肝动脉外科解剖在肝动脉置管术中的应用及意义

目的 目前术中肝动脉置管术(IHAC)已广泛应用于肝脏恶性肿瘤的综合治疗，但多采用盲目插管的方法，影响了IHAC的疗效。通过术中肝动脉的外科解剖结合肝动脉造影，了解肝总动脉及其主要分支的行径及相互关系，证明肝动脉外科解剖在IHAC中的意义。方法 采用电凝锐性解剖技术对116例肝脏或胆道疾病患者行肝动脉外科解剖，详细记录肝总动脉(CHA)、肝固有动脉(PHA)、肝左、右动脉(LHA、RHA)及胃十二指肠动脉(GDA)的位置和相互间的成角(锐角或钝角)，并在术中观察自然状态下导管经胃网膜右动脉插入后的走向。部分病例结合肝动脉造影资料进行分析。结果 (1)GDA与CHA呈水平或钝角72例(62％)。其中20例行IHAC，导管经胃网膜右动脉插入时全部进入CHA；(2)GDA与CHA呈锐角，而与PHA呈水平或钝角36例(31％)，13例行IHAC，导管或进入PHA或RHA；(3)PHA缺如8例(7％)。此外，116例中RHA起源于肠系膜上动脉9例(7．7％)，肝左动脉源于胃左动脉7例(6．0％)，肝左、右动脉之间在肝门部存在明显异常交通支2例(1．7％)。结论 影响IHAC准确性的关键是GDA与CHA的成角，以及肝动脉解剖异常。由于绝大多数GDA与CHA成角为钝角，加上一定比例的肝动脉解剖异常，因此，非肝动脉外科解剖的盲目插管其成功率不足25％，应引起临床的高度重视。     

Diagnosis and treatment of hepatic artery stenosis after orthotopic liver transplantation

PURPOSE: The purpose of this study was to evaluate the accuracy of Multidetector Computed Tomographic Angiography (MDCTA) to detect hepatic artery (HA) stenosis after orthotopic liver transplantation (OLT) and the efficacy of treatment using percutaneous transluminal angioplasty (PTA). MATERIALS AND METHODS: Twenty-two consecutive patients with OLT underwent MDCTA for evaluation of HA, followed by digital subtraction angiography (DSA) (gold standard). Source images (Ax) were processed, obtaining multiplanar reformations (MPRs), maximum intensity projections (MIPs), and volume renderings (VRs). Images were evaluated to identify the following: (1) arterial depiction (celiac axis, anastomosis, and left [LHA] and right [RHA] HA), (2) detection of stenoses, and (3) grading of stenoses. Indications for PTA were set at MDCTA and DSA, and PTA was performed when appropriate. RESULTS: MDCTA depicted the celiac axis and anastomoses in all patients; LHA and RHA were visualized in 21 of 22 patients with Ax, MPRs, and MIPs, and in 17 of 22 with VRs. All reconstruction modalities enabled correct diagnosis of celiac (n = 3) and anastomotic stenoses (n = 14). Of 6 LHA and RHA stenoses, 4 (66.7%) were visualized with Ax, MPRs, and VRs, and 5 (83.3%) were visualized with MIPs. Stenosis was overestimated in 9 (39.1%) cases with VRs and in 3 (13%) with the other modalities. PTA was performed in 8 cases, with 1 case of arterial dissection requiring re-OLT. At a median follow-up of 28 months, the primary and secondary patency rates were 71.4% (5 of 7) and 85.7% (6 of 7), respectively. CONCLUSIONS: MDCTA and accurate postprocessing enable confident depiction of the arterial anatomy and detection of stenosis after OLT. PTA is safe and allows allograft saving, at least until another suitable donor becomes available.     

肝移植供体切取中变异肝动脉的保护

目的 探讨在肝移植供体切取过程中如何避免损伤变异肝动脉。资料与方法 分析123例供肝切取资料，统计变异肝动脉发生率。结果 肝动脉解剖变异32例（26．02％），其中仅肝右动脉（RHA）变异11例（8．94％），仅肝左动脉（LHA）变异10例（8．13％），左右肝动脉均变异3例（2．44％），肝总动脉（CHA）起于肠系膜上动脉7例（5．69％），其它少见类型1例（0．81％），为肝固有动脉（PHA）来源于胃左动脉。结论 肝动脉解剖复杂，熟悉肝动脉解剖变异可减少供肝切取过程中的肝动脉损伤。     

Back-table arterial reconstructions in liver transplantation: single-center experience

Anatomic variations of the arterial supply to donor liver grafts often require complex hepatic artery reconstructions on the back table. Therefore, because of the additional anastomoses, there is a greater risk of arterial thrombosis and graft loss. Among the 620 orthotopic liver transplantations (OLT) in 549 adult and pediatric patients performed from June 1983 through August 2004, the rates and types of donor hepatic artery variations (HAV) and the type of reconstructions were reviewed as well as the 1- and 5-year grafts and patient survival rates after OLT. At least 1 HAV was present in 133 liver grafts (21.4%). The most frequent variations were as follows: right hepatic artery (RHA) from superior mesenteric artery (SMA) (44 cases); RHA from aorta (4 cases); and RHA from SMA, combined with a left hepatic artery (LHA) from left gastric artery (3 cases). No graft was discarded. Fifty-six of 133 (42%) HAV required arterial reconstructions, generally a termino-terminal (TT) anastomosis between RHA and splenic artery (26 cases, 46.4%). Less frequently performed anastomoses were the "fold-over" technique (15 cases, 26.8%) and the anastomosis between the RHA and the gastro-duodenal artery (6 cases, 10.6%); rare reconstructions were performed in 9 cases (16.0%). The rate of hepatic artery thrombosis was 5.4% (3 of 56 OLT) in complex hepatic artery reconstructions and 2.2% in other grafts. One- and 5-years graft and patient actuarial survival rates have been respectively 73.2%- 71.4% in hepatic artery reconstructions and 78.6%-76.8% in the absence of an artery reconstruction, respectively.     

Anatomic variation of the right hepatic artery and its reconstruction for living donor liver transplantation using right lobe graft

We analyzed the anatomy and reconstruction of the right hepatic artery (RHA) in 96 cases of adult-to-adult living donor right liver transplantations, during 2002. Most right livers had a single orifice (n = 185, 96%). Seven right livers (4%) showed multiple arteries, namely a replaced artery in five cases and accessory arteries in two cases. Three liver grafts had two separate orifices: both arterial stumps were reconstructed in one case, and accessory arteries were ligated in two cases because of sufficient back bleeding. The mean diameter of the graft RHA was 2.4 mm (1-4). More than 60% (59 of 96) of graft arteries were anastomosed with distal branches of recipient RHA for size matching. Eleven graft arteries were anastomosed to vessels other than the RHA, namely the left hepatic artery [LHA] in eight right gastroepiploic artery in three: for size matching in five and due to previous injury of RHA in six. Five cases showed significant size-mismatches of more than twofold. The median follow-up period was 270 days. In one patient, an intramural thrombus developed on postoperative day 3 requiring a revision of the anastomosis. In another patient, arterial stenosis occurred on postoperative day 16 a time when collateral arteries had developed. The overall complication rate related to arterial reconstruction was 2%. In conclusion, with precise knowledge of the anatomy, an adequate selection of recipient arterial stump, and an experienced technique, a desirable result may be achieved in right lobe transplantation.     

Management of Massive Arterial Hemorrhage After Pancreatobiliary Surgery: Does Embolotherapy Contribute to Successful Outcome?

Massive arterial hemorrhage is, although unusual, a life-threatening complication of major pancreatobiliary surgery. Records of 351 patients who underwent major surgery for malignant pancreatobiliary disease were reviewed in this series. Thirteen patients (3.7%) experienced massive hemorrhage after surgery. Complete hemostasis by transcatheter arterial embolization (TAE) or re-laparotomy was achieved in five patients and one patient, respectively. However, 7 of 13 cases ended in fatality, which is a 54% mortality rate. Among six survivors, one underwent selective TAE for a pseudoaneurysm of the right hepatic artery (RHA). Three patients underwent TAE proximal to the proper hepatic artery (PHA): hepatic inflow was maintained by successful TAE of the gastroduodenal artery in two and via a well-developed subphrenic artery in one. One patient had TAE of the celiac axis for a pseudoaneurysm of the splenic artery (SPA), and hepatic inflow was maintained by the arcades around the pancreatic head. One patient who experienced a pseudoaneurysm of the RHA after left hemihepatectomy successfully underwent re-laparotomy, ligation of RHA, and creation of an ileocolic arterioportal shunt. In contrast, four of seven patients with fatal outcomes experienced hepatic infarction following TAE proximal to the PHA or injury of the common hepatic artery during angiography. One patient who underwent a major hepatectomy for hilar bile duct cancer had a recurrent hemorrhage after TAE of the gastroduodenal artery and experienced hepatic failure. In the two patients with a pseudoaneurysm of the SPA or the superior mesenteric artery, an emergency re-laparotomy was required to obtain hemostasis because of worsening clinical status. Selective TAE distal to PHA or in the SPA is usually successful. TAE proximal to PHA must be restricted to cases where collateral hepatic blood flow exists. Otherwise or for a pseudoaneurysm of the superior mesenteric artery, endovascular stenting, temporary creation of an ileocolic arterioportal shunt, or vascular reconstruction by re-laparotomy is an alternative.     

Double Arterial Anastomosis in Liver Transplantation: Is Two Better than One?

Arterial revascularization during liver transplantation is normally achieved by anastomosing the graft hepatic artery to the largest artery available at the recipient pedicle—either the common hepatic artery (CHA) or an accessory right hepatic artery (RHA) originating from the superior mesenteric artery (SMA). When a small caliber RHA is present, the artery is ligated and a single anastomosis with the CHA is performed. In the absence of a vascular reconstruction of the graft, the gastroduodenal artery is usually ligated as well. In this article, we describe a new type of arterial anastomosis in the case of a small accessory RHA and/or severe graft hepatic artery atherosclerosis that is commonly seen in elderly donors. To our knowledge, these are the first cases reported in the literature. This technique can be easily performed without increasing the arterial revascularization time or increasing the risk of complications associated with arteriosclerotic arteries. A 12-month follow-up revealed excellent function of the liver grafts.     

动脉造影初步分析肝脏Ⅸ段肿瘤肝动脉血供

目的 研究肝脏Ⅸ段肿瘤的肝动脉血供方式.方法 回顾性分析8例肝脏Ⅸ段肿瘤病例的CT和DSA资料,由CT做出定位诊断,在DSA上观察肝脏Ⅸ段肿瘤的肝动脉血供情况.观察肝动脉的各级分支,统计这些分支向病灶供血的例数,分析肝脏Ⅸ段肿瘤的肝动脉血供来源.根据病灶染色情况,以积分法确定这些肝动脉分支向病灶供血的多少.结果 肝脏IX段肿瘤的肝动脉血供来源十分广泛,MHA、RPHA、RAHA、LMHA和CallA向病灶供血的例数分别是7、6、5、5和2例(X2=2.800,P=0.592,Chi-square test),积分分别是15、13、11、6和2分(X2=9.657,P=0.047,Kendall's W).RHA和LHA的积分分别是38和9分(Z=-2.243,P=0.025,Wilcoxon).未见CyA和LLHA向病灶供血的病例.结论 RHA和LHA系统都有可能向肝脏Ⅸ段肿瘤供血,RHA供血比LHA多.MHA、RPHA、RAHA、LMHA是主要的供血支.     

肝门区域血管阻断下肝段切除术的要点、扩展和评估

目的 总结1987-2008年344例通过肝门H沟中阻断肝叶、肝段或肝亚段入肝血管分支施行肝切除的经验.方法 (1)根据病变部位和大小分别实行大型肝切除(66例)、间隔性多个肝亚段切除(15例)、邻接多个肝亚段切除(216例)和单个肝亚段切除(47例),其中含肝尾叶切除29例.(2)肝左外段切除时在肝门左纵沟外侧游离、切断从门静脉左干矢状部外侧发出的左外上、下分支和肝左动脉.肝左内段切除时游离、切断从门静脉左干矢状部内侧发出的左内上、下分支和肝中动脉.肝右前段切除时游离、阻断肝右纵沟前支中的门静脉右前支和肝总管后的肝右动脉.肝右后段切除时阻断右纵沟后支中的门静脉右后支和肝右动脉.(3)断肝时尽量保护相应的肝静脉主干.结果 (1)术后病死10例(2.9%),其中死于肝衰8例,出血2例;(2)肝细胞癌病人(n=200)术后生存11～20年10例,7年4例,5年19例,5年生存率18.3%(33/180).肝内胆管癌(n=13)术后生存1/2～3年.肝门胆管癌(n=14)生存13、6、4年各1例.胆囊癌(n=12)生存1/2～1年.良性肝病(n=92)切肝后皆痊愈.7例肝内胆管结石尚需处理他处残留结石.结论 (1)间隔性多个肝段切除是一次手术治愈多支肝内胆管簇集性结石的有效方法.(2)该手术免去了阻断全入肝血流,缩小了术中肝缺血范围,减少了术中失血,提高了大肝癌切除率,减轻了术后肝功能损害,可以满足各种肝病肝切除要求,是一种合理、有效的切肝手术方法.     

Significance of intraoperative monitoring of arterial blood flow velocity and hepatic venous oxygen saturation for performing minimally invasive surgery in a patient with multiple calcified pancreaticoduodenal aneurysms with celiac artery occlusion

Even for patients with multiple pancreaticoduodenal aneurysms, successful treatment with noninvasive operative procedures can be employed, if intraoperative devices are considered. A 73-year-old man, without any symptoms, was admitted to our hospital and had computed tomography (CT) scanning to examine his liver for hepatitis C virus (HCV). Selective superior mesenteric artery (SMA) angiography confirmed multiple aneurysms in the anterior inferior pancreaticoduodenal artery (AIPDA), one aneurysm in the posterior inferior mesenteric artery (PIPDA), and another in the occluded celiac trunk, all with severe calcification. All of the aneurysms were thought to communicate with each other. With the celiac artery occlusion, the right hepatic artery (RHA) was revealed to be supplied by collateral arteries from the aneurysms in the AIPDA, and the left hepatic artery was shown to be supplied by collaterals from the left gastric artery. Intraoperative Doppler echography, at the time of the clamping of both IPDAs, demonstrated a marked decrease of blood velocity in all aneurysms (before clamping, >50 cm/s; after, <10 cm/s), although loss of pulsation and a marked decrease of flow in the RHA were inevitable. Therefore, each of these two IPDAs were ligated on the proximal side to the aneurysm, thus preserving the blood flow of the pancreas head fed by the PIPDA; bypass grafting from the AIPDA to the RHA, using the great saphenous vein, was done at the same time. After the creation of an anastomosis, the hepatic venous oxygen saturation (ShvO2) increased from 38% (at the time of ligation of the IPDAs) to 57% under ventilation. The patient's postoperative clinical course was uneventful. We describe and discuss our successful noninvasive operative management of multiple pancreaticoduodenal aneurysms, done while monitoring the blood flow and ShvO2, with some consideration of the literature.     

Treatment of Visceral Artery Aneurysms: Description of a Retrospective Series of 42 Aneurysms in 34 Patients

Visceral artery aneurysms (VAA) can be treated by revascularization, ligation, or, most often, endovascular techniques depending on clinical presentation, hemodynamic status, and location. From 1975 to 2002 a total of 42 VAA in 34 patients were treated. The lesion involved the splenic artery (SA; 19), pancreaticoduodenal artery (PDA; 6), celiac trunk (CT; 5), superior mesenteric artery (SNA; 4), common hepatic artery (CHA; 3), gastroduodenal artery (GDA; 2), left hepatic artery (LHA; 1), a branch of the inferior mesenteric artery (BIMA; 1), and a branch of the SMA (BSMA; 1). Twenty-seven VAA in 21 patients (64%) were uncomplicated (group I) and 15 VAA in 13 patients (36%) had ruptured (group II) (PDA; 6; CT, 3; SA, 1; CHA, 1; LHA, 1; BSMA, 1; BIMA, 1). In group I VAA were treated by embolization (n = 11), splenectomy (n = 6), bypass (n = 7), ligation (n = 2), and aneurysmorraphy (n = 1). No deaths were observed. The morbidity rate associated with surgical treatment was 12% including hepatic bypass thrombosis without ischemic complications in two cases. The morbidity rate associated with endovascular treatment was 18% including cholecystitis in one case and bile duct stenosis in one case. The VAA recanalization rate following embolization was 9%. In group II, 12 VAA (80%) were treated by ligation in association with splenectomy in two cases and left hepatectomy in one case. Only one bypass procedure was performed and embolization was used to treat two VAA (1 SMA and 1 PDA). The mortality rate was 20% (3/15). The morbidity rate associated with surgical treatment was 46% (6/13) including bile duct stenosis in one case, ischemic cholecystitis in one case, duodenal fistula in one case, pancreatic fistula in one case, bile tract fistula in one case, and colonic ischemia in one case. No patient died after endovascular treatment and the morbidity rate was 50% (1/2) with duodenal stenosis occurring in one case. In sum, VAA can rupture. Emergency cases can be treated by ligation in most cases or by embolization if the hemodynamic status of the patient allows. Regardless of treatment technique, the morbidity and mortality rate remains high after rupture, especially in cases involving PDA. Embolization can be proposed as a first-line treatment for most VAA. Because of the risk of rupture, endovascular or open repair is warranted for VAA and has a favorable prognosis.     

Advantage in using living donors with aberrant hepatic artery for partial liver graft arterialization

BACKGROUND: In living-related partial liver transplantation, the feasibility and safety of using left-sided liver grafts from donors with aberrant hepatic arteries remains to be evaluated. METHODS: Between 1996 and 2000, we harvested left-sided liver grafts from 101 living donors. Hepatic arterial variation in the donors was classified into three types: type I (n=69), normal anatomy; type II (n=24), aberrant left hepatic artery arising from the left gastric artery; and type III (n=8), replaced right hepatic artery arising from the superior mesenteric artery. We performed arterial reconstructions using the donor's left hepatic artery in 70 cases (69 in type I, 1 in type II), an aberrant left hepatic artery in 24 cases (23 in type II, 1 in type III), and the common hepatic artery in 7 cases (all in type III). RESULTS: The diameter and length of the anastomosed hepatic artery were larger (2.5+/-0.7 vs. 2.0+/-0.8 mm, P=0.03) and longer (42.0+/-14.7 vs. 9.0+/-7.3 mm, P<0.0001) in cases in which the aberrant left hepatic artery or common hepatic artery was used for the anastomosis (n=31) than in those using the left hepatic artery (n=70). Hepatic arterial occlusion occurred in nine patients, with the incidence of occlusion tending to be lower in the former cases in which aberrant left or common hepatic arteries were used (3.2% vs. 11.4% for the left hepatic artery group, P=0.15). CONCLUSION: Because thicker and longer arterial branches can be obtained in left-sided liver grafts with aberrant hepatic arteries than in grafts with normal left hepatic arteries, their use is advantageous for safe arterialization in partial liver grafts.     

Arterial Reconstruction during Pancreatoduodenectomy in Patients with Celiac Axis Stenosis—Utility of Doppler Ultrasonography

Celiac axis stenosis is found at an incidence of 2%–24% in the general population. During pancreatoduodenectomy in patients with celiac axis stenosis, division of the gastroduodenal artery from the common hepatic artery may cause acute ischemia of the upper abdominal organs, such as the liver, stomach, or spleen. Under these circumstances, the clinical indications of arterial reconstruction remain controversial. Between 1994 and 2003, seven patients with celiac axis stenosis (n = 4) or occlusion (n = 3) underwent pancreatoduodenectomy at our hospital. Arterial reconstruction, including division of the median arcuate ligament, was conducted in two patients; the replaced right hepatic artery was preserved in one patient, and no vascular refinement was undertaken in the remaining four of the seven patients. In two of the four patients without arterial reconstruction or preservation, the serum levels of liver enzymes were markedly elevated (> 800 IU/l) on postoperative day 1, and these patients subsequently developed liver abscesses. Two patients who underwent arterial reconstruction and three patients who showed no decrease in intrahepatic arterial flow under Doppler ultrasonography after clamping of the gastroduodenal artery developed no ischemic complications. Although our experience is limited, when intraoperative Doppler ultrasonography indicates a decrease in the hepatic arterial signals, we believe that reconstruction of the hepatic artery will be necessary to minimize ischemic complications in the liver in patients with celiac axis stenosis.     

Collateral circulation after the division of the common hepatic artery--experimental study in dogs

The influence of division of the common hepatic artery (CHA) was studied using dogs, by measuring the blood flow of the proper hepatic artery (PHA) by an electromagnetic flowmeter, and tissue blood flow of the liver and the gallbladder by the H2 gas clearance method. The results expressed as relative values (value before the division of CHA = 1.0) were as follows. 1) PHA blood flow decreased to 0.40 +/- 0.18 (n = 14) after the division of CHA. 2) After the division of CHA, tissue blood flow of the liver decreased to 0.61 +/- 0.16 (n = 27), and tissue blood flow of the gallbladder, to 0.51 +/- 0.16 (n = 40). After additional occlusion of the gastroduodenal artery, these values were 0.51 +/- 0.16 and 0.23 +/- 0.13, respectively. 3) On the seventh day after CHA division, tissue blood flow of the gallbladder recovered to 0.84 +/- 0.50. 4) Necrosis of the gallbladder, which was mostly partial was found in 20% of the experimental dogs at autopsy. These results showed that there is effective arterial collateral circulation after division of the CHA, which makes Appleby's operation practicable. However, considering the degree of ischemia observed in the gallbladder, preservation of collaterals during Appleby's operation will be essential for the prevention of necrosis of the gallbladder.     

Nonneoplastic celiac axis occlusion in patients undergoing pancreaticoduodenectomy

BACKGROUND: Celiac artery occlusion occurs in a small percentage of the population. Identifying this is critical in planning for pancreaticoduodenectomy. We reviewed 332 patients treated with pancreaticoduodenectomy, and identified 14 patients with celiac artery occlusion. METHODS: Between 1988 and 2006, 14 (4%) of 332 patients treated with pancreaticoduodenectomy had median arcuate ligament syndrome with celiac artery occlusion (6 men, 8 women; mean age, 70 y; range, 38-80 y). Patients underwent preoperative imaging with computed tomography (n = 14) and angiography (n = 13). RESULTS: Patients were diagnosed preoperatively (n = 13) and intraoperatively (n = 1) with celiac artery occlusion. Surgeries included classic pancreaticoduodenectomy (n = 12), pylorus-preserving pancreaticoduodenectomy (n = 1), median arcuate ligament release (n = 10), and vascular reconstructions (n = 4), with no surgical mortalities and postoperative complications in 6 patients (46%). CONCLUSIONS: We report our experience of median arcuate ligament syndrome with celiac artery occlusion in 4% of our patients treated with pancreaticoduodenectomy. Patients underwent median arcuate ligament release, vascular reconstruction, and/or stenting. Angiography diagnosed celiac artery occlusion and allowed preoperative planning. Pancreatic surgeons must understand the importance of identifying celiac artery occlusion before resection to prevent severe complications.     

大鼠肝移植肝动脉重建方法改进的实验研究

目的 构建重建肝动脉血供的大鼠肝移植模型.方法 在经典"二袖套"法的基础上,利用24G静脉留置针外鞘管制作动脉支架管吻合供体腹腔动脉及受体肝总动脉.结果 共进行肝移植26次.所有手术均单人操作完成.手术成功率(存活24 h以上)为92.3%(24/26).动脉吻合时间仅需(1.70±0.46)min.经解剖发现术后第1天及第30天所有动物肝动脉均通畅,搏动良好,各肝叶入口处动脉亦充盈良好.未发现胆道坏死,胰腺坏死或由于周围组织包绕形成的胆道内漏等.结论 利用支架法吻合供体腹腔动脉及受体肝总动脉的方法 是一种操作简便、耗时短、对正常生理干扰小、通畅率高的理想的大鼠肝移植肝动脉重建方法 .     

肝移植中变异肝动脉的处理

目的探讨肝移植中变异肝动脉的保护及重建方法。方法回顾性分析2005年6月至2013年12月进行的340例肝移植的临床资料,着重分析变异肝动脉的保护及重建方法。取修肝过程注意保护变异的肝动脉,变异的肝动脉采用显微缝合技术与供受体腹腔动脉干的分支行端端吻合,术中根据变异动脉的条件,选择管径相互匹配、位置合适的腹腔动脉干的属支进行吻合,其中管径≧3 mm采用连续缝合;3 mm采用间断缝合。术后常规多普勒超声监测肝动脉血流情况,肝素+低分子右旋糖酐抗凝。结果 340例中出现肝动脉变异64例,其中左肝动脉变异33例,来源于胃左动脉20例、腹腔动脉干11例,腹主动脉2例;右肝动脉变异30例,来源于肠系膜上动脉19例,胃十二指肠动脉10例,腹主动脉1例;肝总动脉变异1例,来源于腹主动脉。误扎变异左肝动脉2例,术后出现左肝管缺血坏死2例。结论供肝肝动脉变异率高,取修肝过程中应注意对变异肝动脉的保护,选择供受体合适的腹腔动脉干分支与变异肝动脉吻合是处理肝动脉变异的良好方法。     

Celiac compression syndrome and liver transplantation.

OBJECTIVE: The authors assessed the prevalence and clinical significance of the celiac compression syndrome in liver transplantation patients. SUMMARY BACKGROUND DATA: Compression of the celiac axis by the median arcuate ligament of the diaphragm, causes a decrease in celiac artery blood flow which may lead to hepatic artery thrombosis in patients undergoing orthotopic liver transplantation. METHODS: From July 1991 to July 1992, 17 (10%) cases of celiac compression syndrome were identified among 164 consecutive adult patients who underwent liver transplantation. The diagnosis was confirmed by blood flow recording demonstrating a typical pattern of accentuated decrease in celiac blood flow during expiration. RESULTS: Surgical transection of the median arcuate ligament resulted in normalization of the hepatic artery blood flow. In two cases (11.7%), an interposition iliac graft from the recipient supra-celiac aorta was used for the arterial reconstruction. During the follow-up period of up to 15 months, there was no incidence of hepatic artery thrombosis. CONCLUSIONS: The clinical significance of the celiac compression syndrome is evident in liver transplantation in which the collateral circulation to the liver is compromised and the celiac artery remains the only source of arterial blood. It is imperative to identify and remove the obstruction of the celiac axis to prevent severe complications and potential graft loss.     

磁共振成像在肝移植术后并发症诊断中的应用

目的探讨磁共振成像在肝移植并发症诊断中的价值。方法回顾分析11例肝移植术后发生并发症者的磁共振检查影像资料。结果11例患者术后出现皮肤和巩膜黄染、发热以及尿黄等症状，丙氨酸转氨酶、天冬氨酸转氨酶、γ-谷氨酰转移酶和胆红素升高．经B型超声波检查不能明确原因，采用磁共振（MRI、MRA和MRCP）检查，明确肝动脉吻合口狭窄1例；肝动脉闭塞2例；下腔静脉吻合口狭窄及血栓形成各1例；胆管吻合口狭窄4例，其中1例伴胆汁瘤形成；肝门水平非吻合口狭窄6例；肝坏死2例；肝包膜下血肿及右肾上腺出血各1例；均显示不等量的右侧胸腔积液、腹腔积液及肝门部水肿。结论磁共振一次检查可显示肝内外的多种结构，能为肝移植术后并发症的诊断提供丰富的肝脏、血管、胆道以及肝外结构的图像信息。     

Effectivity of laser-induced thermotherapy: in vivo comparison of arterial microembolization and complete hepatic inflow occlusion

BACKGROUND AND OBJECTIVES: Laser-induced thermotherapy (LITT) is a promising method for local treatment of liver metastases. The aim of this study was to compare the effect of LITT on lesion size when combined with hepatic arterial microembolization or complete hepatic blood flow occlusion. STUDY DESIGN/MATERIALS AND METHODS: In a porcine liver model, LITT (30 W 15 minutes) was performed with either normal (n = 12), partially interrupted (arterial microembolization via a hepatic artery catheter n = 12) or completely interrupted hepatic perfusion (Pringle's maneuver, n = 12). LITT lesions were macro- and microscopically assessed after liver dissection. RESULTS: Hepatic inflow occlusion led to a fourfold increase in lesion volume after arterial microembolization and a ninefold increase after complete interruption (6.3. cm3 vs. 27.1 cm3 vs. 58.8 cm3, P < 0.01). CONCLUSIONS: Interrupting hepatic perfusion significantly increases lesion volumes in LITT. This beneficial effect can also be achieved in the percutaneous application mode by LITT combined with arterial microembolization via a hepatic artery catheter.