彩色多普勒超声对肝移植术后11例血管并发症的诊断

目的评价彩色多普勒超声对肝移植术后血管并发症的诊断意义。方法回顾性分析和总结11例肝移植术后血管并发症的彩色多普勒超声检查资料,检测指标包括肝动脉及左右分支的峰值速度、阻力指数、加速度及加速时间,门静脉平均流速。结果5例经手术或造影证实为动脉并发症(血栓形成2例,肝动脉狭窄2例,肝动脉痉挛1例),彩色多普勒超声表现有肝动脉狭窄处的高速高阻血流并伴有湍流,而狭窄远端肝内动脉峰值速度<40cm/s,阻力指数<0.5,加速时间>0.08s,加速度<300cm/s2,2例肝动脉血栓形成肝门部无动脉血流信号;6例为门静脉并发症(3例门静脉狭窄,3例门静脉血栓形成)。结论彩色多普勒超声对肝移植术后血管并发症的诊断具有重要的指导意义。     

肝移植术中血管超声检查在血管并发症预防和诊断中的价值

目的 探讨肝移植术中血管超声检杳在预防和诊断血管并发症中的价值.方法 肝移植术中对116例患者进行血管超声检查,检测血管吻合后肝动脉峰值流速和门静脉流量.以肝动脉峰值流速2>30 cm/s为正常肝动脉标准,以门静脉流量2>800ml/min为正常门静脉标准.结果 在116例患者中,有14例肝动脉峰值流速<30 cm/s,其中9例通过应用利多卡因腹腔于根部浸润、罂粟碱及盐酸消旋山莨菪碱肝动脉内注射,解除血管痉挛后,肝动脉峰值流速达到正常标准,但术后仍有3例患者发生肝动脉并发症;另5例经过上述处理,肝动脉峰值流速仍<30 cm/s,故采用供者髂内动脉对受者腹主动脉与供者肝动脉进行搭桥吻合,吻合后测肝动脉峰值流速2>30 cm/s,术后未发生肝动脉并发症.116例患者中,有5例门静脉流量<800 ml/min,其中4例经证实存在门腔分流,行门腔分流静脉结扎后,门静脉流量达到正常标准,但术后仍有1例发生门静脉血栓;另1例存在门静脉Ⅲ级血栓,血栓切除后进行门静脉端端吻合,门静脉流量仍达不到标准,故利用供者髂静脉通过胰腺前胃十二指肠后与受者肠系膜上静脉远端进行搭桥吻合,术中测量门静脉流量达到正常标准,术后未发生门静脉并发症.结论 肝移植术中血管超声检查对血管并发症具有较高的预防和诊断价值.对术中超声检查提示异常的患者,术后应该严密监测,以尽早发现可能出现的血管并发症并进行相应治疗.     

脾切除对活体肝移植术后肝脏血流动力学的影响

目的 研究活体肝移植联合脾脏切除术后患者肝脏血流动力学变化情况.方法 回顾性分析2006年8月至2009年3月开展的66例活体肝移植手术患者的病例资料,肝移植时行脾切除者共22例(脾切除组),年龄(45±11)岁,按1∶2的比例随机抽取同期具有可比性的肝移植时未行脾切除的44例患者作为对照组,年龄(44±10)岁,对比分析移植术后两组间患者肝脏血流动力学变化.结果 术前、术后1 d保留脾脏组和脾切除组门静脉血流速度分别为(12±2)cm/s和(11±3)cm/s、(35±18)cm/s和(32±17)cm/s,两组术后门静脉血流速度均显著大于术前水平(P＜0.05),术后1周两组肝右静脉血流速度分别为(44±18)cm/s和(31±15)cm/s,术后保留脾脏组肝右静脉血流速度明显大于脾切除组(P＜0.05),术后2周两组肝动脉血流速度分别为(18±8)cm/s和(26±7)cm/s,肝动脉阻力系数分别为0.66±0.13和0.57±0.12,1周后脾切除组肝动脉血流速度明显大于保留脾脏组(P＜0.05),而肝动脉阻力系数明显小于后者(P＜0.05).结论 活体肝移植联合脾切除术后肝脏的血流动力学情况优于单纯活体肝移植术式.

Abstract：

Objective To investigate the changes of hepatic hemodynamics in patients with splenectomy plus living donor liver transplantation (LDLT). Methods The data of 66 patients received LDLT from August 2006 to March 2009 were analyzed retrospectively:22 cases received splenectomy with LDLT (splenectomy group) and aged (45±11) years. Forty-four comparable cases received LDLT only in the mean time were selected as control group and aged (44±10) years. Comparative analysis was performed between the two groups with respect to the changes of hepatic hemodynamics after transplantation.Results Blood velocity in portal vein in control group and splenectomy group at 1 day before and after the transplantation were (12 ±2) cm/s vs. (11+3) cm/s, (35±18) cm/s vs. (32 ± 17) cm/s, respectively. Postoperative blood velocity in portal vein in both groups increased significantly than the preoperative level ( P ＜ 0.05).Blood flow velocity in right hepatic vein in both groups at 1 week after the treatment were (44±18)cm/s and (31±15) cm/s(P＜0.05), respectively. Blood flow velocity in hepatic artery in both groups 2 weeks after the operation were (18±8) cm/s vs. (26±7) cm/s(P＜0.05) and resistance coefficient of hepatic artery were 0.66±0.13 vs. 0.57±0.12 (P＜0.05), respectively. Conclusion Hepatic hemodynamics in patients received LDLT plus splenectomy is superior to that in patients received LDLT only.     

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目的：分析10例活体肝移植术中的血管变异，总结其外科处理经验，进一步提高手术成功率，减少并发症。方法：2001年1月至12月，行活体肝移植10例，其中左半肝8例，左外叶1例，右半肝1例，供肝者均为其母，经术中B超及胆管造影以确定肝切线。供体单支肝动脉分支与受体肝动脉吻合，两支肝动脉分别与受体肝左、右动脉吻合。门静脉分支与受体门静脉主干吻合。供体肝静脉与受体下腔静脉行端侧吻合。胆管重建均采用肝管分支与受体胆总管端端吻合，置T管引流。结果：10例活体肝移植，1例因肝动脉血栓形成，术后5天需次肝移植；1例发生排斥；其余8例均康复出院，5例已上学。结论：活体肝移植术中血管重建技术是其重要环节，术前和术中了解供受体解剖变异并正确处理，可减少术后血管和胆道的并发症。     

肝移植术后肝动脉并发症的介入治疗

目的评价介入治疗对肝移植术后肝动脉并发症的价值。方法回顾性分析我院2001年10月—2010年3月对21例肝移植术后肝动脉并发症患者进行介入治疗的资料。结果 21例患者中,肝动脉狭窄16例,对其中14例成功植入肝动脉支架15枚,另2例未予治疗;肝动脉血栓2例,对1例行动脉溶栓治疗,1例行二次肝移植;肝动脉假性动脉瘤3例,对其中1例行血管内栓塞治疗,1例伴有肝动脉吻合口狭窄者行血管内支架植入,1例转为外科手术治疗。结论介入治疗肝移植后肝动脉部分并发症是安全、有效的临床治疗方法。     

活体肝移植术后早期肝动脉血栓形成的诊断与治疗

目的探讨活体肝移植术后早期肝动脉血栓形成的诊断与治疗。方法2006年9月至2009年8月天津市第一中心医院单一外科组共实施110例活体肝移植,移植术后7d内每日用彩色多普勒超声(彩超)监测肝动脉血流,怀疑肝动脉血栓形成行肝动脉造影或腹部CT检查,确诊者予介入治疗或手术治疗。结果该组3例术后5～6d发生肝动脉血栓,肝动脉血栓发生率2.7%(3/110)。其中1例再次手术行肝动脉取栓,术后血流正常;2例行介入治疗,放置支架,术后1例再次血栓形成,1例血流流速偏低,2例均发生胆道并发症,但肝功能正常。3例均存活。结论术后早期用彩超监测对肝动脉血栓的诊断至关重要,及时手术取栓或介入放置支架效果良好。     

彩色多普勒超声在婴幼儿肝移植术后肝动脉检测中的意义

目的探讨彩色多普勒超声在婴幼儿肝移植术后肝动脉检测的意义。方法应用彩色多普勒超声对57例婴幼儿肝移植患者术后进行肝动脉检测,观察有无血流信号,肝动脉收缩期流速(S)、舒张期流速(D)及S/D情况。随访时间最短2个月,最长9个月。收集所有患者的动脉检测数据进行分析。结果 52例患儿彩色多普勒超声提示肝动脉血流通畅,未见明显异常;5例患儿分别在术后5~8天内彩色多普勒超声检查于肝门部及肝内均未探及到动脉血流信号,考虑肝动脉血栓形成,3例经血管造影证实、1例经超声造影及增强CT证实,1例超声出现假阳性,血管造影显示肝动脉未见明显异常。彩色多普勒超声对肝动脉检测的诊断符合率达98%。结论彩色多普勒超声为婴幼儿肝移植术后动脉的监测及并发症的早期诊断提供重要的依据。     

门静脉高压症原位肝移植前后内脏血流动力学变化的临床研究

目的 研究门静脉高压症原位肝移植前后内脏血流动力学变化及其对脾功能亢进、侧支循环、术后肝功能恢复的影响.方法 2002年6月至2005年10月上海交通大学医学院附属瑞金医院外科共完成173例原位肝移植术.选取其中38例肝硬化门静脉高压症患者,分别于术前、术后1、3、5、7 d、1个月、6个月、1、2、3年行彩色多普勒超声检查,监测患者门静脉血流平均速度、门静脉血流量、肝动脉阻力指数等血流动力学指标和脾脏大小变化,并与8例急性重症肝炎患者及20名健康人进行对照,同时观察其对肝功能和食管胃底曲张静脉的影响.结果 肝硬化门静脉高压症患者术后门静脉血流平均速度从术前(13.7±4.2)cm/s升至(58.4±25.2)cm/s,门静脉血流量从(958±445)ml/min升至(3024±1207)ml/min,肝动脉阻力指数从0.65±0.11升至0.74±0.12,均明显高于急性重症肝炎组和正常对照组(P<0.05),门静脉血流平均速度和门静脉血流量分别于术后6个月、2年降至正常对照组水平.肝硬化门静脉高压症组术后脾功能亢进从术后第2天开始改善,至术后1个月完全恢复,但脾脏肿大在术后3年仍然存在.术后食管胃底曲张静脉亦明显改善.结论 肝硬化门静脉高压症患者原位肝移植术后内脏高血流动力学仍将长期存在,但并不影响脾功能亢进和食管胃底静脉曲张以及肝功能的恢复.     

婴幼儿活体肝移植与劈离式肝移植供体手术的区别及手术配合的体会

目的总结婴幼儿活体肝移植和劈离式肝移植供体手术方式的区别以及手术配合体会。方法 2006年9月至2013年12月,上海交通大学医学院附属仁济医院实施婴幼儿肝移植200例,其中活体肝移植170例,劈离式肝移植30例。收集活体肝移植和劈离式肝移植供体获取的手术资料,总结分析两种术式的术前准备(人员准备和器械准备)、术中配合、手术时间的差异。结果与劈离式肝移植供体获取比较,活体肝移植供体获取的手术操作较为复杂,参与手术的人员与所需特殊器械和物品相应较多。活体肝移植供体手术为在体劈离,分别离断肝动脉左支、门静脉左侧主干及在肝左静脉汇入下腔静脉处离断肝左静脉。劈离式肝移植供体获取则在体外修肝盆中完成,手术方式与活体肝移植类似。活体肝移植组供体手术组的手术时间为(4.3±0.2)h,劈离式肝移植组供体手术则为(1.6±0.2)h,两组比较差异具有统计学意义(P0.05)。结论活体肝移植和劈离式肝移植两种婴幼儿肝移植的手术方式有所区别。与劈离式肝移植供体获取比较,活体肝移植术供体获取手术所需工作人员、特殊器械和物品的数量较多,手术时间较长。因此,所有参与手术的人员均应密切配合,手术过程中要求护理人员尤其需要有极强的无菌观念、动作敏捷、熟练掌握肝移植术的配合过程。     

门静脉-下腔静脉吻合术预防活体肝移植术后小肝综合征3例报道

目的探讨门静脉-下腔静脉吻合术用于预防活体肝移植术后小肝综合征(small-for-size liver syndrome,SFSS)的效果。方法 3例活体肝移植均采用不含肝中静脉的右半肝作为移植物。术中发现实测移植物(肝)重量/受体的体质量(体重)的比值(graft to recipient weight ratio,GRWR)为0.58%、0.77%及0.71%,均<0.8%,符合小移植物的诊断。处理:首先吻合肝静脉流出道,其次吻合门静脉,将受体门静脉右支与移植肝门静脉右支端端吻合,将受体门静脉左支与下腔静脉行端侧吻合达到门腔分流的作用,之后按顺序吻合动脉和胆道。术中均未行脾静脉结扎或脾切除等处理。术后定期随访。结果 3例患者术后均未发生SFSS并顺利出院,出院时间分别为术后25d、34d及56d。移植肝功能逐步好转,术后1d门静脉流速理想。移植肝增长良好。门静脉-下腔静脉短路通畅时间:除1例通畅持续仅104d,其余2例持续通畅。结论 LDLT术中进行门静脉-下腔静脉吻合术可以及时有效预防小移植物背景下的SFSS,受体门静脉左支与下腔静脉行端侧吻合的分流技术安全可靠。     

成人间活体右半肝移植术中变异门静脉右支切取与重建技术

目的 探讨成人间活体右半肝移植术中变异门静脉支(APVB)切取与重建的技巧.方法 2002年1月至2007年4月,共实施70例成人间活体右半肝移植.术前肝脏血管三维CT成像显示供肝动脉及静脉走向,70例右半供肝中有9例门静脉分支变异,其中7例为Ⅱ型变异,2例为Ⅲ型变异.除1例供者行狭窄桥状连接单口切取APVB外,其余8例均采用供者优先的原则即距门静脉主干2～3mm处双口切断APVB.Ⅱ型变异中有2例双口切取其右前、右后支成形为一个开口后与受者门静脉主干吻合,4例右前、右后支分别与受者门静脉左、右支吻合,1例行右前、右后支间狭窄桥状组织连接单口切取后与受者门静脉主干单口吻合.Ⅲ型变异中有1例双口切取其右前、右后支分别与受者门静脉支双口吻合,1例双口切取后行新型的U形血管移植物间置与受者门静脉主干单口吻合.结果 9例受者均无门静脉狭窄或血栓、肝动脉狭窄或血栓以及肝静脉流出道狭窄等血管并发症发生.1例供者术后3 d并发门静脉血栓,手术取栓及门静脉壁修补成形后痊愈.新型的U形血管移植物间置重建术后通畅,无并发症发生.结论 成人间活体右半肝移植术中采用供者优先的原则双口切取APVB、双口吻合重建以及新型的U形血管间置等门静脉重建技术是安全可行的,未增加手术难度,且临床效果良好.     

Vascular complications after living donor liver transplantation: a Brazilian, single-center experience

Background

In living donor liver transplantation (LDLT), vascular complications are more frequently seen than in deceased donor transplantation. Early arterial, portal vein, or hepatic vein thromboses are complications that can lead to graft loss and patient death. The aim of this study was to assess the incidence, treatment, and outcome of vascular complications after LDLT in a single Brazilian center.

Methods

Between December 2001 and December 2010, we performed 130 LDLT. Sixty-four recipients were children (27 weighing <10 kg).

Results

Nine recipients had vascular complications. Hepatic artery thrombosis (HAT) occurred in 4 (3.1%), portal vein thrombosis (PVT) in 3 (2.3%), and hepatic vein thrombosis (HVT) and hepatic arterial stenosis (HAS) in 1 (0.8%) patient each. Complications were identified by Doppler and confirmed by angiography or angiotomography. Patients with HAT were listed for retransplantation. One died before retransplant. Two children were submitted to retransplantation; one is still alive, with neurologic sequelae. One adult with HAT was retransplanted with a deceased donor graft and is doing well 58 months after surgery. Two patients with PVT died as a consequence of graft malfunction. In the other case, portal vein arterialization was performed, but patient died 11 months posttransplant. HVT was detected after cardiac reanimation and was treated with an endovascular stent. This patient died 3 months after LDLT. HAS was diagnosed after liver abscess development and was successfully treated by endovascular angioplasty. No recurrence was observed after 22 months. Follow-up ranged from 9 to 117 months.

Conclusion

Pediatric patients are more prone to develop vascular complications after LDLT. Long-term survival was statistically lower for recipients with vascular complications (33.3% vs 77.7%; P = .008).     

Hepatic arterial buffer response after pediatric living donor liver transplantation: report of a case

Background

Excessive portal pressure at an early stage after living-donor liver transplantation (LDLT) can damage sinusoidal endothelial cells and hepatocytes through shear stress leading to graft failure, or hepatic arterial complications due to low hepatic artery flow from a hepatic arterial buffer response. We encountered a case in which excessive portal vein flow was observed from an early stage after pediatric LDLT. The hepatic artery flow decreased due to a hepatic arterial buffer response.

Case report

A 6-month-old boy with biliary atresia showed excessive portal vein flow early after LDLT with a decreasing hepatic artery flow without anastomotic stenosis from postoperative day 3. The PV flow gradually exhibited a decrease at approximately postoperative day 8 and, similtaneously, hepatic artery flow exhibited improvement.

Conclusion

Because excessive portal pressure after LDLT is reversible, it has been suggested that it may be possible to prevent the progress of hepatic arterial complications if temporary portal pressure modulation can be performed for cases among the high-risk group for hepatic arterial complications.     

肝门部胆管癌术前门静脉栓塞的血流动力学与肝再生的关系

目的 研究肝门部胆管癌术前门静脉栓塞(PVE)前后血流动力学的变化,并分析其与非栓塞肝叶增生速度的关系.方法 回顾性分析2008年4月至2009年12月第二军医大学东方肝胆外科医院收治的21例肝门部胆管癌患者的临床资料.在手术治疗前进行钢圈PVE治疗,在该治疗前和治疗后第3、7、14天采用彩色多普勒超声对门静脉的血流动...     

Vascular reconstruction and complications in living donor liver transplantation in infants weighing less than 6 kilograms: the Kyoto experience.

Smaller-size infants undergoing living-donor liver transplantation (LDLT) are at increased risks of vascular complications because of their smaller vascular structures in addition to vascular pedicles of insufficient length for reconstruction. Out of 585 child patients transplanted between June 1990 and March 2005, 64 (10%) weighing less than 6 kg underwent 65 LDLTs. Median age and weight were 6.9 months (range: 1-16 months) and 5 kg (range: 2.8-5.9 kg), respectively. Forty-five lateral segment, 12 monosegment, and 8 reduced monosegment grafts were adopted, and median graft-to-recipient weight ratio was 4.4% (range: 2.3-9.7). Outflow obstruction occurred in only 1 patient (1.5%). Portal vein complication occurred in 9 (14%) including 5 with portal vein thrombosis. Hepatic artery thrombosis (HAT) occurred in 5 (7.7%). Patient and graft survivals were 73% and 72% at 1 yr, and 69% and 68% at 5 yr after LDLT, respectively. Thirteen of 22 grafts (58%) lost during the follow-up period occurred within the first 3 months posttransplantation. Overall graft survival in patients with and without portal vein complication was 67% and 65%, respectively (P = 0.54). Overall graft survival in patients with and without HAT was 40% and 67%, respectively. HAT significantly affected graft survival (P = 0.04). In conclusion, our surgical technique for smaller-size recipients resulted in an acceptable rate of vascular complications. Overcoming early posttransplantation complications will further improve outcomes in infantile LDLT.     

Vascular Complications After Deceased and Living Donor Liver Transplantation: A Single-Center Experience

Introduction

Vascular complications (VC) after liver transplantation (OLT) are one of the most feared problems that frequently result in graft and patient loss. Herein we have reported our experience with VC after either deceased donor liver transplantation (DDLT) or living donor liver transplantation (LDLT).

Patients and Methods

Between April 2001 and September 2009, we performed 224 OLT: 155 DDLT and 69 LDLT. The overall male/female ratio was 136/88 and the adult/pediatric ratio was 208/16. We retrospectively identified and analyzed vascular complications in both groups.

Results

In the DDLT group, 11/155 recipients (7%) suffered vascular complications; hepatic artery thrombosis (HAT; n = 5; 3.2%), portal vein thrombosis occurred (n = 4; 2.6%); hepatic vein stenosis (n = 1; 0.6%), and severe postoperative bleeding due to a slipped splenic artery ligature (n = 1, 0.6%). In the DDLT group, 4/11 (36.4%) patients died as a direct result of the vascular complications. In the LDLT group, 9/69 recipients (13%) suffered vascular complications: HAT (n = 3; 4.3%), portal vein problems (n = 5; 7.2%), and hepatic vein stenosis (n = 1; 1.5%). Among LDLT, 3/9 (33.3%) patients died as a direct result of the vascular complications. In both groups vascular complications were associated with poorer patient and graft survival.

Conclusions

In our experience, the incidence of vascular complications was significantly higher among the LDLT group compared with the DDLT group. Vascular complications were associated with poorer graft and patient survival rates in both groups.