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。     

肝移植受体肝动脉异常的诊断及处理

目的研究肝移植受体肝动脉解剖变异、病理异常与吻合部位选择的关系。方法回顾性分析2004年3月至2006年7月期间我院80例成人肝移植患者的临床资料。术前磁共振血管成像结合术中动脉解剖鉴别动脉变异、病理异常及其类型，记录动脉吻合部位和口径，对动脉解剖变异组与无变异组的吻合部位和吻合口直径进行比较。结果全组受体肝动脉解剖变异率为11．3％（9／80），肝右动脉变异8／9例，分别来自胃十二指肠动脉（GDA）、肝总动脉（CHA）、腹腔动脉或肠系膜上动脉。吻合部位为CHA（7／9例）或GDA（2／9例）分支袖片。病理异常为2例，其中肝动脉内、外膜分离1例，以CHA端吻合；肝动脉狭窄1例，选择肾上腹主动脉前壁吻合。解剖变异组与无变异组吻合部位差异有统计学意义（x^2=18．679，P〈0．01），解剖变异组CHA分支袖片吻合口径与无变异组肝固有动脉或CHA分支袖片比较差异均无统计学意义（P〉0．05）。结论受体肝动脉解剖变异影响吻合部位选择，CHA分支袖片是首选部位；无变异组肝固有动脉分支袖片与变异组CHA分支袖片的吻合口径相似，前者可作为无动脉变异时的常用吻合部位。     

供肝动脉解剖变异之修整

目的: 探讨供肝动脉解剖特点，掌握供肝修整技术尤其动脉解剖变异之供肝修整方法及技巧。方法:对64例人肝（含24例无脑胎肝和40例成人肝脏）动脉实施解剖及修整，其中31例应用于临床肝移植。结果:64例中肝动脉解剖变异者共12例（18.75%）。其中24例胎儿供肝中5例（20.83%）肝动脉解剖变异，起源于肠系膜上动脉（SMA）替代肝右动脉型1例；起源于SMA副肝右动脉型3例；肝动脉起自SMA型1例。成人供肝动脉变异7例 (17.5%)，来源于SMA替代肝右动脉型2例；来自胃左动脉替代肝左动脉型2例；来自SMA副肝右动脉型3例。应用于临床原位肝移植的31例供肝中，4例存在肝右动脉解剖变异。肝移植时对变异之供肝动脉根据不同情况，可选用变异血管结扎、就近与胃十二指肠动脉、脾动脉或肠系膜上动脉吻合、应用供体髂总动脉搭桥与受体腹主动脉吻合等方法进行修整。结论:肝动脉的修整在供肝修整中占重要地位，供肝切取时避免损伤变异之肝动脉是保障修整成功的关键，对过细的副肝动脉修整时，术中观察侧支反流后可考虑是否予以结扎。     

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.     

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。     

肝癌治疗术中肝动脉插管途径的选择

目的探讨肝癌治疗术中肝动脉插管途径的选择。方法回顾性分析我们近5年来在手术中经肝动脉插管对100例肝癌病人进行栓塞化疗的临床资料。结果经导管注入美蓝证实,有95例肝脏全部染色,另5例仅见约3/4的肝脏被染色。成功率高达95%。术后发生剧烈腹痛14例,胰头出血、坏死1例,异位栓塞6例。发生导管移位9例。死亡2例。经胃网膜右动脉插管者,其术后导管移位率高达37%。经胃十二指肠动脉插管病人的术后死亡率高达20%。结论为预防肝癌肝内广泛转移,肝动脉插管应以肝动脉能覆盖全肝为原则。经胃右动脉插管最为方便、可靠,并发症少;经胃网膜右动脉插管者并发症最多见;经胃十二指肠动脉插管者并发症最为严重。     

起源于肝动脉的副胃左动脉DSA表现

目的观察起源于肝动脉的副胃左动脉(ALGA)的DSA表现。方法回顾性分析500例肝脏肿瘤患者腹腔动脉和肝动脉DSA影像,观察起源于肝动脉的ALGA、并分析其发生率。结果 500例患者中,共39例(39/500,7.80%)发现ALGA,其中起源于肝左动脉弓27例(27/39,69.23%),肝固有动脉5例(5/39,12.82%),迷走肝左动脉7例(7/39,17.95%)。另外发现4例(4/500,0.80%)左膈下动脉起源于肝左动脉,其中3例发出胃上动脉供应胃底。共22例发生ALGA或左膈下动脉胃上支化疗药物误灌注,9例发生碘油乳剂误栓。结论起源于肝动脉的ALGA并不少见,正确认识此类血管变异对肝脏肿瘤和胃部疾病的介入治疗具有重要意义。     

肝总动脉与副左肝动脉变异一例北大核心CSCD

患者男,74岁,因“间断上腹不适5年”入院,诊断“胃近端癌”.术中未见肝、胆、脾、胰腺及大网膜转移,决定行胃癌根治加食管-胃吻合术.显露腹腔动脉干,起点外径约为11 mm,距起点1.5 cm处分为胃左动脉和脾动脉,外径分别约3 mm和6.5 mm.沿动脉干向中心侧解剖,切开肝胰皱襞被膜,发现脾动脉走行异常,于小网膜区形成一襻状,先向右下,然后转向左侧沿胃后壁走向胰腺上缘,走行约6 cm发出肝总动脉.结扎胃左动脉,处理胃小弯侧胃前、胃后壁相应分支.胃左动脉上方约4 cm处发出1支动脉,外径约2mm,向右走行于肝胃韧带的较高处,至尾状叶左侧肝左纵沟而入肝,确定左、右半肝均有完整的肝动脉血供后予以切断、结扎.完成第1、2、3、4sa、4sb、4d、7、8a、9、10、11p、11d、12a组淋巴结清扫,在肿瘤下缘5 cm处离断胃体,完成消化道重建.术后患者恢复良好,肝功能及腹部彩超正常,术前螺旋CT检查见图1,2.     

左外区活体肝移植动脉的临床应用解剖研究

目的 观察肝左区肝动脉解剖结构，模拟肝左外区活体肝移植动脉切取方法。方法 解剖非肝病死亡之成人甲醛固定尸体肝脏标本30例，观察新鲜成人尸体肝脏铸型标本30例，测量肝左及左外区动脉长度、管径及属支分布情况。结果 左半肝动脉的血供来自肝固有动脉、肝左动脉、肝中动脉，肝外迷走动脉支有左膈下动脉、胃左动脉和胃右动脉，并于不同部位发出后分别进入左外区上、下段。结论 左半肝动脉主要有5种类型，因此解剖变异较多，左外区活体取肝前应仔细研究其结构特点，设计合理的切取模式；移植前肝动脉需进行必要的整形，以便与受体动脉吻合。     

原位肝移植术中肝动脉变异及术后肝动脉血栓形成的处理

目的探讨肝移植术中肝动脉变异及术后肝动脉血栓形成的处理。方法统计2000年8月至2002年12月期间进行肝移植术的67例次供、受者肝动脉的变异情况；分析肝动脉的重建方式，探讨肝动脉变异与手术后肝动脉血栓形成的关系、肝动脉血栓形成的危险因素及肝动脉血栓形成后的处理。结果67例次供者肝脏和65例受者肝脏共出现肝动脉变异12例次，发生频率最高的为右肝动脉起源于肠系膜上动脉(5例)及左肝动脉起源于胃左动脉(3例)。肝动脉的重建方式如下：供者及受者肝总动脉与胃十二指肠动脉分叉处成型后吻合58例；腹主动脉与肝动脉搭桥2例；利用变异的肝动脉分支吻合7例。手术后发生肝动脉血栓形成3例，均经腹股沟处股动脉插管行肝动脉溶栓治疗，此3例患者中死亡1例。结论避免变异的肝动脉损伤、选择适当的肝动脉吻合方式可以保证移植肝脏的动脉血供。肝动脉血栓形成与肝动脉变异无关。作为肝动脉血栓形成后的保守治疗方法，肝动脉内溶栓治疗有可能避免2次移植。     

Traumatic and postoperative ischemic liver necrosis: causes, risk factors and treatment

BACKGROUND: To study the cause and outcome of ischemic liver necrosis and suggest treatment of these patients. METHODS: Retrospective study of 13 patients with ischemic liver necrosis treated at our departments from 1990 until 1997. RESULTS: Ischemic liver necrosis was caused by general hypoxia (n = 1) or acute arterial occlusion (n = 12) of the celiac and superior mesenteric artery (SMA, n = 3), proper hepatic artery (PHA, n = 1), right hepatic artery (RHA, n = 2), left hepatic artery (LHA, n = 2) and intrahepatic vessels (n = 4). Six of the cases were related to surgical procedures, 5 of these (38%) were unintended arterial injuries after biliary surgery. Ten patients (77%) had risk factors contributing to the development of liver necrosis: septicemia (n = 4), jaundice and septicemia (n = 2), shock and hypoxia (n = 3) and alcoholic cirrhosis (n = 1). Five patients (38%) needed resection of the liver necrosis due to infected necrosis. Three patients (23%) died; two of these had celiac/SMA occlusion. One died due to complete gastrointestinal ischemia and severe lactacidosis, two died of multiorgan failure after bile leakage and septicemia. CONCLUSION: Ischemic liver necrosis is mainly caused by arterial occlusion due to arteriosclerosis, arterial transection during biliary surgery or blunt liver trauma, and seldom occurs without additional risk factors. 50% of the patients develop infected necrosis and need liver resection. Patients with sterile necrosis may recover without surgical procedures of the liver. The mortality in patients with central (celiac/SMA) and peripheral (CHA, PHA, RHA, LHA, intrahepatic branches) occlusions was 67% (2/3) and 11% (1/9), respectively.     

Arterial reconstruction in rat liver transplantation – development of a new tubing technique of the common hepatic artery

Arterialization of liver transplants in rats results in an improved function compared with grafts without artery. Here we compared techniques of reconstruction, focusing on thrombosis, duration of procedure and severity of pancreas damage after dissecting the gastroduodenal artery (GDA). Group 1: tube was inserted into the proper hepatic artery (PHA) of donor and recipient. Group 2: tube was placed into common hepatic artery (CHA) of donor and recipient. Group 3: cuff was placed over the CHA of the recipient and the graft's artery was slipped over the cuff. Tubing in PHA leads to a thrombosis rate of 40% after 6 months. Arteries remain perfused by using a cuff or tube in CHA. Dissection of the GDA does not influence pancreatic perfusion. Reconstruction took 19 s using the large tube, about 30 s for the tube into PHA and 1 min for the cuff. The method of choice is using a tube for the CHA.     

Clinical Implications of an Aberrant Right Hepatic Artery in Patients Undergoing Pancreaticoduodenectomy

Background  Sometimes, it seems to be difficult to preserve the aberrant hepatic artery (HA) during pancreaticoduodenectomy (PD), with respect to en bloc lymph node dissection, especially in the case of aberrant right hepatic artery (RHA). Therefore, we evaluated the influence of incomplete en bloc lymph node (LN) dissection when aberrant RHA arises. Methods  We reviewed 103 patients with mid-to-distal common bile duct (CBD) cancers who underwent PD by one surgeon at Asan Medical Center from December 1994 to November 2005 (73 men, 30 women; mean age, 61.1 ± 9.4 (range: 40–84) years). The mean follow-up period was 32.7 months. We compared the normal RHA group with the aberrant RHA group. Results  Eighty-eight cases showed normal RHA anatomy, including nine cases (8.7%) of aberrant left hepatic artery (LHA) with normal RHA cases (normal HA group). RHA anomalies were observed in 15 cases (14.6%, aberrant HA group). In all cases, there was no direct invasion of cancer to aberrant HA. Among two groups, 43 cases (41.7%) showed recurrence and there was no significant difference in recurrence between two groups (p = 0.202). Three-year and 5-year overall survivals were 33.3% and 28.5% in the normal HA group, whereas 47.1% and 28.3% in the aberrant RHA group, respectively. There also was no statistically significant difference in survival (p = 0.763). Conclusions  When performing PD for CBD cancer, aberrant RHA should be preserved if there was no cancerous invasion and it does not seem to affect the recurrence of disease and overall survival of patients.     

Preoperative dual-phase 3D CT angiography assessment of the right hepatic artery before gastrectomy

Purposes

In the current study, we evaluated the efficacy of dual-phase three-dimensional (3D) CT angiography (CTA) in the assessment of the vascular anatomy, especially the right hepatic artery (RHA), before gastrectomy.

Methods

The study initially included 714 consecutive patients being treated for gastric cancer. A dual-phase contrast-enhanced CT scan using 32-multi detector-row CT was performed for all patients.

Results

Among the 714 patients, 3D CTA clearly identified anomalies with the RHA arising from the superior mesenteric artery (SMA) in 49 cases (6.9 %). In Michels’ classification type IX, the common hepatic artery (CHA) originates only from the SMA. Such cases exhibit defective anatomy for the CHA in conjunction with the celiac–splenic artery system, resulting in direct exposure of the portal vein beneath the #8a lymph node station, which was retrospectively confirmed by video in laparoscopic gastrectomy cases. Fused images of both 3D angiography and venography were obtained, and could have predicted the risk preoperatively, and the surgical finding confirmed its usefulness.

Conclusion

Preoperative evaluations using 3D CTA can provide more accurate information about the vessel anatomy. The fused images from 3D CTA have the potential to reduce the intraoperative risks for injuries to critical vessel, such as the portal vein, during gastrectomy.     

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.     

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.     

Clinical Significance of the Interposition Graft for Reconstruction Between the Common Hepatic Artery and Gastroduodenal Artery for Arterial Patency of the Pancreas Graft in Pancreas Transplantation

BackgroundDue to the limited number of organ donations from deceased donors in Japan, pancreas grafts for pancreas transplantation (PTx) are frequently harvested from the donor in the same donation surgery as the liver graft. In such a situation, the common hepatic artery (CHA) and gastroduodenal artery (GDA) are dissected, resulting in decreased blood flow to the head of the pancreas graft. Therefore, GDA reconstruction using an interposition graft (I-graft) between the CHA and GDA has been traditionally performed to maintain blood flow. This study investigated the clinical significance of GDA reconstruction with the I-graft regarding the arterial patency of the pancreas graft in patients after PTx.MethodsFifty-seven patients underwent PTx for type 1 diabetes mellitus at our hospital between 2000 and 2021. Twenty-four cases in which GDA reconstruction was performed using the I-graft and artery blood flow of the pancreas graft was evaluated by contrast-enhanced computed tomography or angiography were included in this study.ResultsThe patency of the I-graft was 95.8%, and only one patient had a thrombus in the I-graft. Nineteen patients (79.2%) had no thrombus in the artery of the pancreas graft; the other five cases had thrombus in the superior mesenteric artery (SMA). The patient with the thrombus in the I-graft required graftectomy for the pancreas graft.ConclusionsThe patency of the I-graft was favorable. Furthermore, the clinical significance of the GDA reconstruction with the I-graft is suggested to maintain blood flow in the pancreas head if the SMA is occluded.     

Management of Type 9 Hepatic Arterial Anatomy at the time of Pancreaticoduodenectomy: Considerations for Preservation and Reconstruction of a Completely Replaced Common Hepatic Artery

Recognition and management of aberrant hepatic arterial anatomy for patients undergoing pancreaticoduodenectomy (PD) are critical to ensure safe completion of the operation. When the common hepatic artery (CHA) is noted to emanate from the superior mesenteric artery (Michels’ type 9 variant), it is vulnerable to injury during the dissection required for PD. While this anatomy does not preclude an operation, care must be taken to avoid injury, often by identifying the CHA throughout its entire course before beginning the dissection of the portal venous structures. The oncologic principle that cautions against resection of a pancreatic cancer when it involves the CHA in its standard position may not universally apply to tumors that focally involve the CHA in the type 9 anatomic variant. In highly selected patients, surgical resection may be entertained as disease biology may be analogous to local involvement of the gastroduodenal artery in a patient with standard anatomy. Here, we review the indications, techniques, and outcomes associated with arterial resection and reconstruction during pancreatectomy among patients with a pancreatic tumor involving a common hepatic artery arising from the superior mesenteric artery.     

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.