成人间活体肝移植供体肝中叶静脉回流类型与移植物的选择

目的分析供体肝中叶静脉回流类型,探讨其对移植物选择的指导意义。方法回顾性分析2005年4月至2009年3月期间,在瑞金医院器官移植中心参加活体肝移植供体筛选的109例潜在供体的CT检查资料,根据Marcos分型和Nakamura分型分别分析供体肝中静脉回流类型和Ⅳb段静脉回流类型。结果本组供体的肝中静脉按其两侧分支的不同可分为3型,其中Ⅰ、Ⅱ型相对较多,分别占44.0%(48/109)、37.6%(41/109),Ⅲ型最少,占18.3%(20/109)。各型供体的全肝体积、左半肝体积、左半肝体积占全肝比例等的差异均无统计学意义(P0.05)。Ⅳb段静脉则以Ⅰ型最多,占72.5%(79/109),Ⅱ、Ⅲ型较少,分别占12.8%(14/109)及14.7%(16/109)。最终有37例供体捐出右半肝,其中MarcosⅠ、Ⅱ及Ⅲ型供体保留肝中静脉者分别占12/17、8/11及5/9,NakamuraⅠ、Ⅱ及Ⅲ型供体保留肝中静脉者则分别占16/26、4/6及5/5。结论成人间活体肝移植切取右半肝移植物时,Marcos分型和Nakamura分型结果对肝中静脉的取舍可能有重要意义。     

二例成人间双活体供肝移植的手术重建技巧

目的探讨成人间双活体供肝移植的手术重建技巧。方法2例成人患者,1例原发病为乙型肝炎后肝硬化、巨块型肝癌,接受其2位姐姐的左半肝移植,移植物与受者体重比(GR/WR)为1.5%,移植于原肝位置左侧的左半肝,其肝左静脉、门静脉分别于受者的肝左静脉、门静脉左支端端吻合,胆肠吻合方式重建供肝胆道;移植至右侧的左半肝,沿矢状位旋转180°,其肝左静脉、门静脉分别与受者的肝右静脉、门静脉右支端端吻合,左肝管与受者的肝总管端端吻合。另1例原发病为乙型肝炎后肝硬化,接受其母亲的右半肝移植,但由于供肝存在大泡状空泡变性,且供、受者的体重差较大,为能满足患者的生理需要,故该例同时行尸体左半肝移植,GR/WR为1.2%,右半肝的肝右动脉、肝右静脉分别于受者的同名血管端端吻合,其门静脉与受者的门静脉右支端端吻合,右肝管与受者的肝总管端端吻合;左半肝的肝左静脉、门静脉及肝动脉分别与受者的肝左静脉、门静脉左支及脾动脉端端吻合,胆肠Roux-en-Y吻合方式重建供肝胆道。结果除母亲供者术后3d出现短暂乳糜漏,经对症治疗11d后痊愈外,供者无其它并发症发生。2例患者术后恢复良好,未发生排斥反应及全身感染,现已随访10个月以上,肝功能正常,均恢复正常工作和生活。结论成人间双活体供肝移植可为受者提供更大的肝脏,又可减少供者的风险,但手术操作复杂,需要对供、受者的条件进行充分评估后施行。     

成人间活体肝移植体会：附3例报告

目的总结和分析成人间活体肝移植(LDLT)的临床经验。方法对2007年2月—2007年7月的3例成人间活体肝移植的临床资料进行回顾性分析。结果供体为供体右半肝(不带肝中静脉)1例,供体扩大左半肝(带肝中静脉、尾状叶)2例,GV/SLV均≥40%。3对供者及患者术后均恢复良好,无小肝综合征发生,均未出现严重并发症。术后左半肝供者较右半肝供者肝功能恢复更快。结论如左半肝GV/SLV≥40%,可优先选择左半肝作为供肝;胆道重建不必放置胆管引流管;成人间LDLT是治疗终末期肝病的安全有效的手段。     

双左叶供肝成人间活体肝移植

用左叶肝作成人间的活体肝移植的最大障碍是植肝量的不足。而右叶供肝作移植供者的安全性依赖于残余左叶的大小 ,很多情况下残留的左叶不够维持供者的生理需求 ,此时供者不能捐献右叶。本文报道采用两个供体的双左叶同时移植于一个受体取得成功 ,它既弥补了单个左叶移植肝量不足的缺陷 ,又保证了供体的安全。4 8岁男性病人。第一个供者是病人兄弟 ,第二个供者为病人女儿。手术过程　受体游离门静脉、肝动脉和胆管至左右分叉以上便于作两侧血管吻合 ,作保留肝后下腔静脉的全肝切除。第一个左叶 (重 4 0 0ｇ)常法原位移植 ,完成左肝静脉和左门…     

成人间活体肝部分移植

８０年代末开展的活体肝部分移植,部分解决了小儿供肝短缺的矛盾,该技术的开展克服了供、受体肝脏大小不相配的难题,使得体重大于受者１０倍的供肝移植变为可能,使一个体重仅有１０公斤的患儿便可以利用一个体重达１００公斤的供者的肝左外叶,而且手术效果与全肝移植...     

成人间活体肝移植肝动脉重建并发症预防

目的总结成人间活体肝移植(adult-to-adult living donor liver transplantation,A-A LDLT)肝动脉重建并发症的预防经验。方法总结2002年1月-2008年3月收治的127例A-A LDLT临床资料,分析肝动脉重建并发症的预防。131例供体中(移植右半肝127例,移植左半肝4例),男69例,女62例;年龄19～65岁,平均36.2岁。127例受体中男109例,女18例;年龄18～64岁,平均41.9岁。62例供体右肝动脉与受体右肝动脉吻合,34例与受体肝固有动脉吻合,7例与受体左肝动脉吻合,6例与受体肝总动脉吻合,8例与受体肠系膜上动脉发出的副右肝动脉吻合,5例与受体肝总动脉自体大隐静脉间搭桥,2例受体腹主动脉与供体右肝动脉自体大隐静脉搭桥,3例用尸体冷冻保存髂血管行受体腹主动脉与供体右肝动脉搭桥。结果术后1、7d,发生肝动脉血栓形成2例(1.6%),采用自体大隐静脉、肾下腹主动脉至供体右肝动脉搭桥术后痊愈;1例于术后46d发生肝动脉血栓形成,无临床症状未予处理。术后及随访期未发现肝动脉狭窄、肝动脉假性动脉瘤等并发症。围手术期无与肝动脉并发症有关的死亡患者。患者均获随访,随访时间9～67个月,术后1、2、3年实际生存率分别为82.2%、64.7%和59.2%。结论供、受体肝动脉解剖变异,受体肝动脉病理改变,以及肝动脉血管吻合技术是肝动脉重建并发症发生的重要影响因素。     

成人间右半肝活体肝移植肝中静脉的处理

目的 总结成人间右半肝活体肝移植肝中静脉的处理经验。方法 回顾性分析两例成人间右半肝活体肝移植肝中静脉的处理方法，1例采取含肝中静脉的右半肝活体肝移植，肝中静脉移植供肝和剩余肝脏各保留一半，既有利于保证供体左肝内叶静脉回流，同时供肝右前叶静脉回流也不受到影响；另1例则采取不含肝中静脉的右半肝活体肝移植，术中重建供肝右前叶肝静脉回流通道，使供肝前叶淤血明显改善。结果 两例供体均存活，术后顺利出院，无并发症；受体1例存活，1例术后20d死于急性重度排斥反应。结论 成人间右半肝活体肝移植肝中静脉的处理十分关键，要注意保持供受体肝流出道的通畅，既要保证供体的绝对安全，又要尽量为受体提供足够的肝容量。     

成人间活体肝移植供体麻醉处理

目的 研究成人间活体肝移植(A-ALDLT)供体术中的麻醉管理及术中病理生理的变化,探讨如何提高A-ALDLT的供体麻醉质量.方法 回顾分析2005年9月至2007年1月华西医院47例A-ALDLT供体术中基本生命体征、麻醉处理、肝功能、凝血功能及并发症发生的情况. 结果 47例供体术前一般状况较好,ASA分级均为Ⅰ级.术中采用静吸复合麻醉方法, 连续监测心电图、脉搏血氧饱和度、体温,有创动脉测压并行中心静脉置管,用血液回收机采集出血洗涤后回输.47例供体术中出血量平均(603.13±317.00) ml,输入自体血(381.25±171.15) ml,仅4例供体输入异体血.术中心率和平均动脉压平稳,插管后、切肝前、后及关腹前各时点差异无统计学意义(P>0.05); 切肝前控制中心静脉压(CVP),切肝前、后CVP明显低于插管后及关腹前(P＜0.05).切肝后至术后第1 d,HGB及Alb明显下降(P＜0.05),ALT、AST及TBIL明显升高(P＜0.05); PT于切肝后升高(P＜0.05), APTT于术后第1 d开始明显升高(P＜0.05).47例供体均于术后第1 d在肝移植ICU拔气管导管,苏醒好.术后有3例(6.38%)发生并发症,分别为漏胆、门静脉血栓形成及大量胸腔积液生成,给予相应处理后好转出院.结论 供体肝叶切除术中采用丙泊酚、瑞芬太尼和异氟醚静吸复合麻醉,降低麻醉药物对肝脏的损害,保证肝脏充分的氧供,维持平稳的麻醉,采用有效的血液保护措施,包括降低CVP减少出血和血液回收避免异体血的输入,是保证供体安全、减少并发症的关键.     

成人间活体肝移植新进展

切取成人肝脏的左外叶或左叶作供肝的小儿活体肝移植 (ｌｉｖｉｎｇｄｏｎｏｒｌｉｖｅｒｔｒａｎｓｐｌａｎｔａｔｉｏｎ,ＬＤＬＴ)现已在世界上广泛开展并取得良好的临床效果。但对于成人ＬＤＬＴ ,切取供者的左叶作移植往往不够 ,而右叶虽然够大 ,但由于切取右肝的风险而曾使外科医生犹豫。现对成人ＬＤＬＴ最新进展作一综述。一、供体的选择和评估1 .供体选择的伦理学问题 :ＬＤＬＴ的首要原则是供体的安全性及无害性。ＬＤＬＴ的供者仍存在潜在的并发症甚至较严重 ,应在各移植中心建立ＬＤＬＴ供者正式同意的方式并标准化[1 ] 。第二个…     

活体供肝肝移植成功的初步经验--附3例报告

目的 报告3例活体供肝肝移植成功的初步经验。方法 回顾性分析1例肝细胞癌伴肝硬化、1例先天性肝内胆汁淤积症及1例药物性肝炎病人活体供肝肝移植经过和供受体恢复情况。结果 供肝均取自病人父亲，1例为右半肝，另2例为扩大左外叶，供肝重量分别为835g、295g及320g。第1例供体术后有一过性黄疸，且有轻度胆漏，另2例供体术后恢复顺利，无手术并发症。3例病人手术均顺利，1例成人一成人活体供肝肝移植胆道重建为胆管端端吻合，术后定期行全身化疗预防肿瘤复发。2例成人-儿童活体供肝肝移植胆道重建为胆管、空肠Roux-en-Y吻合。3例病人均行肝静脉整形以保证静脉回流通畅。随访至今，供受体已分别健康生存16、14、13个月。结论 严格的病例选择，完善的术前准备，精细的手术操作及正确的术后处理是活体供肝肝移植成功的关键。     

Outcomes of Donor Evaluations for Adult-to-Adult Right Hepatic Lobe Living Donor Liver Transplantation

The purpose of this study is to determine the role of liver biopsy and outcome of patients undergoing donor evaluation for adult-to-adult right hepatic lobe living donor liver transplantation (LDLT). Records of patients presenting for a comprehensive donor evaluation between 1997 and February 2005 were reviewed. Liver biopsy was performed only in patients with risk factors for abnormal histology. Two hundred and sixty patients underwent a comprehensive donor evaluation and 116 of 260 (45%) were suitable for donation, 14 of 260 (5.4%) did not complete evaluation and 130 of 260 (50%) were rejected. Four patients underwent unsuccessful hepatectomy surgery due to discovery of intraoperative abnormalities. Between 1997 and 2001, the acceptance rate of donor candidates (63%) was higher than 2002-2005 (36%), p < 0.0001. Sixty-six of the 150 eligible patients (44%) fulfilled criteria for liver biopsy and 28 of 66 (42%) had an abnormal finding. Less than half of the patients undergoing donor evaluation were suitable donors and the donor acceptance rate has declined over time. A large proportion of the patients undergoing liver biopsy have abnormal findings. Our evaluation process failed to identify 4 of 103 who had aborted donor surgeries.     

Allograft Survival Following Adult-to-Adult Living Donor Liver Transplantation

Adult-to-adult living donor liver transplantation (AALDLT) is emerging as a method to treat patients with end-stage liver disease. The aims of this study were to identify donor and recipient characteristics of AALDLT, to determine variables that affect allograft survival, and to examine outcomes compared with those achieved following cadaveric transplantation. Cox proportional hazards models were fit to examine characteristics associated with the survival of AALDLT. Survival of AALDLT was then compared with cadaveric allografts in multivariable Cox models. Older donor age (>44 years), female-to-male donor to recipient relationship, recipient race, and the recipient medical condition before transplant were factors related to allograft failure among 731 AALDLT. Despite favorable donor and recipient characteristics, the rate of allograft failure, specifically the need for retransplantation, was increased among AALDLT (hazard ratio 1.66, 95% C.I. = 1.30-2.11) compared with cadaveric recipients. In conclusion, among AALDLT recipients, selecting younger donors, placing the allografts in recipients who have not had a prior transplant and are not in the ICU, may enhance allograft survival. Analysis of this early experience with AALDLT suggests that allograft failure may be higher than among recipients of a cadaveric liver.     

Laparoscopic Living Donor Hepatectomy for Pediatric Liver Transplantation

Living donor liver transplantation is a well established modality, especially for pediatric transplantation with excellent early graft function and long-term results. Left lateral sectionectomy through open approach is a well-standardized procedure. Considering our acquired experience in both laparoscopic liver resection and standard open surgery for live donation in pediatric and adult patients, we decided to offer, for the first time in Belgium, a laparoscopic approach for the left lateral sectionectomy to a young mother. The patient was a child 6-months old, affected by biliary atresia and rapidly deteriorating while waiting on a deceased donor liver graft. Surgical technique and key-points of this procedure in the living donor are hereby discussed.     

活体肝移植小肝综合征的研究进展

目的 探讨在活体肝移植中小肝综合征发生的原因、预防及治疗方法.方法 复习国内、外近几年活体肝移植术后有关小肝综合征的相关报道.结果 供体年龄、脂肪肝程度、受体术前疾病状态(MELD评分)、术后高门静脉灌注、流出道不畅及移植物大小和质量对活体肝移植术后小肝综合征的发生起着重要作用,术前选择最佳的供体,术中的脾脏切除或脾动脉结扎或对门静脉限流,保证流出道的绝对通畅,术后及早发现并积极治疗能显著减少小肝综合征的发生.结论 小肝综合征的危险因素是可以预测的,积极的应对措施可以用于小肝综合征的预防与治疗.     

Portal Vein Complications in Pediatric Living Donor Liver Transplantation Using Left‐Side Grafts

The aim of this report is to assess the rate of portal vein complications (PVCs), the success rate of treatment for PVCs and the prognosis of patients with PVCs for pediatric living donor liver transplantation (LDLT). Pre‐ and postoperative records of 521 pediatric LDLTs, using left‐side grafts were retrospectively reviewed. The overall rate of PVC was 9%, with early PVC occurring in nine patients (1.7%) with a mortality rate of 67% and late PVC in 38 patients (7.3%). Fifteen of these patients with late PVC showed complete portal vein occlusion despite various treatments, and in six of them the graft was lost. Histological examination revealed fibrosis in portal areas in 13 patients, around the central veins associated with cholestasis in the parenchyma in 10, and hepatocyte ballooning in 12. Correction of portal vein flow or retransplantation is necessary for the rescue of patients with early PVCs. Graft loss in the long term may be high with the occurrence of liver failure or portal hypertension related causes, such as hepatopulmonary syndrome and gastrointestinal bleeding in patients with late PVCs. For the rescue of these patients, especially for patients with body weight < 6 kg, regular monitoring of portal vein flow is essential.     

Intraoperative ‘No Go’ Donor Hepatectomies in Living Donor Liver Transplantation

Donor safety is the paramount concern of living donor liver transplantation (LDLT). Although LDLT is employed worldwide, there is little data on rates and causes of ‘no go’ hepatectomies—patients brought to the operating room for possible donor hepatectomy whose procedure was aborted. We performed a single‐center, retrospective review of all patients brought to the operating room for donor hepatectomy between October 2000 and November 2008. Of 257 right lobe donors, the donor operation was aborted in 12 cases (4.7%). The main reasons for stopping the operation were aberrant ductal or vascular anatomy (seven cases), unsuitable liver quality (three cases) or unexpected intraoperative events (two cases). Over the median period of follow‐up of 23 months, there were no long‐term complications of patients with aborted donor procedures. This report focuses exclusively on an important issue: the frequency and causes of no go decisions at a single large volume North American LDLT center. The rate of no go donor hepatectomies should be as low as possible without compromising donor safety—however, even with rigorous preoperative evaluation the rate of donor abortions will be significant. The default surgical position should always be to abort the donor operation if there is an unexpected finding that places the donor at increased risk.     

Long-Term Outcome of Adult-to-Adult Living Donor Liver Transplantation for Post-Kasai Biliary Atresia

Our objective was to analyze problems in the perioperative management and long-term outcome of living donor liver transplantation (LDLT) for biliary atresia (BA). Many reports have described the effectiveness of liver transplantation (LT) for BA, particularly in pediatric cases, but little information is available regarding LT in adults (> or =16 years old). Between June 1990 and December 2004, 464 patients with BA underwent LDLT at Kyoto University Hospital, of whom 47 (10.1%) were older than 16 years. In this study, we compared the outcomes between adult (> or =16 years old) and pediatric (<16 years old) patients. The incidence of post-transplant intestinal perforation, intra-abdominal bleeding necessitating repeat laparotomy and biliary leakage was significantly higher (p < 0.0001, <0.001 and <0.001, respectively) in adults. Overall cumulative 1-, 5- and 10-year survival rates in pediatric patients were significantly higher (p < 0.005) than in adults. Two independent prognostic determinants of survival were identified: a MELD score over 20 and post-transplant complications requiring repeat laparotomy. Outcome of LDLT in adult BA patients was poorer than in pediatric patients. It seems likely that LT will be the radical treatment of choice for BA and that LDLT should be considered proactively at the earliest possible stage.     

Efficacy of Living Donor Liver Transplantation for Patients With Methylmalonic Acidemia

Application of liver transplantation to methylmalonic acidemia (MMAemia) is controversial because MMAemia is caused by a systemic defect of methylmalonyl-CoA mutase. The clinical courses of seven pediatric patients with MMAemia undergoing living donor liver transplantation (LDLT) were reviewed. Serum and urinary methylmalonic acid (MMA) levels were found to be significantly decreased after LDLT, whereas serum and urinary MMA levels did not return to normal in any patient. One patient died of sepsis 44 days after LDLT. The other six patients are currently doing well. All patients had preoperative history of acute metabolic decompensation and/or metabolic stroke. However, no episode of acute metabolic decompensation or metabolic stroke was observed postoperatively in any surviving patients. In the preoperative period, all patients showed lethargy and cognitive deficit, both of which were eradicated after LDLT in all surviving patients. Preoperatively, all patients were subjected to dietary protein intake restriction and tube feeding, and were administered several metabolism-correcting medications. The metabolism-correcting medications being administered remained mostly unchanged after LDLT, whereas protein restriction was liberalized and tube feeding became unnecessary in all surviving patients. In addition, physical and neurodevelopmental growth delay remained in all surviving patients during the observation period, which ranged from 4 to 21 months with a median of 10.5 months.