1例"两供一受"活体肝移植手术配合体会

肝脏移植是目前治疗终末期肝病最为有效的手段,但移植界多年来一直面临尸体供肝来源短缺的难题.为缓解受体需求和供体短缺之间的矛盾,20世纪末活体肝移植应运而生.在外科技术层面上,活体肝移植相对于尸体肝移植更加复杂、技术难度更高."两供一受"活体肝移植是指用两个供体的双左叶或一左叶一右叶供肝形成人活体肝移植手术,适用于体重较重的病人[1,2].     

1例“两供一受”活体肝移植手术配合体会

肝脏移植是目前治疗终末期肝病最为有效的手段,但移植界多年来一直面临尸体供肝来源短缺的难题。为缓解受体需求和供体短缺之间的矛盾,20世纪末活体肝移植应运而生。在外科技术层面上,活体肝移植相对于尸体肝移植更加复杂、技术难度更高。     

活体肝移植供体与受体护理进展

我国肝移植技术经多年的发展已经十分成熟,但供体短缺问题日益严重。活体肝移植（ Living Donor Liver Transplantation, LDLT）成为缓解供肝短缺的重要手段之一,LD—LT手术复杂,术前术后护理有其特殊性。近年来,我国的LDIT发展很快,对临床LDLT供体与受体的护理也提出了新的要求。     

多层螺旋CT在活体供肝移植供体术前的应用

活体供肝移植（living donor liver transplantation,LDLT）是将活体的部分肝组织移植给受体,该技术解决了肝源紧缺的难题,是肝移植的一大突破,现临床多采用LDLT。为筛选出合适的肝脏供体,确保手术顺利进行,术前影像学评估尤为重要,其应包括：     

活体肝移植术前MSCT评估肝静脉

目的 探讨MSCT在评价活体肝移植供体肝静脉解剖及变异中的价值及各种血管变异对移植手术的影响.方法 对拟作为活体肝移植供体的238例受试者行MSCT检查,并对其肝静脉解剖及变异进行评估.结果 238例受试者中,Nakamura肝静脉分型Ⅰ型164例,Ⅱ型60例,Ⅲ型14例.167例肝左静脉(LHV)和肝中静脉(MHV)共干;105例存在直径大于5 mm的Ⅷ段分支经过肝切面汇入MHV;68例Ⅳ段肝静脉汇入MHV,7例汇入LHV,其余汇入LHV及MHV;108例共出现139支直径大于3 mm的右肝下副静脉,55例65支右肝下副静脉与肝右静脉(RHV)的距离大于4 cm.结论 术前MSCT可提供关于供体静脉的详细、准确的信息,是拟肝移植供体术前静脉评估的重要无创性检查方法.     

术中超声在活体肝移植供体手术中的应用

目的探讨术中超声在活体肝移植（LDLT）供体手术中的应用。方法2005年3月-2005年11月我院15例右半供肝活体肝脏移植，由术中超声在肝中静脉的右侧1cm处确立切右半肝切除线，并提示直径0．5cm以上的肝中静脉属支、肝短静脉和副右肝静脉。结果沿术中超声所确定的切肝界线成功切取移植物；术中超声提示的肝V、Ⅶ段肝中静脉粗大属支以及肝下右静脉（IRHV）的类型及例数如下：V5（n=2）、V8（n=2）、V5和V8（n=1）、V5和IRHV（n=1）、V8和IRHV（n=1）。结论术中超声的引导在切除供体右肝时非常重要，可以明确切肝界线，提示较粗大的肝中静脉属支及第三肝门的血管，有利于这些静脉的重建，确保移植物有足够的静脉引流。     

亲属成人间活体肝移植1例临床分析

背景:活体肝移植的开展扩大了供体来源,有效缓解了供肝匮乏的局面,且活体供肝冷缺血时间短、质量好;若供、受者为亲属,可能具有免疫相容的优势.目的:总结1例亲属成人间活体肝移植的临床体会,探讨成人间活体肝移植治疗终末期肝病的手术方式及移植效果.方法:乙型肝炎后肝硬化(失代偿期)并门脉高压症患者1例,女性,年龄54岁,拟行肝移植手术.供者为患者外甥,23岁,既往身体健康.经术前评估后,切取供者右半肝并原位移植给受者.术后常规给予免疫抑制、防治感染、护肝、支持等治疗.结果与结论:术后供者生命体征平稳,手术历时4 h,失血约150 mL,术后第5天肝功能基本恢复正常,术后10 d行上腹部CT平扫加增强提示符合活体肝移植供体右半肝切除术后改变.术后受者生命体征平稳,手术历时7 h,失血约500 mL,彩超检查移植肝血管通畅,血供良好;生化指标逐渐恢复至正常范围,提示移植肝功能情况良好.术后供、受者无严重并发症发生,均健康存活,门诊随访肝功能正常.结果说明成人间活体肝移植为术前周密的准备工作,选择最佳的移植手术时机以及手术的成功创造了最佳条件,是在尸体供肝短缺的情况下治疗终末期肝病的理想方法.     

活体肝移植供体与受体的护理进展

肝移植至今已有半个多世纪的历史，已成为治疗终末期肝病的一种最有效的方法，得到了广泛应用。然而，供肝的短缺和受体数量不断增加的矛盾已成为制约肝移植手术开展的主要问题。活体肝移植在此背景下应运而生的发展”。活体肝移植（living liver transplantation）或活体供体肝移植（living donor liver transplantation，LDLT）是指把健康人的一部分肝脏切取下来，     

成人右半肝活体肝移植受体术后正常胆道及胆道并发症的超声表现

目的探讨成人右半肝活体移植(LDLT)术后正常胆道与胆管并发症的超声表现,并与尸体全肝移植(OLT)相关超声表现进行比较。方法回顾性分析21例LDLT与同期所行55例OLT受体胆道声像图,对两组间的胆管并发症发生率及其类型、正常胆管及胆管并发症者的声像图特点进行比较。结果 (1)LDLT胆道并发症发病率稍高于OLT(38.1%vs 36.4%)。(2)LDLT及OLT组正常胆道表现基本一致,但LDLT组则有少数(4/13,30.8%)病例肝门部胆管无法显示。(3)两组的胆管非吻合口狭窄(NAS)表现一致;但在胆管吻合口狭窄(AS)中,OLT组肝门部胆管显示清晰,LDLT组往往显示困难。结论活体肝移植受体胆道超声表现与全肝移植有所不同,有必要加强对活体肝移植声像图表现的深入研究。     

活体肝移植中轻度脂肪变性供肝的应用

背景：在活体肝移植中使用脂肪变性供肝不但影响供者的安全,同时也影响受者的生存。目的：评价活体肝移植中使用轻度脂肪变性供肝时供者的安全性及受者预后情况。方法：回顾性分析104例成人间右半肝活体肝移植的资料,根据移植过程中供肝活检病理标本的脂肪变性程度将所有病例分成4个组。比较各组移植供受者移植后2周的肝体积增生率,分析104例成人间活体右半肝肝移植受者移植后死亡情况及原因。结果与结论：4组病例在供受者移植后肝功能的恢复和受者后移植预后无明显差别,没有肝功能延迟恢复和原发无功发生。轻度大泡性脂肪肝者只要残肝足够可以成为合适的活体肝移植供者。使用轻度大泡性脂肪肝并不增加受者病死率和移植物失功。     

超吸刀结合氩气刀在活体肝移植中的应用

背景：活体肝移植供者的安全令人关注,供肝切取过程复杂、技术要求高、难度大,因而移植中减少出血量和副损伤是减少并发症发生率的关键。目的：观察活体肝移植过程中超吸刀结合氩气刀应用的优势。方法：回顾昆明市第一人民医院移植中心自2006-05/2010-10应用超吸刀结合氩气刀开展的26例活体肝移植,其中13例使用右半肝,9例使用左半肝,4例使用双供肝。活体供者年龄22～63岁。通过对供肝切取过程中的失血情况及供者术后相关并发症的观察,总结应用超吸刀及氩气刀进行供肝切除的优势。结果与结论：无供者死亡,且无供者因出血等原因而二次手术,仅有1例供者移植后出现胆瘘,充分引流后痊愈。右半供肝切取平均失血683mL,输血820mL,切除肝质量平均为530g。在活体肝移植供肝切取中应用超吸刀及氩气刀不仅可以缩短移植时间,减少移植损伤,同时也能够降低移植后并发症的发生率,因此联合应用超吸刀及氩气刀是一种安全而有效的供肝切取方法。     

超声造影监测活体肝移植术后血流灌注变化的研究

目的探讨超声造影在不含肝中静脉的成人间活体右半肝移植（A—ALDLT）中的作用。方法对7例不含肝中静脉的成人间活体右半肝移植患者进行超声造影检查。结果7例中1例移植肝肝动脉栓塞，门静脉栓塞，移植物失功能；4例移植肝V5、V8段回声增高，微循环血流灌注与V6、V7段明显不同步，呈现早灌注早消退的图像特征，于移植后28d恢复正常；1例术后出现肝梗塞灶于第7天移植肝失功能；1例肝移植术后超声造影检查正常。结论超声造影有助于观察A—ALDLT的血流灌注，早期发现肝移植术后并发症。     

Liver transplantation

Living donor liver transplantation (LDLT) had been started for pediatric patients since 1989, and indication of LDLT has been expanded to adult patients in concomitance with overcoming small-for-size graft. Recently, around 500 cases of LDLT have been performed annually, and outcome of pediatric patients after LDLT has been improved with more than 90% of patient survival rate. Deceased donor liver transplantation (DDLT) also had been started since 1999, however, annual number of DDLT remained less than 10 cases. Therefore, condition of liver transplantation in Japan is quite unique, which consist of more than 98% of LDLT and less than 2% of DDLT. Law of organ transplantation had been modified in July 2010, which had been changed to world standard one.     

Effect of respiration on the spectral Doppler wave of the right hepatic vein in right lobe living donor liver transplant recipients.

OBJECTIVE: The purpose of this study was to evaluate the effect of respiration on the spectral Doppler wave of the right hepatic vein (RHV) in right lobe living donor liver transplant (LDLT) recipients. METHODS: A spectral Doppler wave of the RHV was obtained from 23 consecutive right lobe LDLT recipients who had no complications and from 26 healthy subjects during free breathing, breath holding at expiration, and breath holding at inspiration. To assess the RHV flow quantitatively, the venous periodicity index (VPI) was calculated as follows: VPI=(V(F)-V(R))/V(F), where V(F) was the measured peak forward velocity, and V(R) was the measured peak reversed velocity. The mean VPIs of the RHV obtained in the 3 respiratory states were compared by repeated measures analysis of variance. Spectral Doppler waves of the RHV were categorized as triphasic with or without reversed flow, biphasic, or monophasic and were compared among the 3 respiratory states. RESULTS: In both right lobe LDLT recipients and healthy subjects, the mean VPIs of the RHV obtained during breath holding at inspiration were significantly lower than those during free breathing (P<.001) and breath holding at expiration (P<.001). The wave pattern during breath holding at inspiration was monophasic in 7 (30.4%) right lobe LDLT recipients and 3 (11.5%) healthy subjects, whereas the monophasic pattern was not seen during free breathing or breath holding at expiration in any of these subjects. CONCLUSIONS: Breath holding at inspiration significantly reduces the periodicity of RHV flow and can make otherwise pulsatile RHV flow monophasic in right lobe LDLT recipients without postoperative complications as well as in healthy individuals.     

Evaluating Biliary Anatomy and Variations in Living Liver Donors by a New Technique: Three-Dimensional Contrast-Enhanced Ultrasonic Cholangiography

Accurate assessment of the biliary anatomy is important for the safety of liver donors in living donor liver transplantation (LDLT). We evaluated the biliary anatomy and variations of 12 living liver donors with 3-D contrast-enhanced ultrasonic cholangiography (3-D CEUSC) by injecting microbubble contrast agents into the common hepatic ducts intraoperatively. Two radiologists assessed the diagnostically adequate, delineation of biliary branch orders, visibility scores (grades 0 to 3) and anatomical patterns of the intrahepatic biliary tree by consensus. The results were compared with findings on intraoperative cholangiography (IOC) and surgery. 3-D CEUSC successfully demonstrated the spatial structure of the intrahepatic biliary tree in all 12 donors. The maximum branching order of intrahepatic bile ducts displayed on 3-D CEUSC was the fifth order in the right lobe and fourth order in the left lobe of the liver, respectively. The visibility scores of the first-order (3.00 ± 0.00) and second-order (2.67 ± 0.69) branches were significantly (p < 0.001) higher than that of the third-order (1.98 ± 1.13) branches, whereas visibility scores of the second-order (2.88 ± 0.34) and third-order (2.44 ± 1.01) branches in the right lobe were significantly (p = 0.040 and p < 0.001, respectively) higher than those in the left lobe (2.46 ± 0.88 and 1.33 ± 0.99). The 3-D CEUSC images of the 12 donors were diagnostically adequate for evaluating the biliary anatomy. Normal biliary pattern in nine donors and biliary variations in three donors were confirmed by both IOC and surgical findings. 3-D CEUSC may be a potential alternative to IOC in the evaluation of biliary anatomical variation before graft harvesting in LDLT. (E-mail: ghchen.gzsums@gmail.com)     

MSCT、IQQA评价肝移植供体术前肝体积的价值

目的探讨CT手动法、IQQA半自动法、门静脉右支流域法测量右半肝体积与术中移植肝体积的相关性,分析其影响因素。方法对79名供体分别以CT手动法及IQQA半自动法测量全肝体积(以CTV全、IQQAV全表示)及右半肝体积(以CTV、IQQAV表示),用门静脉右支流域法测量右半肝体积(以RPVTV表示),并分别将3种术前右半肝体积测量结果与术中右半肝体积(IOV)对比,计算术前所测3种右半肝质量与受体体质量的比例(GRWR),比较其准确性。结果 IQQAV大于IOV,其与IOV的相关性比CTV与IOV的相关性更好。RPVTV与IOV亦有相关性,但相关性不如IQQAV。CTV及IQQAV的GRWR各有1例小于0.8%。结论与CTV相比,IQQAV更准确。     

Living donor liver transplantation: selection, perioperative care, and outcome

A perception that living donor liver transplantation can be accomplished with an acceptable donor complication rate and recipient survival rate has led to the acceptance of living donor liver transplantation as a viable alternative to decreased deceased donor transplantation. Careful candidate evaluation and selection has been crucial to the success of this procedure. Advancements in the understanding of the lobar nature of the liver and of liver regeneration have advanced the surgical technique. Initial attempts at adult-to-adult donation utilized the left hepatic lobe, but now have evolved into use of the right hepatic lobe. Size matching is very important to successful graft function in the recipient. There is great concern regarding morbidity and mortality in donors. Biliary complications and infections continue to be among the most highly reported complications, although rates vary among centers and countries. Reports of single center complications have ranged from 9% to 67%. A survey of centers in the United States in 2003 reported complications of 10%. A series from our institution reported complications arising in 13 (33%) of 39 patients. A review focused on documenting donor deaths found 33 living liver donor deaths worldwide. The much publicized immediate postoperative mishap of 2002 that resulted in a donor's death resulted in a drop in the utilization of living donor liver transplantation in the United States, from which this procedure has never fully recovered. The future development and expansion of living donor liver transplantation depends on open communication regarding donor complications and deaths. Close immediate postoperative monitoring and meticulous management will remain an essential aspect in limiting donor complications and deaths.     

活体右半肝肝移植超声造影微灌注检查的初步研究

目的 探讨超声造影评价活体右半肝肝移植术后早期血流微灌注的价值.方法 应用超声造影剂声诺维对26例活体右半肝肝移植受者分别于术后1d、7d、15d、30d进行超声造影检查,观察移植肝的微灌注情况,并结合术式进行分析.结果 26例活体右半肝肝移植受者中,15例为正常灌注模式,均未发现血流动力学异常;11例为异常灌注模式,其中8例存在桥血管回流障碍,4例门静脉流量过高.异常灌注模式表现为术后第1d检查动脉早期出现增强过程中的瞬间不同步现象,出现高增强区及低增强区,与周围肝组织相比差异明显,且该差异在随后的几次检查中随时间延长而逐渐消失.结论 活体肝移植术后早期.移植物微灌注异常与人肝血流和出肝血流的异常相关,静脉回流障碍和门静脉过度灌注是主要因素,超声造影可作为评价移植物微灌注的有效方法.     

Cholangiojejunostomy for multiple biliary ducts in living donor liver transplantation: A case report

BACKGROUNDLaparoscopic living donor hepatectomy (LLDH) has been successfully carried out in several transplant centers. Biliary reconstruction is key in living donor liver transplantation (LDLT). Reliable biliary reconstruction can effectively prevent postoperative biliary stricture and leakage. Although preoperative magnetic resonance cholangiopancreatography and intraoperative indocyanine green cholangiography have been shown to be helpful in determining optimal division points, biliary variability and limitations associated with LLDH, multiple biliary tracts are often encountered during surgery, which inhibits biliary reconstruction. A reliable cholangiojejunostomy for multiple biliary ducts has been utilized in LDLT. This procedure provides a reference for multiple biliary reconstructions after LLDH.CASE SUMMARYA 2-year-old girl diagnosed with ornithine transcarbamylase deficiency required liver transplantation. Due to the scarcity of deceased donors, she was put on the waiting list for LDLT. Her father was a suitable donor; however, after a rigorous evaluation, preoperative magnetic resonance cholangiopancreatography examination of the donor indicated the possibility of multivessel variation in the biliary tract. Therefore, a laparoscopic left lateral section was performed on the donor, which met the estimated graft-to-recipient weight ratio. Under intraoperative indocyanine green cholangiography, 4 biliary tracts were confirmed in the graft. It was difficult to reform the intrahepatic bile ducts due to their openings of more than 5 mm. A reliable cholangiojejunostomy was, therefore, utilized: Suture of the jejunum to the adjacent liver was performed around the bile duct openings with 6/0 absorbable sutures. At the last follow-up (1 year after surgery), the patient was complication-free.CONCLUSIONIntrahepatic cholangiojejunostomy is reliable for multiple biliary ducts after LLDH in LDLT.