Simplified technique for auxiliary orthotopic liver transplantation using a whole graft

Background

Acute liver failure is associated with a high mortality rate and the main purposes of treatment are to prevent cerebral edema and infections, which often are responsible for patient death. The orthotopic liver transplantation is the gold standard treatment and improves the 1-year survival.

Aim

To describe an alternative technique to auxiliary liver transplant on acute liver failure.

Method

Was performed whole auxiliary liver transplantation as an alternative technique for a partial auxiliary liver transplantation using a whole liver graft from a child removing the native right liver performed a right hepatectomy. The patient met the O´Grady´s criteria and the rational to indicate an auxiliary orthotopic liver transplantation was the acute classification without hemodynamic instability or renal failure in a patient with deterioration in consciousness.

Results

The procedure improved liver function and decreased intracranial hypertension in the postoperative period.

Conclusion

This technique can overcome some postoperative complications that are associated with partial grafts. As far as is known, this is the first case of auxiliary orthotopic liver transplantation in Brazil.     

肝移植治疗转移性肝癌临床价值及评价

肝移植是治疗部分不具备手术切除条件或者其他治疗方法无效的转移性肝癌病人的有效手段。由于不同来源的肝转移肿瘤行肝移植临床效果不同,临床上应严格把握手术适应证及治疗时机,以神经内分泌来源的肿瘤,尤其是类癌来源者肝移植效果最好,是目前转移性肝癌行肝移植手术的主要适应证,而结直肠癌肝转移行肝移植的价值还尚须进一步研究。目前,对于乳腺癌等其他肿瘤来源的转移性肝癌的报道较少。     

原位肝移植治疗急性肝功能衰竭21例临床分析

目的探讨原位肝移植治疗急性肝功能衰竭的临床疗效。方法回顾性分析天津市第一中心医院21例因急性肝功能衰竭行原位肝脏移植术病人的临床资料，总结急性肝衰竭实施肝移植的经验。结果21例病人随访时间为3～60个月，中位随访时间为25个月。生存时间为1—1530d，中位生存时间为517d。病人的围手术期存活率为66．7％，1年存活率为66．7％，2年存活率为66．7％。死亡原因包括多脏器功能衰竭、颅内出血、上消化道出血、急性成人呼吸窘迫综合征、移植物原发性无功能。14例的远期性生存病人中，13例移植前合并乙型肝炎（乙肝），其中有1例（1／13）在术后1年出现乙肝复发。结论肝移植术是治疗急性肝功能衰竭最有效的方法，严格把握适应证、合理选择手术时机是提高疗效的关键。     

两种微囊化肝细胞包裹技术对肝细胞移植疗效影响的实验研究

目的 探讨两种不同微囊化肝细胞包裹技术移植后对急性肝衰鼠的治疗作用.方法 建立急性肝衰大鼠模型,分离纯化SD大鼠肝细胞,应用两种不同的微囊化包裹肝细胞方法 I组(Ba2+-Alg)和Ⅱ组(Alg-P11-Alg),移植后观察其模型鼠肝功能生化指标和存活率.结果 对照组48 h内存活率仅15.4%,I组和Ⅱ组存活率在96 h后始终维持在60%左右.两组对比无显著性差异,并且肝功能生化指标两组对比亦无显著性差异.结论 两种不同微囊化肝细胞包裹方法 ,移植后对急性肝衰鼠具有相同的治疗效果.     

原发性肝癌切除术后复发的肝移植治疗

目的总结原发性肝癌切除术后复发行肝移植治疗的经验。方法2002年8月至2004年11月上海交通大学医学院附属瑞金医院对4例肝癌切除术后复发病例（其中1例合并急性肝功能衰竭）行同种异体肝移植治疗。结果3例移植术后已分别无瘤存活17个月、12个月和27个月至今。1例术后第3天死于多器官功能衰竭。结论对原发性肝癌切除术后复发病例的肝移植治疗，小肝癌切除后复发肿瘤仍符合Milan标准者有着良好的预后；个别合并门静脉癌栓者预后较好；合并急性肝功能衰竭者应相当谨慎。     

原发性肝癌切除术后复发的肝移植治疗

目的探讨原发性肝癌切除术后复发病人的肝移植手术指征和注意事项。方法总结2003年7月至2005年8月59例因肝癌接受肝移植的临床资料，其中肝癌切除术后复发12例（复发组），移植术前未接受手术治疗47例（对照组），分析两组病人移植术前肝功能、治疗情况、术中探查、手术时间、无肝期时间、出血量以及术后恢复情况。结果复发组病人移植手术时间、术中出血量及输血量均明显大于对照组，但两组无肝期时间以及1、2年存活率（75％vs．86％，P〉0．05；70．8％vs．83，3％，P〉0．05）差异无显著性意义。结论肝移植是肝癌切除术后复发病人的有效治疗方法，合理掌握肝移植指征是治疗肝癌切除术后复发的关键。     

肝移植治疗暴发性肝功能衰竭17例临床观察

目的 观察肝移植治疗暴发性肝功能衰竭的效果及失败原因。方法 总结本所17例暴发性肝衰行肝移植治疗的临床资料。结果 17例暴发性肝衰行肝移植6例存活1年，1年存活率为35．3％。死亡原因分别为肺部感染致呼吸衰竭6例，多器官衰竭2例，术后胸腔大出血1例，DIC1例，颅内出血1例。结论 病人术前状况决定肝移植效果；肺部并发症是暴发性肝功能衰竭肝移植术后死亡的主要原因。     

Orthotopic liver transplantation in hemophilia B: a case report

Liver transplantation is a treatment modality that is being used with increasing frequency in cases of liver-based metabolic defects. This is a case report of a patient with hemophilia B who was treated since childhood with factor IX replacement for recurrent hemarthroses. Subsequent hepatitis B (HBV) and C (HCV) infection had resulted in the development of chronic active hepatitis, ultimately leading to cirrhosis. Orthotopic liver transplantation performed for endstage liver disease resulted in a rise in factor IX levels from 2% to 83% of normal values within 24 h post-operatively, and levels remained above 90% of normal values after postoperative day 3 without factor IX replacement. To our knowledge, only two cases of hemophilia B treated by orthotopic liver transplantation have been reported. This procedure has, however, only been implemented in cases of terminal liver insufficiency in hemophiliacs.     

Liver resection and transplantation — Therapeutic concepts in surgical treatment of hepatic metastases

Summary Background: Surgical procedures such as liver resection or liver transplantation are the only treatment modalities that provide a chance of cure for patients with liver metastases. Methods: This report reviews results of liver resection and liver transplantation for liver metastases from colorectal cancer and neuroendocrine tumors as compared to the natural course. Results: Overall 5 year survival after curative liver resection for colorectal metastases ranges between 25 and 48%. The operative mortality is between 0 and 5%. Risk factors for tumor recurrence are more or less defined. Reresections of metastases can be performed with comparable mortality rates and results. Liver transplantation for unresectable colorectal metastases offers a median survival of 28 months, but the chance of cure only for individual patients. Exclusion of patients with positive lymph nodes of the primary tumor improves median survival. As there are alternative treatment options for neuroendocrine metastases, indication for liver resection or transplantation is not clearly defined, but the chance of cure by means of surgical treatment should not be missed. Curative resections of neuroendocrine liver metastases can achieve 5-year survival rates of more than 80%. Conclusions: Radical surgical removal of liver metastases from colorectal and neuroendocrine cancer can improve the prognosis for selected patients. Further improval is expected from a multimodal approach.      

Central pontine myelinolysis after liver transplantation: a case report

A patient development deteriorating mental status, quadriparesis, and severe pseudobulbar palsy with the inability to speak or swallow following orthotopic liver transplantation (OLT). Subsequently, abnormalities were found in the pons on MRI that were consistent with central pontine myelinolysis (CPM). Marked recovery occurred following transfer to the rehabilitation medicine service. Seven months following development of CPM, a mild dysarthria has persisted, but full ambulation has returned. Although no significant fluctuations in serum sodium were seen perioperatively, multiple risk factors associated with the development of CPM were present, including end-stage liver disease, a history of alcohol abuse, malnutrition, hypoxia, and use of cyclosporin medication postoperatively. This case demonstrates that the development of CPM may occur following OLT despite meticulous attention to serum sodium concentrations. We conclude that CPM is multifactorial in nature. There can be a great variation in its clinical course.     

肝移植及术后并发症的处理(附18例报告)

目的探讨采用肝移植技术治疗肝脏终末期病变的方法及术后并发症的处理。方法对采用背驮式肝移植和经典的原位肝移植技术治疗18例肝脏终未期患者进行回顾性分析。结果本组无手术中死亡。18例患者(9例为终末期肝硬化,9例为肝细胞癌)术后出现19例次并发症(包括切口血肿、胸腔积液、脓液、肺炎、胆汁漏、严重胆管炎、急性排斥反应,感染性休克,多器官功能不良综合征等)。5例于术后1个月内死亡,死亡原因为肺部感染合并呼吸衰竭,急性肾功能衰竭,急性心功能衰竭,肝功能衰竭及感染性休克。术后随访3月～3年,9例仍然存活,后期死亡4例,其中2例死于肺炎并呼吸衰竭,另2例死于脑转移和肝癌复发。结论肝移植是治疗末期肝病的有效手段。为了肝移植能取得良好的疗效,合理选择肝移植的手术适应证,正确的围手术期及手术后合并症的处理是非常重要的。     

Tuberculosis following liver transplantation: report of a case and review of the literature

We report on a 44-year-old man who developed tuberculosis 4 months after liver transplantation. The diagnosis was confirmed using a polymerase chain reaction (PCR) technique in bronchial alveolar lavage (BAL) fluid, and the patient was successfully treated by reducing his immunosuppression and administering antituberculous drugs. The patient became afebrile 20 days after starting antituberculous therapy and remains well at home. A review of the literature revealed that tuberculosis after liver transplantation is a rare complication with a reported mortality rate of as high as 40%. The mortality is highest for patients who become symptomatic within 3 months after transplantation (83% vs 0%, P<0.01; Fisher's exact test) and for those with an interval between the initial symptom and diagnosis of more than 2 weeks (71% vs 0%, P<0.05). Early diagnosis is, therefore, essential for successful resolution of tuberculosis after liver transplantation.     

2023中国转移性肝癌肝移植多中心合作项目研讨会会议纪要

由浙江大学郑树森院士领衔,汇集全国28家肝移植中心的中国首个转移性肝癌肝移植多中心合作项目在上海启动,围绕转移性肝癌肝移植入组条件、转移性肝癌肝移植风险评估与预后判断、转移性肝癌肝移植围手术期用药、多中心合作项目实施细节四项议题,与会专家展开深入交流和讨论,并以调查问卷形式凝聚共识、明确方向,致力于推动国内高质量规范化开展转移性肝癌肝移植临床研究。     

肝胆管结石病肝移植(附4例报告)

目的 探讨肝胆管结石终末期病变肝移植的适应证及术中技术和围手术期处理的改进方法。方法 回顾性分析我科近年来施行的肝胆管结石终末期病变肝移植4例。结果 3例均为肝胆管结石继发胆汁性肝硬化失代偿期。病例1行先转流后游离肝脏的原位肝移植，病例2、3行不转流的改良背驮式肝移植，病例4行不转流的原位肝移植。平均手术时间7．9h，失血800ml。4例手术均成功。病例1术后第6天出现消化道出血，经保守治疗痊愈；病例2术后第44天并发消化道出血和胆肠吻合口漏，经治疗痊愈；病例4术后第8天和第10天并发肝动脉吻合口出血，经再次手术治疗，痊愈出院。术后病理结果为胆汁性肝硬化。所有病例均随访，健康存活。结论 肝胆管结石继发胆汁性肝硬化失代偿期是肝移植适应证。先转流后游离肝脏及改良背驮式肝移植技术的应用可以减少术中出血、降低术后并发症。     

Liver transplantation for PNH with Budd-Chiari syndrome

A 54-year-old male patient with end-stage liver failure from Budd-Chiari syndrome due to paroxysmal nocturnal hemoglobinuria (PNH) underwent liver transplantation (OLT) in 1989. Retransplantation became necessary 1 year later when thrombotic occlusion of the portal vein and common hepatic artery led to graft loss after withdrawal of anticoagulation therapy because of several gastrointestinal bleeding episodes. The patient is now alive 3 years after the first OLT. To the best of our knowledge and according to the literature, this is, to date, the longest that any PNH patient has survived after liver transplantation. Although the course of this patient was complicated in a way similar to that reported for other cases in the literature, patients with PNH should not, in principle, be excluded from liver transplantation. Lifelong anticoagulation with coumarin and the use of steroids together with cyclosporin reduce the risk of recurrent thrombosis and PNH crises.     

原发性肝癌肝移植11例临床资料小结

目的探讨肝移植在原发性肝癌治疗中的意义。方法回顾分析2004年3月-2006年7月11例肝癌肝移植的临床资料。结果11例手术全部成功,围手术期无死亡。随访时间最长40个月,最短12个月,其中1例因乙肝复发,爆发性肝功能衰竭、肝肾综合症,于术后16个月死亡。1例在术后2个月因肺部巨细胞病毒感染,呼吸衰竭死亡。其余健康成活,1-3个月复查一次,无肿瘤复发,肝脏功能正常,α-FP<8ng/ml,HBV-DNA<103拷贝/毫升。结论肝移植治疗原发性肝癌仍要严格控制适应症;早期预防感染和长期治疗乙肝也是提高成功率的一个重要环节。     

Liver transplantation for Budd-Chiari syndrome: A retrospective study

A retrospective study was performed on 11 patients who underwent orthotopic liver transplantation for Budd-Chiari syndrome (BCS), 3 of whom had fulminant type BCS and 8, chronic type BCS. Both the 3- and 5-year actuarial survival rates were 64%, after one patient with fulminant, and three with chronic disease died of sepsis or multiple organ failure following transplantation. Anticoagulation therapy in the early postoperative period was tailored to each individual patient. Most of the patients received heparin for several days and were then converted to Coumadin therapy, although some were not given heparin in the immediate postoperative period but were instead commenced on oral Coumadin after the prothrombin time had recovered to wihtin the normal range. All the long-term survivors had received Coumadin therapy and there was no recurrence of BCS and no early thrombotic or hemorrhagic event. One patient developed late thrombosis of the portal vein despite having received apparently adequate Coumadin therapy. It was thus concluded that liver transplantation is an effective therapy for both fulminant and chronic BCS, and that immediate postoperative heparinization is not mandatory for all patients.     

猪原位辅助性部分肝移植治疗急性肝功能衰竭的模型

目的建立猪原位辅助性肝移植(APOLT)治疗急性肝功能衰竭的动物模型,并评价其治疗效果。方法选取健康雌性良种幼猪18头,其中12头建立急性肝功能衰竭模型,另6头作为肝移植的供者。将急性肝功能衰竭的幼猪随机平均分为2组:对照组,不作任何处理;实验组,进行APOLT术,切除受者肝脏左叶,将修整后的供肝右叶移植于原肝左叶肝床处,供肝肝上下腔静脉与受者肝肝上下腔静脉行端侧吻合,供肝门静脉与受者肝门静脉行端侧吻合,受者脾动脉在结肠后与供肝动脉行端端吻合,胆总管置管外引流。结果对照组7d生存率仅为17%,而实验组为83%。实验组术后第7d肝功能基本恢复正常,组织学检查示原肝细胞再生明显。结论门静脉注射氨基半乳糖 脂多糖诱导的猪急性肝功能衰竭是一个理想的动物模型;APOLT对急性肝功能衰竭具有较好的疗效。     

Liver resection for hepatic metastases: 15 years of experience

Background/Purpose: Liver metastases, especially those from primary colorectal cancers, are treatable and potentially curable. Imaging techniques such as computed tomography, magnetic resonance, and ultrasonography have advanced in recent years and led to increased sensitivity and specificity in the diagnosis of liver metastases. Liver surgery also has been revolutionized in the past two decades. Dissection along nonanatomical lines has permitted the resection of multiple lesions that previously might have been considered unresectable. Methods: From 1986 to 2000, 181 patients underwent liver resection for hepatic metastasis from colorectal cancer. Of these, 56 patients underwent systematic anatomical major hepatic resection and 125 underwent nonanatomical limited resection. Results: Operative morbidity and mortality rates were higher in patients in whom anatomical procedures were performed. The overall 5-year survival rate of the 181 patients was 39.8%. Conclusions: An aggressive surgical procedure in patients with hepatic colorectal metastases is safe, and may prolong overall survival, and therefore should be considered in all patients with metastases confined to the liver. Received: April 14, 2002 / Accepted: May 12, 2002 Offprint requests to: G. Belli Via Cimarosa 2/a, 80127 — Naples, Italy Accepted at fifth World Congress of the International Hepato-Pancreato-Biliary Association (IHPBA)