原位肝移植术的麻醉管理

目的探讨成年原位肝移植术病人围手术期血流动力学、内环境变化和麻醉管理方法。方法52例晚期肝病行背驮式原位肝移植术病人，采用静吸复合全身麻醉。术中监测血流动力学、血气、生化指标、凝血功能、体温、尿量及出血量等。根据成人原位肝移植术无肝前期、无肝期、新肝期的特点及术中具体情况，给予相应的处理。结果52例行肝移植术病人无术中死亡。围手术期血液动力学基本平稳。pH值和BE等代谢性指标变化较大；所有病人手术期间血游离Ca^2 均偏低。术中体温变化不大。结论肝移植手术期间血流动力学、凝血因子、电解质和酸碱平衡等变化复杂，应加强麻醉管理和监测，并积极实施血液保护措施。     

二次或多次肝移植术患者的麻醉管理

本院自2002年以来完成二次或多次肝移植术68例,取 得较好效果。现将围术期麻醉管理的经验报告如下。 临床资料 二次和多次肝脏移植术患者68例,ASAⅡ～Ⅳ级;其中 二次肝脏移植术61例,三次肝脏移植术5例,四次移植术2     

亲体部分肝移植现状

亲体部分肝移植现状严律南自３０年前Ｓｔａｒｚｌ为先天性胆道闭锁患儿作了第一例原位肝移植以来，迄今全世界肝移植已逾５０００例，近１０年来由于药物及手术技术的进展（环孢霉素，ＵＷ液、生物泵转流技术、围手术期监护的进步等），成功率和安全性大大增加，目前一年...     

小儿肝移植术麻醉管理专家共识

自20世纪60年代成功进行第1例小儿肝移植术以来,随着外科技术、抗排异治疗以及围术期麻醉管理水平的进步,小儿肝移植术后存活率和远期预后均得到了很大改善.目前我国每年实施的小儿肝移植术的数量已超千例,其中亲属供体的活体和部分肝(含劈离式)肝移植术的比例正逐年增加,患儿术后5年存活率约80％,已接近国际先进水平.肝移植患儿...     

高龄患者同种异体肝移植术的麻醉与围术期管理

(1)一般情况:患者男性, 年龄77岁, 体重72 kg, 身高168 cm, BMI 25.5 kg/m2。发现乙肝抗原阳性30年, 1月前无明显诱因出现全身酸软乏力、黄疸, 便血5 d。以抗感染、纠正凝血功能等对症支持治疗, 拟在全身麻醉下行同种异体肝移植术。     

原位肝移植术临床麻醉管理的探讨

目的 探讨成年人原位肝移植术期的变化及麻醉处理。方法 采用全身麻醉或全身麻醉或全身麻醉复合硬外麻醉;无肝期采用体外静脉转流;术中监测动力学、呼吸功能、血气、生化、凝血功能、体温、血糖、尿量及出血量。根据原位肝移植术无肝前期、无肝期、新肝期的特点,给予相应的麻醉处理。结果 无肝期均外静脉转流技术,可以使术中血液动力学埸于稳定。无肝期初期及新肝期理。结果 无肝期均采用体外静脉转流技术,可以使术中血液动     

亲体部分肝移植二例

在总结我院首次施行活体供肝原位部分肝移植经验的基础上 ,2 0 0 1年 1月 6日、2月 18日我院再次开展 2例亲体原位部分肝移植 ,现供受体情况良好 ,报告如下。1.一般情况 :例 1,女 ,10岁 ,体重3 5ｋｇ ,诊断Ｗｉｌｓｏｎ’ｓ病。供体为其母亲 ,3 5岁 ,血型相同 ,体重 5 0ｋｇ。例 2 ,男 ,8岁 ,体重 2 5ｋｇ ,诊断Ｗｉｌｓｏｎ’ｓ病 ,供体为其母亲 ,3 2岁 ,血型相同 ,体重 4 5ｋｇ。2 .供肝切取 :取上腹屋顶形切口。术中Ｂ超探查肝内血管位置及走向 ,确定肝切线。经胆囊管行术中造影 ,了解胆道解剖结构。切除胆囊 ,游离出肝左动脉和门静脉左…     

儿童亲体肝移植手术视频

儿童肝移植的病肝游离切除过程中,因胆汁淤积性病变的病肝肿大明显,分离第二三肝门时血管显露困难,可首先依次钳夹门静脉、肝下下腔静脉、肝上下腔静脉,阻断并切断门静脉,沿肝下腔静脉由下而上锐性切除大部分肝实质,保留与肝静脉及肝下腔静脉关系密切的尾状叶肝组织,然后直视下分离与肝组织相连的肝静脉及各个肝短静脉,并逐一结扎肝短静脉...     

Anesthetic management of living liver donors

PURPOSE: Living organ donation is being performed with increasing frequency to overcome the shortage of organs for transplantation. Our experience in the anesthetic management of donors with relevant issues is discussed and complications encountered are recorded. METHODS: Data were collected retrospectively and analyzed on all 22 left lateral hepatectomies performed at our institution between 1993 to 1997 for transplantation. RESULTS: Major ethical concern was the risk to the donors and anesthetic issues were those of a major abdominal procedure. All except four donors were parents (mother/father). Average blood loss was 805 +/- 479 ml and only two donors required blood transfusion. Mean operative time was 8.2 +/- 1.5 hr. Thoracic epidural analgesia was the most commonly adopted mode of pain relief. Average time to return of bowel sound postoperatively was 3.1 +/- 1.0 days and was not influenced by the postoperative analgesic technique used. Total duration of hospital stay was 8.4 +/- 1.1 days. Three donors developed minor postoperative complications atrial fibrillation and retained JP drain; left lower lobe pneumonia; and incisional hernia. All patients recovered uneventfully. CONCLUSION: Living organ donors contribute towards decreasing the shortage of organs for transplantation. Minimizing the discomfort associated with the surgical intervention and providing a complication-free perioperative course will positively influence the continued availability of such donations. On review of the first 22 left lateral hapatectomies performed, we observed only minor complications. Postoperative pain was a serious problem and thoracic epidural provided satisfactory analgesia.     

Partial liver transplantation from living related donors.

Living related liver transplantation was performed in five cases between June 1989 and July 1991 at Shinshu University Hospital. All of the donors were fathers of the patients and blood type was identical in each case. All of them were discharged from the hospital 2 weeks after hepatectomy without any complications. They started to work 2 months after surgery. Four recipients are surviving but one died. Three are enjoying daily life 17 months after LT in case 1, 5 months after LT in case 4, and 4 months after LT in case 5. Case 2 is still in the hospital 14 months after LT. Advantages of LRLT we noted were (1) cases can be performed totally electively and allow full preparation for the family and the transplant team, (2) primary graft nonfunction has not been observed to date, and (3) 38 patients received the chance of liver transplantation in their own country, which under current legislation would not otherwise have been possible. Disadvantages of LRLT were (1) partial hepatectomy was performed in healthy persons, and (2) retransplantation is difficult.     

Vascular complications after pediatric liver transplantation from the living donors

Early arterial or portal vein thrombosis is a complications that can lead to graft loss and patient death or need of immediate retransplantation. The aim of the study was to assess the incidence, causes, treatment, and outcome of vascular thrombosis after living related donor liver transplantation (LRdLTx). Between 1999 and 2004 71 LRdLTx were performed in children aged from 6 months to 10 years. Vascular thrombosis was found in 12 recipients. Hepatic artery thrombosis (HAT) occurred in 4 (5.6%), portal vein thrombosis (PVT) in 8 (11.2%) cases. HAT occurred 5 to 8 days, PVT 1 to 22 days after LTx. Diagnosis of vascular thrombosis was confirmed by routine Doppler ultrasound examination. Thrombectomy was successful in one patient with HAT and in three patients with PVT. Venous conduit was performed in one patient with PVT after second thrombosis. Two children developed biliary strictures as a late complication of HAT and required additional surgical interventions. Two children with PVT developed portal hypertension with esophageal bleeding, which required surgical intervention; one another underwent endoscopic variceal ligation for grade III varices. Follow-up ranged from 7 to 60 months. One patient died as a result of HAT after retransplantation due to multiple intrahepatic abscesses 2 months after first transplant. Any risk factors of vascular thrombosis that can be controlled should be avoided after transplantation. Routine posttransplant Doppler examination should be performed at least twice a day within 7 to 14 posttransplant days. Immediate thrombectomy should be always carried out to avoid late complications and even mortality.     

Portal vein reconstruction in pediatric liver transplantation from living donors.

OBJECTIVE: The authors analyze the surgical pattern and the underlying rationale for the use of different types of portal vein reconstruction in 110 pediatric patients who underwent partial liver transplantation from living parental donors. SUMMARY BACKGROUND DATA: In partial liver transplantation, standard end-to-end portal vein anastomosis is often difficult because of either size mismatch between the graft and the recipient portal vein or impaired vein quality of the recipient. Alternative surgical anastomosis techniques are necessary. METHODS: In 110 patients age 3 months to 17 years, four different types of portal vein reconstruction were performed. The portal vein of the liver graft was anastomosed end to end (type I); to the branch patch of the left and right portal vein of the recipient (type II); to the confluence of the recipient superior mesenteric vein and the splenic vein (type III); and to a vein graft interposed between the confluence and the liver graft (type IV). Reconstruction patterns were evaluated by their frequency of use among different age groups of recipients, postoperative portal vein blood flow, and postoperative complication rate. RESULTS: The portal vein of the liver graft was anastomosed by reconstruction type I in 32%, II in 24%, III in 14%, and IV 29% of the cases. In children <1 year of age, type I could be performed in only 17% of the cases, whereas 37% received type IV reconstruction. Postoperative Doppler ultrasound (mL/min/100 g liver) showed significantly (p < 0.05) lower portal blood flow after type II (76.6 +/- 8.4) versus type I (110 +/- 14.3), type III (88 +/- 18), and type IV (105 +/- 19.5). Portal vein thrombosis occurred in two cases after type II and in one case after type IV anastomosis. Portal stenosis was encountered in one case after type I reconstruction. Pathologic changes of the recipient native portal vein were found in 27 of 35 investigated cases. CONCLUSION: In living related partial liver transplantation, portal vein anastomosis to the confluence with or without the use of vein grafts is the optimal alternative to end-to-end reconstruction, especially in small children.     

Anesthetic management of a pregnant living related liver donor

Pregnancy is often considered a contraindication to living related liver donation. There are serious medical and ethical considerations if a pregnant woman insists on undergoing partial hepatectomy to save her sick child. Herein we report a case of living related liver donation from a pregnant woman at 18 weeks of gestation to her 1-year-old child with decompensated cirrhosis due to biliary atresia. The left lateral segment of the liver was harvested for donation. Meticulous surgical technique and anesthetic management were mandatory in assuring a successful outcome. While this isolated case demonstrated that living related liver donation can be performed successfully with a pregnant donor, it should be undertaken only when there is absolutely no other donor and the recipient is in urgent need.     

Assessment of potential donors for living related liver transplantation

BACKGROUND: Living related liver transplantation has been developed as an important potential source of organs for treatment of children with acute and chronic liver disease. A single UK centre performing living related liver transplantation was established in 1993. METHODS: Parents who were potential donors for their children for living related liver transplantation were assessed for suitability according to a protocol based on one developed and published by the University of Chicago Transplant Group. Records kept by the transplant coordinators were retrieved and data were extracted. RESULTS: Of 64 potential donors for 32 potential recipients ten were excluded at a preliminary stage. Fourteen ultimately became donors. Of 54 parents who began evaluation 23 were finally considered to be suitable. There were 19 non-disease-related reasons for unsuitability: blood group mismatch (eight cases), size discrepancy (six), pregnancy (two), oral contraceptive medication (one), vascular anatomy variant (one) and age (one). Sixteen were unsuitable because disease was found, namely fatty liver (four), thyroid disease (two), hepatitis B positivity (two), cardiac murmur (one), anaemia (one), glucose-6-phosphate dehydrogenase deficiency (one), diabetes mellitus (one) and psychological problems (one), and three parents were affected by the same disorder as the child (Alagille syndrome, one; mitochondrial disorder, one; recurrent cholestasis, one). Three parents were rejected for more than one reason. Both parents were unsuitable for donation in 21 per cent of cases. CONCLUSION: Parents approach living related liver transplantation with enthusiasm. They should be advised of the high chance of unsuitability, including the finding of significant pathology. The limitation of living related liver transplantation as the major source of organs for children is recognized.