活体右后叶肝移植的应用进展

随着肝移植技术的发展,肝移植疗效显著提高,受者和移植物的存活率得到显著提升。但公民逝世后器官捐献仍不能满足肝移植需求,供肝短缺仍是阻碍肝移植进一步发展的关键因素。近年来,活体肝移植作为克服器官短缺的手段之一,广泛应用于终末期肝病患者的治疗。右后叶肝移植作为活体肝移植一种特殊类型,为进一步扩大活体肝移植潜在供者池提供了一种新的解决方案。本文从活体肝移植的发展概况、活体右后叶肝移植供者的选择、右后叶供肝获取的解剖学挑战以及右后叶供肝获取的手术技巧进行介绍,并对活体右后叶肝移植进行展望,以促进临床肝移植的进一步发展,造福更多终末期肝病患者。     

81岁供者供肝移植成功一例并文献复习

目的探讨肝移植中供、受者选择、获取和匹配的优化,能够让老年供肝的使用达到最佳的效果。方法对中山大学附属第一医院1例81岁老年供者供肝移植手术进行报道,供者为81岁女性,为脑死亡供者,受者为21岁男性,因慢性乙型病毒性肝炎合并肝细胞癌行肝移植手术。结合文献讨论与年龄相关的边缘供肝应用于临床肝移植时的初步经验。结果受者术后恢复顺利,术后第1天天冬氨酸转氨酶(AST)为1131 U/L、丙氨酸转氨酶(ALT)为846 U/L,术后均进行性下降,2周后均降至正常,术后第1天总胆红素(TBIL)56.4 μmol/L,第3天下降至22.1 μmol/L,但术后第5天开始升高,最高66.0 μmol/L,术后2个月左右降至正常。术后未出现并发症,术后随访AST、ALT、TBIL等指标均正常,甲胎蛋白进行性下降。结论对高龄供者进行仔细的评估,选择一些低风险的受者,老年供肝可以安全应用于临床。     

活体及分肝肝移植的现状和发展

为了解决脑死亡供肝不足的难题 ,近年来逐步发展活体供肝和分肝肝移植。活体肝移植世界上首 2例活体肝脏移植是在 1988年由Ｒａｉａ在巴西采用左外侧叶为供肝为儿童病人进行的[1] 。但受者却未存活。 1989年 ,Ｓｔｒｏｎｇ成功完成了首例存活的活体肝移植[2 ] 。在日本 ,由于政府不允许脑死亡者捐赠器官 ,活体供肝是唯一来源。因此 ,日本成为世界上活体肝移植经验最丰富及发展最快的国家。活体肝移植手术因供肝采用左外侧叶或左叶(包括肝中静脉 )只能适用于青少年受者。对于成人受者来说 ,左叶供肝肝容量不足 ,而且小体积供肝可能在灌注后受…     

成人右半肝活体肝移植供者的处理

目的 探讨成人右半肝活体肝移植供者处理的技术问题.方法 对我院2007年4月至2009年2月完成的19例成人右半肝活体肝移植供者资料进行回顾性分析.结果 19例右半肝移植物中带肝中静脉者4例,不带肝中静脉者15例;供肝重量为585～920 g,平均(727.32±117.01)g,与受者标准肝体积比为43%～67%(53.69%±1.77%),与受者重量比为0.82%～1.46%(1.10%±0.04%),供者残肝百分比为32%～55%(47%±2%),供者术中失血量400～1000 ml,平均(660±39.11)ml,输自体血0～735 ml,平均(216.37±62.28)ml,输新鲜冰冻血浆600～2000 ml,平均(789.47±75.66)ml,手术时间480～930min,平均(695.53±26.57)min.供者术后无死亡,发生并发症23例次,按照Clavien分级,Ⅰ级为15例次,Ⅱ级为8例次,经对症处理后均痊愈.住院时间13～58 d,平均(25.42±2.67)d.随访时间6～28月,全部供者均恢复正常工作生活.受者术后1年存活率为78.95%.结论 仔细术前评估,精细手术操作,合理地分配并保证移植物和残肝的功能性体积,术后密切监护、妥善处理并发症是供受者安全的重要保证.     

活体肝移植的供肝处理技巧

目的 探讨活体肝移植术供肝的选择，切取和修整，方法 1997至2001年期间，第四军医大学西京医院共完成活体肝移植术3例。其中2例是儿童活体肝移植术，另1例是成人辅助性原位活体肝移植术，供肝切取均为左外叶，供者术中作必要的肝周韧带游离和肝门解剖，超声刀切取供肝，不阻断肝脏血流。结果 供者手术时间为5-6.5h，失血量为200-400ml，无并发症发生。目前所有的供者肝功能均正常。恢复正常的工作和生活。结论 左肝外叶切除对供者是非常安全的。一般无手术并发症发生。     

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。     

婴幼儿亲属活体部分供肝肝移植中的供、受者安全性分析

目的 探讨婴幼儿亲属活体部分供肝肝移植中的供、受者的安全性.方法 2006年9月至2009年11月,行婴幼儿亲属活体部分供肝肝移植者8例,受者原发病均为先天性胆道闭锁.供者术前常规行三维CT观察和计算全肝及肝叶(段)体积及形状,磁共振胰胆管造影术(MRCP)了解胆道情况.根据婴幼儿受者腹腔容积切取合适肝叶(段)行肝移植术.受者术后给予抗排斥反应和预防感染等治疗;供者术后给予保肝和抑酸治疗.分析供、受者术前、术中及术后情况.结果 8对供、受者手术均获成功.6例供肝为左外侧叶,1例为S3肝段,1例为减体积S3肝段,供肝重量为(235.9±53.6)g(148～302 g),供肝重量与受者体重比(GW/RW)为(2.65±0.48)%(2.11%～3.36%).对供、受者随访3～40个月(中位数18个月),8例供者均存活,发生并发症2例(25%).8例受者中,死亡1例(12.5%),其他受者发生并发症13例次.结论 术前对供、受者行精确评估,切取合适供肝行肝移植术,术中精细操作,术后精心治疗可最大程度保证供、受者的安全.     

成人右半肝活体肝移植21例分析

目的 探讨成人右半肝活体肝移植供受者处理的关键性技术问题。方法 回顾性分析2007年4月至2009年5月首都医科大学附属北京佑安医院肝胆外科完成21例成人右半肝活体肝移植的资料。 结果 供者术后无死亡,发生并发症23例次,按照Clavien系统分级：Ⅰ级15例次,Ⅱ级8例次。经积极非手术治疗后,所有供者均痊愈。受者术后发生胆道并发症7例,均经外科手术处理痊愈,术后1个月内死亡4例。移植物含肝中静脉4例,不含肝中静脉17例,两组受者1年存活率分别为75%与76%（χ2 = 1.000,P = 0.617）。 结论 右半肝活体肝移植是治疗终末期肝病尤其是各种原因导致的急性肝功能衰竭的重要手段。仔细术前评估,精细手术操作,合理地分配肝中静脉并保证移植物和残肝的功能性体积,术后密切监护、妥善处理并发症是供受者安全的重要保证。     

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。     

成人间双供体活体肝脏移植成功2例报告

目的供肝短缺是影响肝脏移植发展的主要因素之一，活体供肝是解决这一矛盾的重要措施，供者提供足够的肝脏是影响活体肝脏移植的重要因素。方法施行成人间双供体活体肝移植2例，1例由受者的两位姐姐分别提供左半肝作为供肝，另1例由受者母亲提供右半肝，由无心跳供者提供左半肝(采用劈裂方式，其另一部分肝脏同时为另一成人受者实施肝脏移植)作为供肝。结果术后供、受者肝功能均恢复良好。结论成人问双供肝活体肝脏移植可以为受者提供更大重量的肝脏，又可减少供者提供较多肝脏所带来的风险；双供肝一受者肝脏移植手术操作复杂。     

Adult living donor liver transplantation using right posterior segment

Varying circumstances call for various types of donor hepatectomy. We report here on an unusual type of donor hepatectomy, right posterior segmentectomy. A 46-year-old sister of the recipient was the donor. Her preoperative CT showed that the right anterior portal vein originated from the umbilical portion of the left portal vein. Intraoperative cholangiography revealed that the right posterior hepatic duct joined the common hepatic duct in the extrahepatic area. Right posterior segmentectomy was performed without transfusion in the donor. The postoperative course proceeded favorably in both donor and recipient until postoperative day 41, when the recipient unexpectedly expired as a result of cerebral hemorrhage. The donor was discharged with good liver function. We can conclude that the right posterior segment of the donor can be used as a graft, when the volume of left liver is not enough for both donor and recipient, or the vascular structures favor right posterior segmentectomy.     

Impact of graft thickness reduction of left lateral segment on outcomes following pediatric living donor liver transplantation

Reducing graft thickness is essential to prevent large‐for‐size graft problems in pediatric living donor liver transplantation (LDLT). However, long‐term outcomes of LDLT using reduced‐thickness left lateral segment (LLS) grafts are unclear. In 89 patients who underwent LDLT using reduced LLS grafts between 2005 and 2017, short‐term and long‐term outcomes were compared between a nonanatomically reduced LLS (NAR‐LLS) graft group and a reduced‐thickness LLS graft group. Estimated blood loss was lower and abdominal skin closure was less needed in the recipient operation in the reduced‐thickness LLS graft group. Postoperatively, portal vein (PV) flow was significantly decreased in the NAR‐LLS graft group, and there was shorter intensive care unit (ICU) stay and fewer postoperative complications, especially bacteremia, in the reduced‐thickness LLS graft group. Graft survival at 1 and 3 years after LDLT using reduced‐thickness LLS grafts was 95.2% and 92.4%, respectively, which was significantly better than for NAR‐LLS grafts. Multivariate analysis revealed that fulminant liver failure, hepatofugal PV flow before LDLT, and NAR‐LLS graft were associated with poor graft survival. In conclusion, LDLT using reduced‐thickness LLS grafts is a safe and feasible option with better short‐ and long‐term outcomes in comparison with NAR‐LLS grafts.     

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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。     

吲哚菁绿荧光引导腹腔镜解剖性肝段获取术在小儿活体肝移植中的应用价值

目的:探讨吲哚菁绿荧光引导腹腔镜解剖性肝段获取术在小儿活体肝移植中的应用价值。方法:采用回顾性描述性研究方法。收集2019年12月至2020年1月首都医科大学附属北京友谊医院收治的2例行活体肝移植患儿和2例供者的临床资料。病例1,女,年龄为1岁,体质量为8.7 kg。供者为患儿父亲,年龄为35岁,体质量为93.1 kg...     

婴幼儿活体肝移植33例

目的 探讨活体肝移植治疗婴幼儿终末期肝病的疗效.方法 回顾性分析2006年10月至2009年9月上海交通大学医学院附属仁济医院33例实施活体肝移植的婴幼儿的临床资料.本组患儿中位年龄10.9个月,平均体质量8.2 kg,供肝均采用肝左外叶.术后采用他克莫司或环孢素A+激素二联方案或在此基础上再加用吗替麦考酚酯的三联方案行免疫抑制治疗.分析评价手术方法、围手术期处理和随访结果.结果 供者和受者手术时间、术中出血量、术中输血量分别为(384±108)min、(183±35)ml、0和(500±103)min、(296±163)ml、(292±159)ml,供肝冷缺血时间为(64±23)min,移植物质量为(249±52)g,移植物质量与受者体质量比为2.1%±0.4%.全部供者均顺利康复,无手术并发症.受者出现肝动脉栓塞3例,门静脉栓塞2例,各类胆道并发症9例,感染11例,急性排斥反应2例,围手术期死亡5例.本组患儿1年累积生存率为85%(28/33).结论 婴幼儿终末期肝病可通过活体肝移植取得理想的效果.外科技术的提高、围手术期管理经验的积累和规范的随访可提高手术成功率和长期生存率.

Abstract：

Objective To evaluate the efficacy of living donor liver transplantation in the treatment of infants with end-stage liver diseases. Methods The clinical data of 33 infants who received living donor liver transplantation at the Renji Hospital of Shanghai Jiaotong University from October 2006 to September 2009 were retrospectively analyzed. The median age of the infants was 10.9 months, and the mean body weight was 8.2 kg.All of the grafts were left lateral lobes. Tacrolimus (or cyclosporine A) + steroid or tacrolimus (or cyclosporine A)+ steroid + mycophenolate mofeti] were applied to the infants to suppress the immune reaction. Operative techniques, perioperative management and results of follow-up were analyzed. Results The mean operation time,blood loss and blood transfusion of the donors were (384±108)minutes, (183±35) ml and O, and the three indexes of the recipients were (500± 103) minutes, (296±163) ml and (292 ± 159) ml , respectively. The cold preservation time of the grafts was (64 ±23)minutes, the mean weight of the grafts was (249 ±52)g, and the mean graft to recipient weight ratio was 2.1% ± 0.4%. All donors recovered smoothly and no complication occurred. Of the recipients, three were complicated with hepatic artery thrombosis, two with portal vein thrombosis,nine with biliary complications, 11 with infection, two with acute rejection and five infants died perioperatively.The one-year cumulative survival rate of the infants was 85% (28/33). Conclusions Infants with end-stage liver diseases could be treated by living donor liver transplantation. The development of surgical techniques and perioperative managements improves the success rate of operation and the long-term survival rate.     

双肝移植后移植物萎缩的动物实验探究

目的通过动物实验验证临床双肝移植后移植物萎缩的现象。 方法清洁级雄性SD大鼠18只,8～10周龄,体质量230～250 g,术前禁食12 h。12只SD大鼠作为供体,6只作为受体。建立大鼠双肝移植模型,通过磁共振检查观测受体大鼠术后移植物体积变化。采用成组t检验比较受体大鼠左、右侧移植物体积和重量。P<0.05为差异有统计学意义。 结果移植肝叶均为双右上叶。供肝重量和受体大鼠肝重量分别为(4.30±0.06)和(9.4±0.2)g,移植物与受体大鼠体质量、肝重量比分别为1.79%～1.88%、45.7%～46.8%。手术时间(70±4)min,冷缺血时间(30.0±1.5)min,热缺血时间(12.0±1.5)min,无肝期(20.0±2.5)min。6只受体大鼠双肝移植后1 d行磁共振检查,两侧移植物体积相同;术后15 d行磁共振检查,有3只发生单侧移植物萎缩。 结论大鼠双肝移植后部分受体一侧移植物会发生萎缩。     

Unilateral ischemic preconditioning and heterologous preconditioning in living donor liver transplantation

Testa G, Angelova V, Laricchia‐Robbio L, Rondelli D, Chejfec G, Anthony T, Benedetti E. Unilateral ischemic preconditioning and heterologous preconditioning in living donor liver transplantation.
Clin Transplant 2010: 24: 334–340. © 2009 John Wiley & Sons A/S. Abstract: Ischemic preconditioning (IP) exerts a protective effect on tissues undergoing prolonged ischemia. No studies have been performed to assess the clinical impact of IP on normal human liver used for living donor transplantation (LDLT). Heterologous preconditioning (HP) protects liver tissue as demonstrated in a rat model. Our study investigates the impact that IP and HP have on the donor and recipient liver in LDLT. Twenty candidates for living donor right hepatectomy were divided in two groups. The study group underwent 10′ unilateral ischemia by clamping the right portal vein and hepatic artery at the end of the parenchymal transection. Demographics, laboratory values, biopsy studies, IL‐1Ra, Ki‐67, and CytoDEATH stains were compared. The results show that 10′ ischemia does not exert significant clinical and laboratory changes in living donor hepatectomy candidates.     

Pediatric living donor liver transplantation with large‐for‐size left lateral segment grafts

Usage of “large‐for‐size” left lateral segment (LLS) liver grafts in children with high graft to recipient weight ratio (GRWR) is controversial due to concerns about increased recipient complications. During the study period, 77 pediatric living donor liver transplantations (LDLTs) with LLS grafts were performed. We compared recipients with GRWR ≥2.5% (GR‐High = 50) vs GRWR <2.5% (GR‐Low = 27). Median age was higher in the GR‐Low group (40 vs 8 months, P> .0001). Graft (GR‐High: 98%, 98%, 98% vs GR‐Low: 96%, 93%, 93%) and patient (GR‐High: 98%, 98%, 98% vs GR‐Low: 100%, 96%, 96%) survival at 1, 3, and 5 years was similar between groups (P = NS). Overall complications were also similar (34% vs 30%; P = .8). Hepatic artery and portal vein thrombosis following transplantation was not different (P = NS). Delayed abdominal fascia closure was more common in GR‐High patients (17 vs 1; P = .002). Subgroup analysis comparing recipients with GRWR ≥4% (GR‐XL = 20) to GRWR <2.5% (GRWR‐Low = 27) revealed that delayed abdominal fascia closure was more common in the GR‐XL group, but postoperative complications and graft and patient survival were similar. We conclude that pediatric LDLT with large‐for‐size LLS grafts is associated with excellent clinical outcomes. There is an increased need for delayed abdominal closure with no compromise of long‐term outcomes. The use of high GRWR expands the donor pool and improves timely access to the benefits of transplantation without extra risks.     

Resolution of severe graft steatosis following dual-graft living donor liver transplantation.

Although severely steatotic liver grafts are not suitable for transplantation, they have been used when other, more optimal donors were not available, especially for living donor liver transplantation (LDLT) using two liver grafts. Here we present two cases of dual-graft LDLT in which the recipients showed rapid and complete clearing of fat from livers with previously severe steatosis. In the first case, two left lateral segment grafts were used, one of which was 70% steatotic. Preoperative and posttransplant two-week liver-to-spleen computed tomography-value (L/S) ratios were 0.48 and 1.25, respectively. A liver biopsy taken two weeks after transplantation showed that the fatty changes had almost disappeared. The second case used one left lobe and one left lateral segment graft, the latter of which was 80% steatotic. Preoperative and two-week L/S ratio were 0.58 and 1.34, respectively, and a liver biopsy taken two weeks after transplantation showed less than 3% steatosis. The two donors of the severely steatotic liver grafts recovered uneventfully. These findings show that the fat content of the liver grafts was rapidly removed after transplantation. This observation is helpful in understanding the recovery sequences following transplantation of steatotic liver grafts, as well as expanding the acceptability of steatotic liver grafts.     

活体肝移植供者的死亡

为了探讨活体肝移植供者死亡的原因,我们通过网上外文期刊全文检索,收集到在2008年底以前在英文医学期刊上正式报道的活体肝移植供者死亡病例.结果 共检索到12例活体肝移植供者死亡病例.在有肝移植总数记载的文献中,供者死亡的发生率为0.2%.虽然活体肝移植供者死亡率不高,但任何供者的死亡对医疗机构和供者家庭都是灾难性的.不管受者情况如何,一旦发生供者死亡,则该手术都应该算是失败的.因此,如何能尽量避免供者死亡是活体肝移植的核心问题之一.