肝移植术中复杂的肝动脉重建

目的 探讨供肝肝动脉解剖变异的整形重建方式及对移植后肝动脉血栓形成（HAT）、胆道并发症及移植疗效的影响。方法 回顾性分析1999年5月至2005年9月完成的330例原位肝移植临床资料。应用显微外科技术对变异肝动脉进行整形。供肝肝动脉整形、重建及供受者问动脉的吻合在2．5倍放大镜下以7-0、8-0 Prolene或Vascufil缝线完成。术后每日用多普勒超声检查肝动脉血流1周，其后定期监测。结果 67例供肝肝动脉存在解剖变异，占20．5%（67／327），实施血管重建性吻合79例次。存在动脉变异供肝附加血管整形重建组围手术期HAT发生率与无肝动脉变异供肝肝移植组围手术期HAT发生率比较（1．5％7351．15％）；随访期内胆道并发症发生率与无肝动脉变异供肝肝移植组发生率比较（9．0％vs7．7%），均无显著差异（P〉0．05）。两组受者比较，1、3年生存率无显著差异（91．3％vs90．7％，86．7％vs88．2％）（P〉0．05）。结论 应用存在肝动脉变异并血管整形的供肝，实施肝移植不增加HAT及胆道并发症发生率，并可取得与无变异肝动脉供肝相同的远期疗效。     

肝移植中肝动脉变异的重建

目的进一步探讨和总结供肝肝动脉的解剖变异及整形重建经验.方法回顾性分析1998年4月～2005年12月本组430例原位肝移植中供肝肝动脉的解剖类型和变异肝动脉的重建方式.应用显微外科技术对变异肝动脉进行整形然后再吻合.总结肝动脉变异情况及肝动脉的重建方法.结果430例供肝中,肝动脉解剖正常的为338例(78.6%,338/430),肝动脉解剖变异者92例(21.4%,92/430),其中48例(52.2%,48/92)需血管重建.此48例中异常的肝右或肝左动脉与胃十二指肠动脉吻合32例(67%,32/48),异常肝右动脉与脾动脉吻合16例(33%,16/48).变异肝动脉合理整形后再行肝移植,其动脉血管并发症的发生率并未升高.结论供肝肝动脉变异较为常见,因其是唯一的吻合血管,故修肝时对变异肝动脉进行显微重建是非常重要的.     

原位肝移植供肝动脉变异处理的效果分析

目的分析原位肝移植供肝动脉变异的处理方式和手术效果。方法回顾性分析2018年7月至2020年6月在清华大学附属北京清华长庚医院接受肝移植手术受者的临床病理资料。识别肝动脉变异情况和分布比例,记录变异供肝动脉的处理方式。需重建的变异肝动脉均在体外完成重建吻合。比较变异组和无变异组术后并发症情况及手术后6个月的随访情况。结果肝动脉变异率为16.4%(36/219),其中常见类型为变异的肝左动脉发自胃左动脉,变异的肝右动脉发自肠系膜上动脉。结扎及重建的变异的肝左动脉共20例,其中9例直接结扎,无需重建。结扎及重建的变异的肝右动脉共16例,其中13例与胃十二指肠动脉吻合重建。变异组与无变异组相比,移植术后动脉、胆道并发症发生率差异均无统计学意义(P0.05)。结论体外重建可以很好地重构具有肝动脉变异的供肝动脉血流路径。供肝肝动脉变异不增加移植术后动脉、胆道并发症的发生风险。     

肝移植中肝动脉变异的显微外科重建

目的进一步探讨和总结供肝肝动脉的解剖变异及整形重建经验。方法回顾性分析 14 1例原位肝移植中供肝肝动脉的解剖类型和变异肝动脉的重建方式。应用显微外科技术对变异肝动脉进行整形然后再吻合。术后每天用多普勒超声检查肝动脉血流 1周 ,其后定期监测 ,观察肝动脉的血流及血栓形成情况。结果 14 1例供肝中 ,肝动脉解剖正常的为 12 1例 (85 8% ,12 1/ 14 1) ,肝动脉解剖变异者 2 0例 (14 2 % ,2 0 / 14 1) ,其中 9例 (6 4 % ,9/ 14 1)需行显微外科重建后再与受体肝动脉吻合。此 9例中异常的肝右动脉与胃十二指肠动脉吻合 7例 (4 9% ,7/ 14 1) ,异常的肝左或肝右动脉与脾动脉吻合 2例 (1 4 % ,2 / 14 1)。变异肝动脉合理整形后再行肝移植 ,其动脉血管并发症的发生率并未升高。结论供肝肝动脉变异较为常见 ,应用显微外科技术对变异的肝动脉植肝前采用适当的整形 ,以获得单一的备吻合血管 ,可以提高供肝动脉重建的质量 ,降低肝动脉并发症的发生率。     

肝动脉变异与肝移植

目的总结肝移植中供体及受体肝动脉变异情况与重建方式。方法回顾我院2002年3月～2005年12月107例肝移植供体与107例受体肝动脉变异情况及重建方式。术后应用Doppler超声、胆道镜及介入方法监测肝动脉及胆道并发症的发生情况。结果107例肝移植之供、受体肝动脉(214例肝动脉),3例术中、术后死于多器官功能衰竭,有20例次肝动脉变异,经过术中良好的重建,其结果显示肝动脉及胆道并发症3例(3/19),较正常肝动脉吻合者(15/85)无显著性差异(P>0.05)。结论肝动脉变异发生率约9.35%左右,肝移植时供肝切取、修整及受体病肝切除应引起高度重视,术中良好的重建能取得好的效果。     

供肝动脉变异的术中处理

目的 探讨供肝动脉的变异类型及植入前重建的方法.方法 采取快速切取法获取供肝528例,对肝动脉解剖进行Hiatt分型,存在肝动脉变异者,肝移植前先行肝动脉重建,方法是将变异动脉与脾动脉端端吻合或与胃十二指肠动脉端端吻合,或将肠系膜上动脉远端(或近端)与肝总动脉(或腹腔干吻合),肠系膜上动脉的另一端与受者的备选动脉吻合.供肝的动脉重建以及供肝血管与受者的吻合均在3.2～3.5倍手术放大镜下进行.结果 528例供肝中,肝动脉解剖正常者(Hiatt Ⅰ型)436例(82.6 %,436/528),肝动脉变异者92例(17.4 %,92/528).变异肝动脉中,Hiatt Ⅱ型38例(7.2%,38/528),Hiatt Ⅲ型47例(8.9 %,47/528),Hiatt Ⅳ型3例(0.5 %,3/528),Hiatt Ⅴ型2例(0.4 %,2/528),Hiatt Ⅵ型2例(0.4 %,2/528).92例肝动脉变异者中,53例的异常动脉拥有共同起始之大干,能与受者的动脉直接进行吻合,故无需在植入前进行动脉重建;其余39例需在移植前对变异的动脉进行重建,其中18例将变异动脉与脾动脉端端吻合,13例将变异动脉与胃十二指肠动脉端端吻合,8例将肠系膜上动脉远端(或近端)与肝总动脉(或腹腔干)吻合,另一端与受者的备选动脉吻合.结论 肝动脉的变异率较高,切取和修整供肝时应准确辨认,避免误伤;对于变异的肝动脉,必须确保其入肝血流的连续性完整,否则需进行植入前血管重建,重建方式应根据动脉变异的类型和解剖学特点来决定.     

成人活体肝移植肝动脉重建50例

目的 总结成人活体肝移植的肝动脉重建经验.方法 我院2002年1月至2006年7月施行了50例成人右半肝活体肝移植,供、受者肝动脉的重建采用显微外科技术成形端端连续缝合方式完成.结果 术后肝动脉血栓形成2例(4%).随访时间2～52个月(中位随访时间9个月),术后和随访期未发现肝动脉狭窄、肝动脉假性动脉瘤等并发症.1年实际生存率为92%(46/50).结论 根据供、受者肝动脉解剖及变异情况,选择适宜的长度和匹配的口径,采用显微外科吻合技术重建肝动脉,是减少肝移植围手术期并发症发生的关键.     

肝动脉-腹主动脉架桥重建移植肝肝动脉74例报告

目的探讨原位肝移植术中采用肝动脉-腹主动脉架桥重建移植肝肝动脉的疗效。方法回顾分析2003年10月至2009年8月在中山大学附属第三医院肝移植中心行肝动脉-腹主动脉架桥重建移植肝肝动脉的74例患者的临床资料。全部患者采用供肝动脉通过供者髂动脉间置架桥与受者腹主动脉(肾动脉下方腹主动脉)行端侧吻合。总结手术治疗方法和术后并发症发生情况。所有患者均签署知情同意书,符合医学伦理学规定。结果 74例采用肝动脉-腹主动脉架桥重建肝动脉的患者中,68例治愈,6例术后早期死亡,治愈率为92%。术后急性排斥反应的发生率为18%(13/74),胆道并发症发生率为11%(8/74),肝动脉并发症发生率为14%(10/74),其中5例为架桥动脉血栓形成,5例为肝动脉(含架桥动脉)狭窄,行动脉支架置入溶栓术或动脉支架置入术,除1例上述治疗无效后行再次肝移植外,其余9例血管恢复通畅。结论肝移植术中若无法行供、受者肝动脉端端吻合术重建肝动脉,间置髂动脉的肝动脉-腹主动脉架桥术是一种安全可靠的肝动脉重建方法。     

原位肝移植肝动脉血栓形成的预防和治疗

目的 总结原位肝移植肝动脉重建及其并发症的防治经验，以提高肝移植疗效和受体存活率。方法 分析9年间实施的85例原位肝移植患者的临床资料。肝动脉重建采用供者腹腔动脉干Carrell’s袖片或肝总动脉-脾动脉汇合部与受者肝左-右动脉部吻合16例(18．82％)，与受者胃十二指肠-肝固有动脉汇合部吻合61例(71．76％)，采用髂动脉-腹主动脉搭桥8例(9．42％)。术后根据凝血酶原时间(PT)，使用普通肝素或低分子肝素预防性抗凝。术中、术后应用多普勒超声监测肝动脉血供。结果 1例术中发生肝动脉血栓形成(HAT)，立即行血栓切除，重新吻合动脉，现已随访13个月，肝动脉保持通畅。其余84例随访2～54个月，未见HAT发生。全组HAT发生率为1．2％。结论 正确选择肝动脉重建吻合的部位和术后有效的抗凝治疗可以减少HAT的发生；多普勒超声监测能早期发现HAT，挽救移植物，避免再移植。     

活体肝移植解剖外旁路血管重建能否挽救移植肝？

在活体肝移植（1iving donor liver transplantation，LDLT）手术中，移植肝动脉通常与受者肝动脉直接吻合，即解剖性肝动脉重建。但是，外科医生在血管重建时经常会遇到一些难题，例如肝癌患者术前多次介入治疗导致自身肝动脉损伤或者既往肝脏手术导致肝动脉硬化、狭窄等。这时候，就不得不将移植肝动脉与受者另外的动脉进行重吻合，也就是解剖外旁路血管重建。这种情况下，肝动脉的供血可能受影响，移植肝的肝内胆管可能会发生坏死，以至产生不良后果。日本九州大学的研究者回顾性分析了在他们中心采用解剖外旁路血管重建的LDLT受者的预后情况。     

Accessory left hepatic artery arising from common hepatic artery

The knowledge of anatomical variations in hepatic artery are of importance to surgeons and radiologists while performing complicated procedures like liver transplantation and transarterial chemo-embolization for hepatic tumors. The incidence of accessory left hepatic artery is less common than the right accessory hepatic artery. Here we report an anomalous accessory left hepatic artery arising from common hepatic artery in a 55 year old male cadaver.     

Thrombotic and nonthrombotic hepatic artery complications in adults and children following primary liver transplantation with long-term follow-up in 1000 consecutive patients.

Arterial complications have a major impact on survival after liver transplantation (LTx). The aim of this study was to examine arterial complications in adults and children after LTx. A total of 1000 consecutive primary LTx patients [mean age 40.5 years: 600 males, 400 females, 834 adults; 166 children (age <18 years)] were studied. Forty-two patients (4.2%; 31 adults, 11 children) developed hepatic artery thrombosis (HAT). Thrombosis in children occurred significantly early (mean 5.4 days) compared with adults (mean 418.7 days, P = 0.0001). Nonthrombotic complications occurred in 30 patients (29 adults, one child). Overall, 13-year patient survival after HAT was 43.2% (72.7% children, 32.9% adults). For nonthrombotic complications, 54.3% of adults died and 69.4% grafts were lost. An overall incidence of 4.2% thrombotic and 3.2% nonthrombotic complications was observed. Rate of HAT was higher in children, but survival was better compared with adults.     

Modified technique for aortic cross‐clamping during liver donor procurement

Undue tension on the donor vessels during organ procurement is associated with intimal dissection, which can form the nidus for the thrombosis of the hepatic artery (HA) and graft loss. According to the US OPTN database, 143 grafts were discarded in the last 15 yr due to vascular damage during procurement. The most common technique to expose the supraceliac aorta is dissection between the left lateral segment of the liver and the esophagus–stomach. In obese donors, due to restricted space and in pediatric donors where the vessels are very delicate and this space is very small, the replaced or accessory left HA(R/A LHA) is prone to damage if approached conventionally. We describe a technique for the exposure of the supraceliac aorta in which the aorta is approached from the left side behind the gastroesophageal junction that does not require division of the gastrohepatic ligament. From May 2007 to May 2013, 104 liver procurements were performed. Eighty‐nine (85.6%) were adults, and 15 (14.4%) were pediatric donors. Twenty‐three (22.1%) had R/A LHA. No donor organ suffered any damage. One adult recipient with R/A LHA suffered HA thrombosis not related to it. In summary, this technical modification offers improved safety during cadaveric procurement and increases the ease.     

肝移植术肝动脉栓塞的原因及血管重建的方式

目的　分析肝移植术中和术后肝动脉栓塞(hepaticarterythrombosis,HAT)的原因,并探讨不同血管重建方式的效果。　方法　回顾性总结Pittssburgh大学器官移植中心和南京大学附属鼓楼医院共21例肝移植术中、术后HAT,其中12例(57. 1% )施行了肝动脉重建术(hepaticarteryreconstruction,HAR)。HAR方法有直接吻合(4例)、供体肝动脉-受体腹主动脉架桥术(aortohepaticinterpositiongraft,AHIG) (6例)、髂动脉架桥术(interpositiongraft,IG) (2例)。　结果　肝动脉血流重建成功率为58. 3% (7 /12);其余5例平均3. 8(3~6)d内再次发生HAT。成人HAR成功率为62. 5% (5 /8),儿童为50. 0% (2 /4)。HAR结果与HAT发生时间、HAT原因和HAR方式无明显相关性(P>0. 05)。　结论　肝移植术HAT可能原因有机械因素、受体肝动脉细小、供体肝动脉感染、供体DIC等,尽量减少或避免上述危险因素是最好的预防方法。肝移植术HAT时HAR方式包括直接吻合、AHIG、IG等,成功取决于能否及时获得诊断。有趋势表明机械因素所致HAT,HAR方式采用直接吻合和AHIG有较好的临床结果。     

电凝固化合并肝动脉栓塞治疗不能切除的原发性肝癌

为了提高不能切除原发性肝癌的治疗效果,采用电凝固化合并肝动脉插管栓塞化疗治疗原发性肝癌30例。病变均为单发,大小6cm～13cm,平均7cm。位肝右叶21例,左叶9例,全部病例经细胞学证实。经6月～40个月随访,完全缓解11例(37％),部分缓解15例(50％)总有效率87％。作者认为电凝固化合并肝动脉插管栓塞化疗,对不能切除质发性肝癌是一可选择治疗方法。     

Impact of Hepatic Arterial Reconstruction on Orthotopic Liver Transplantation in the Rat

ABSTRACT

Orthotopic liver transplantation (OLT) models in rats have been investigated in many studies, but detailed information on the impact of hepatic artery (HA) reconstruction on postoperative factors remains to be investigated. HA reconstruction also requires advanced skills. The effect of the reconstruction of the HA by a hand-suture technique in rats with a whole-liver syngeneic graft was investigated. Long-term survival, histopathological assessment, immunohistological evaluation, and blood biochemistry were investigated until postoperative day (POD) 28. From the early postoperative period, significant differences between OLTs with or without HA reconstruction were found in graft parenchymal damage, induction of apoptosis, and transaminase levels, though survival curves and the coagulation profile showed no differences. In OLT without HA reconstruction, biliary proliferation was decreased at POD 5–14, and total bilirubin level was increased at PODs 10 and 14. The study indicates that HA reconstruction is required for reliable OLT in rats.     

Investigation of proper hepatic artery and gastroduodenal artery variations by multidetector computed tomography angiography method

Abstract

Purpose: The purpose of this study is to evaluate the clinical anatomic variations of the proper hepatic artery (PHA) and the gastroduodenal artery (GDA). For this purpose, angiographic images of patients were evaluated.

Materials and methods: We retrospectively reviewed the multiple-detector computed tomography angiography images of 671 patients.

Results: In this retrospective study, 35 different types were identified as associated with PHA and GDA. There were 292 patients (43.52%; 175 females and 117 males) included in normal anatomical classification. Different anatomic variations were detected in 300 patients (44.71%; 129 females and 171 males). In 79 patients, arterial branch follow-up failed. These patients were evaluated as an unidentified group.

Conclusion: We described different vascular variations in the PHAs and GDAs of our patients.     

胰十二指肠切除术后肝梗死、肝脓肿发病原因及诊治研究

目的 探讨胰十二指肠切除术（PD）后肝梗死、肝脓肿病因及治疗方法。方法 回顾性分析中国医学科学院北京协和医院2012年1月至2018年12月期间PD术后诊断为肝梗死、肝脓肿的病例，分析其病因及治疗。结果 共11例病人术后明确诊断肝梗死、肝脓肿，其中3例在围手术期死亡，6例出现胆漏。7例明确合并肝固有动脉、副右肝动脉的截断或狭窄，1例术前存在腹腔干根部狭窄，3例存在门静脉狭窄。肠球菌、克雷伯菌是比较常见的致病菌，真菌作为致病菌较为常见。抗感染及介入治疗是主要的治疗手段。结论 PD后肝动脉、门静脉的缺血是发生肝梗死、肝脓肿的主要原因，常合并胆漏及多重致病菌的感染，病死率较高。