝移植几种术式探讨(附50例报告)

目的探讨活体肝移植不同术式的临床应用。方法对1995年1月至2006年3月我科完成的50例活体肝移植的临床资料进行回顾性分析,探讨活体肝移植不同术式的临床应用和保障供体安全的策略等问题。结果本组资料中,所有供体术后均顺利康复,均未出现严重并发症。适应证：良性终末期肝硬化47例,恶性肿瘤3例。44例受体健在,手术死亡3例,3例死于远期并发症。本组供体右半肝（不包括肝中静脉）9例,右半肝（包括肝中静脉）1例,左半肝（包括肝中静脉）36例,左半肝或左外叶（不包括肝中静脉）4例。结论活体肝移植是解决目前全球供肝短缺问题的重要途径之一。活体肝移植手术过程复杂,根据临床实际选择合理手术方式是保证供体安全和提高手术成功率的关键。     

Living donor liver transplantation for fulminant hepatic failure

BACKGROUND: Living donor liver transplantation (LDLT) was originally indicated only for elective cases of pediatric patients with end-stage liver disease. In Japan, however, where liver transplantation from brain-dead donor is performed very rarely, this indication has been expanded to emergency cases such as fulminant hepatic failure (FHF). METHODS: Thirty-eight patients with FHF were treated between May 1992 and April 1999. Causes of acute liver failure were non-A, non-B hepatitis in 27 patients, hepatitis B virus in seven, and hepatitis A virus, Epstein-Barr virus, herpes simplex virus, and chrome poisoning in one each. RESULTS: Four patients did not undergo LDLT because of severe brain damage or combined multiple organ failure. The remaining 34 patients underwent a total of 36 LDLTs, including two retransplantations; 16 children received transplants of 17 lateral segments, three children and eight adults transplants of 11 left lobes, and seven adults transplants of eight right lobes. A total of 15 recipients died, four of primary graft dysfunction, three of refractory acute rejection, two of pneumonia, and one each of ductopenic rejection, sepsis, aplastic anemis, recurrence of Epstein-Barr virus hepatitis, multiple organ failure by chrome poisoning, and unknown hepatic failure. Primary graft dysfunction developed in adult recipients with small-for-size graft transplants, whereas refractory acute rejection and ductopenic rejection occurred in six grafts each of children with non-A, non-B FHF. CONCLUSIONS: LDLT can be safely expanded to cases of FHF in adult patients. Primary graft dysfunction in adult recipients with small-for-size left lobe grafts can be overcome by using right lobes. However, refractory acute rejection and ductopenic rejection in children remain a major problem.     

Techniques of reconstruction of hepatic veins in living-donor liver transplantation, especially for right hepatic vein and major short hepatic veins of right-lobe graft

Living-donor liver transplantation (LDLT) is now widely accepted as a therapeutic option for adult patients with acute and chronic end-stage liver disease. In the early period, the left lobe was the major liver graft used in adult LDLT to ensure donor safety, especially in Eastern countries. However, the frequent extremes of graft-size insufficiency in left-lobe LDLT represented a greater risk of small-for-size graft syndrome in the recipient, which has focused attention on transplantation of the right lobe from a living donor. The major concern of right-lobe LDLT has focused on its safety for the donor and the necessity for including the middle hepatic vein (MHV) in the graft to avoid congestion of the right anterior segment. The MHV carries out important venous drainage for the right anterior segment and is essential for perfect graft function. The decision of whether to take the MHV with the liver graft (extended right lobe graft) or whether to retain it in the donor, with reconstruction of the MHV tributaries in the liver graft (modified right lobe graft) has been extensively discussed in numerous studies. However, adequate right hepatic vein and major short hepatic vein (middle and inferior right hepatic vein [RHV]) drainage of the liver graft is perhaps equally important as MHV outflow drainage for the integrity of right-lobe graft function. Herein, the author describes various techniques of venoplasty of the right hepatic vein (RHV) and the major short hepatic veins to obviate venous outflow obstruction in these veins.     

Liver transplantation with monosegments.

BACKGROUND: Shortage of size-matched pediatric donors led to the development of surgical techniques to reduce or split livers and thus increase the potential pool of donors. Despite this, neonatal transplantation remains a problem because of the small size of the recipients. Further reduction of the left lateral segment is possible to provide a single segment graft (segment III). We report our experience of transplanting 6 babies using this technique. METHODS: Of 310 children transplanted in our center between October 1989 and March 1998, 6 patients, 2 male and 4 female, median age 37.5 days (range 5 to 92 days), median weight 3.45 kg (range 2.45 to 5.46 kg) were transplanted with a monosegment. The cause of liver failure was neonatal hemochromatosis in 4, retransplantation for hepatic artery thrombosis in 1, and hepatitis B in one. The donor liver was reduced or split to a left lateral segment. Segment II was then resected and discarded before transplantation. RESULTS: Overall, graft and patient survival is 83.3%. Five patients are alive with good graft function at a mean follow-up of 30.4 months (range 8 to 82 months). One child who was transplanted for hepatic artery thrombosis died from sepsis and multiorgan failure 48 hrs after transplant. None of the survivors had vascular or biliary complications. CONCLUSIONS: Monosegment liver transplantation with segment III appears to be a satisfactory option for treating small babies with liver failure.     

Auxiliary Partial Orthotopic Living Donor Liver Transplantation: Kyoto University Experience

Auxiliary partial orthotopic liver transplantation (APOLT) was initially indicated as a potentially reversible fulminant hepatic failure and non-cirrhotic metabolic liver disease to compensate for enzyme deficiency without complete removal of the native liver. We expand our indication of APOLT for small-for-size grafts to support the function of implanted grafts during the early post-operative period, and for ABO-incompatibility to sustain a patient's life if the patient has a graft failure. We retrospectively reviewed 31 patients undergoing APOLT from living donor. The indication of APOLT was fulminant hepatic failure in 6, non-cirrhotic metabolic liver disease in 6, small-for-size grafts in 13 and ABO-incompatible cases in 6. The cumulative survival rate for APOLT at 1 and 5 years was 57.9% and 50.6%, and 78.8% and 73.8% for standard LDLT. None of the patients who underwent transplantation with APOLT for fulminant hepatic failure had long-term patient survival. The incidence of acute cellular rejection was higher in APOLT (58.1%) than standard LDLT (35.0%). Biliary complication was higher and the need for retransplantation was greater in APOLT than standard LDLT (p < 0.01). The results suggest that the indications of APOLT should be reconsidered in view of the risk for complications and retransplantation.     

Safety and necessity of including the middle hepatic vein in the right lobe graft in adult-to-adult live donor liver transplantation

OBJECTIVE: To evaluate the safety of donors who have donated the middle hepatic vein in right lobe live donor liver transplantation (LDLT) and to determine whether such inclusion is necessary for optimum graft function. SUMMARY BACKGROUND DATA: The necessity to include the middle hepatic vein in a right lobe graft in adult-to-adult LDLT is controversial. Inclusion of the middle hepatic vein in the graft provides uniform hepatic venous drainage but may lead to congestion of segment IV in the donor. METHODS: From 1996 to 2002, 93 right-lobe LDLTs were performed. All right-lobe grafts except 1 contained the middle hepatic vein. In the donor operation, attention was paid to preserve the segment IV hepatic artery and to avoid prolonged rotation of the right lobe. The middle hepatic vein was transected proximal to a major segment IVb hepatic vein whereas possible to preserve the venous drainage in the liver remnant. RESULTS: There was no donor death. Two donors had intraoperative complications (accidental left hepatic vein occlusion and portal vein thrombosis) and were well after immediate rectification. Twenty-four donors (26%) had postoperative complications, mostly minor wound infection. The postoperative international normalized ratio on day 1 was better in the donors with preservation of segment IVb hepatic vein than those without the preservation, but, in all donors, the liver function was largely normal by postoperative day 7. The first recipient had severe graft congestion as the middle hepatic vein was not reconstructed before reperfusion. In 7 other recipients, the middle hepatic vein was found occluded intraoperatively owing to technical errors. The postoperative hepatic and renal function of the recipients with an occluded or absent middle hepatic vein was worse than those with a patent middle hepatic vein. The hospital mortality rate was also higher in those with an occluded middle hepatic vein (3/9 vs. 5/84, P = 0.028). CONCLUSIONS: Inclusion of the middle hepatic vein in right-lobe LDLT is safe and is essential for optimum graft function and patient survival.     

Graft and patient survival after adult live donor liver transplantation compared to a matched cohort who received a deceased donor transplantation.

Live donor liver transplantation (LDLT) has become increasingly common in the United States and around the world. In this study, we compared the outcome of 764 patients who received LDLT in the United States and compared the results with a matched population that received deceased donor transplantation (DDLT) using the United Network for Organ Sharing (UNOS) database. For each LDLT recipient (n = 764), two DDLT recipients (n = 1,470), matched for age, gender, race, diagnosis, and year of transplantation, were selected from the UNOS data after excluding multiple organ transplantation or retransplantation, children, and those with incomplete data. Despite our matching, recipients of LDLT had more stable liver disease, as shown by fewer patients with UNOS status 1 or 2A, in an intensive care unit, or on life support. Creatinine and cold ischemia time were also lower in the LDLT group. Primary graft nonfunction, hyperacute rejection rates, and patient survival by Kaplan-Meier analysis were similar in both groups (2-year survival was 79.0% in LDLT vs. 80.7% in case-controls; P = .5), but graft survival was significantly lower in LDLT (2-year graft survival was 64.4% vs. 73.3%; P < .001). Cox regression (after adjusting for confounding variables) analysis showed that LDLT recipients were 60% more likely to lose their graft compared to DDLT recipients (hazard ratio [HR] 1.6; confidence interval 1.1-2.5). Among hepatitis C virus (HCV) patients, LDLT recipients showed lower graft survival when compared to those who received DDLT. In conclusion, short-term patient survival in LDLT is similar to that in the DDLT group, but graft survival is significantly lower in LDLT recipients. LDLT is a reasonable option for patients who are unlikely to receive DDLT in a timely fashion.     

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.     

Potential immunological advantage of intravenous mycophenolate mofetil with tacrolimus and steroids in primary deceased donor liver transplantation and live donor liver transplantation without antibody induction.

With the current immunosuppressive regimens, graft loss secondary to immunological reasons after successful liver transplantation is a rarity; acute rejections, however, do occur, with the majority of them being steroid-responsive. The aim of the present study is to examine the rate of acute rejection with tacrolimus, intravenous (IV) mycophenolate mofetil (MMF), and steroids in primary deceased donor liver transplant (DDLT) and live donor liver transplant (LDLT) recipients. During the year 2005, 130 patients (mean age: 54.9 +/- 10.8, males: 84, females: 46, 112 DDLT and 18 LDLT) received primary liver transplantation. They were followed up for the incidence of acute rejection in the first 12 months. Liver biopsies were performed as clinically indicated; protocol liver biopsies were never performed. A total of 127 liver biopsies were performed. Thirty-two had a rejection activity index (RAI) score of > or =3, of which 24 biopsies in 20 patients were not treated with a steroid bolus. Eight (6.1%) patients (mean RAI score: 5.1 +/- 1.4) received 750 to 1500 mg of methylprednisolone over 3 days. Out of these, 2 were noncompliant, 4 were off MMF, and 1 was on cyclosporine. All patients responded to steroid therapy. None of the patients required any antibody preparation. In conclusion, IV MMF with tacrolimus and steroids is useful and required antirejection therapy in 6.1% of liver transplant recipients.