活体供肝肝移植供肝获取的有关问题

目前，由于供肝来源的严重短缺，活体供肝肝移植(1iving donor liver transplantation，LDLT)已逐渐成为一个可以接受的替代方法。资料显示，自1991年以来，等待供肝准备行肝移植的患者数量增加了10倍，而同期施行的肝移植手术仅增加0．5倍。     

腹腔镜活体供肝切除中的意外及处理

近年来,随着微创外科技术以及设备的迅速进步,极大推动了腹腔镜肝切除术的发展,世界范围的诸多有经验的中心也在逐步扩大腹腔镜肝切除术的适应证,使得腹腔镜下活体供肝切除术成为一种可行的术式选择,促进了供体术后康复过程和生活质量的提高。但由于腹腔镜供肝切取过程相对于普通肝切除更为复杂,术中发生意外的情况更多,处理稍有不当则可能造成中转开放手术。其中术中出血包括了游离肝脏、解剖肝门、离断肝实质以及离断主要管道的各类情形,熟知腹腔镜手术中出血特点、仔细的术前规划、精细的术中操作以及打造默契的团队配合是安全防范和处理术中出血的关键。胆道损伤常常来自于对胆道变异对误判而造成意外,严重者导致供受体恢复不佳甚至移植失败,术前充分的胆道评估和三维重建有助于规避风险,术中离断前后的胆道造影则更是避免胆道损伤的重要环节。此外,由于解剖位置的特殊性,肝静脉的离断可能发生供受体侧的狭窄而影响手术效果,合理的选用仅含单排钉仓的直线切割闭合器则会在很大程度上保护供受体的静脉离断损伤。总之,为减少腹腔镜活体供肝切除术中的意外情况产生,术者应在术前对供体的解剖结构做出充分的评估,并且在术中精细解剖,步步为营,训练打磨良好的...     

腹腔镜活体肝移植供肝获取研究进展

活体肝移植已逐渐成为可以替代尸体供者肝移植治疗终末期肝病和早期肝细胞肝癌最有效的方法, 而腹腔镜活体供肝获取技术在活体肝移植中扮演着越来越重要的角色。本文介绍腹腔镜活体供肝获取在活体肝移植中的应用情况, 从供者选择、腔镜辅助活体供肝获取、腹腔镜左外叶获取、腹腔镜左半肝获取及腹腔镜右半肝获取等几个方面综述腹腔镜手术在活体肝移植中的特点, 从而为提高供者安全性提供新的研究思路。     

儿童肝移植腹腔镜活体供肝切取术

因为尸体供肝来源的缺乏 ,在肝移植中活体供肝的应用越来越多。作者设计了一种安全可行的腹腔镜活体供肝切取技术 ,并进行了两例手术。两受肝者均为供者的儿子 ,均 1岁大小 ,患有胆道闭锁症 ,均在 2个月大小时做了肝门空肠吻合术 ,肝移植前伴有黄疸、腹水和肝功能衰竭。两供肝者为自愿献肝的一名 2 7岁妇女和一名 31岁男子。分别在全麻下进行了腹腔镜肝左外叶 (2、3段 )切除。取截石位 ,在中上腹置放 5个穿刺套管 ,在腹腔镜下对移植肝进行处理 ,步骤包括游离左半肝 ,分离左肝动脉、左门静脉和左肝胆管 ,分离肝左静脉。在肝圆韧带和镰状韧带…     

供肝获取术中供肝质量和灌注情况的快速判断

目的探讨在供肝获取术中快速判断供肝质量和灌注情况的方法。方法对83例供肝获取术中供肝质量和灌注情况的快速判断进行总结。结果83例供体中,有16例在获取术中发现供肝质量有异常(其中7例放弃获取,9例用于移植),有1例在获取术中判断供肝质量为正常,移植术前肝组织活检病理发现血吸虫虫卵。在76例获取的供肝中．有3例术中发现灌注不足。所有用于受体的供肝均在门静脉开放后3—15分钟内可见金黄色胆汁分泌。结论在现阶段我国多为无心跳供体和快速多器官联合获取法广泛使用的情况下。供肝获取术中供肝质量和灌注情况的快速判断尤为重要。     

达芬奇机器人儿童肝移植活体供肝获取的应用进展

<正>儿童肝移植(pediatric liver transplantation,PLT)被认为是治疗各种儿童终末期肝脏疾病的有效方式^[1-2]。PLT的手术方法多采用减体积肝移植、劈离式肝移植和活体供肝移植(living donor liver transplantation LDLT)^[3-4]。     

成人活体供者肝右叶联合脑死亡捐献者肝左外叶的双供肝活体肝移植治疗肝细胞癌的应用价值

目的探讨成人活体供者肝右叶联合脑死亡捐献者肝左外叶的双供肝活体肝移植治疗肝细胞癌的应用价值。方法采用回顾性描述性研究方法。收集2019年10月四川大学华西医院收治的1例行成人活体供者肝右叶联合脑死亡捐献者肝左外叶的双供肝活体肝移植受者的临床病理资料;男性肝细胞癌受者,年龄为46岁,体质量为66 kg,身高为171 cm,血型为A型Rh阳性。移植物1来自女性活体供者,年龄为23岁,体质量为50 kg,身高为150 cm,血型为A型Rh阳性。移植物2来自男性脑死亡捐献者,年龄为44岁,血型为A型Rh阳性。手术在3个手术间施行,2个手术间同时施行移植物1和移植物2的切取手术,第3个手术间施行受者肝脏游离,当移植物的体外拼接接近完成时,完整取出受者肝脏,并施行肝移植。观察指标:(1)活体供者及受者的手术及术后恢复情况。(2)受者病肝术后病理学检查情况。(3)随访情况。采用门诊方式进行随访,随访内容包括肝细胞癌复发监测、移植肝功能监测、免疫抑制剂监测调整、胆道血管并发症监测、排斥反应及药物不良反应等。受者需终生定期随访,最近一次随访时间为2019年12月4日。计数资料采用绝对数或百分比表示。结果(1)活体供者及受者的手术及术后恢复情况:活体供者手术时间为315 min,术中出血量约200 mL,术中输入自体回收血量约200 mL,术后第6天出院,无并发症发生。受者顺利完成改良背驼式肝移植。移植物1取自活体供者不含肝中静脉的肝右叶,质量410 g。移植物2取自脑死亡捐献者肝左外叶,质量400 g,拼接后的供者移植物质量与受者体质量比为1.2%。受者手术时间为815 min,无肝期时间为60 min,术中出血量约1500 mL,术中输血量为1800 mL。住院期间受者体温正常。术后第1天受者白细胞(WBC)和中性粒细胞百分比达到峰值(分别为17.15×109/L和91.7%),后逐渐降低,采用哌拉西林钠舒巴坦钠抗感染,术后第7天WBC和中性粒细胞百分比均降至正常范围(分别为7.90×109/L和70.9%),停用抗菌药物。住院期间,受者白蛋白(Alb)为31.0~41.4 g/L,受者总胆红素(TBil)、丙氨酸氨基转移酶(ALT)、天冬氨酸氨基转移酶(AST)、凝血酶原时间、国际标准化比值肝功能指标均逐渐下降至正常范围,肌酐和肾小球滤过率肾功能指标均在正常范围。术后第10天受者全身状况良好,康复出院。(2)受者病肝术后病理学检查情况:①中分化肝细胞癌,肿瘤包膜欠完整,未侵及肝被膜,周围肝组织呈乙型病毒性肝炎后结节性肝硬化改变,肝门断端未见肿瘤累及;②慢性胆囊炎伴胆固醇沉积;③腹腔淋巴结1枚,呈反应性增生。免疫组织化学染色检测提示乙型肝炎表面抗原(10%细胞为阳性)、乙型肝炎核心抗原阴性。(3)随访情况:受者2019年11月19日复查肿瘤标志物,甲胎蛋白2.92μg/L、异常凝血酶原16 AU/L,结合腹部彩色多普勒超声检查的阴性结果提示肿瘤无复发。受者2019年12月3日复查肝功能:TBil 8.6μmol/L,ALT 23 IU/L,AST 28 IU/L,Alb 44.0 g/L;他克莫司血药浓度4.2μg/L,调整吗替麦考酚酯至250 mg 2次/d,其余治疗不变(他克莫司2 mg 1次/d,西罗莫司1 mg 1次/d);无症状、体征及检查结果提示胆道血管并发症、排斥反应及药物不良反应等。结论成人活体供者肝右叶联合脑死亡捐献者肝左外叶的双供肝活体肝移植安全、有效,可以作为治疗超出米兰标准肝细胞癌患者的次优方案。     

腹腔镜肝左外叶切除免T管治疗肝内外胆管结石

目的探查腹腔镜切除肝左外叶联合术中胆道镜免T管治疗肝左外叶胆管结石合并(或不合并)胆囊结石、肝外胆管结石的可行性及安全性。方法回顾性分析15例肝左外叶胆管结石患者的病例资料,其中合并肝外胆管5例,合并胆囊结石6例。采用腹腔镜切除肝左外叶及胆囊,选择左肝管残端为胆道镜进入通道,探查右肝管及肝外胆管,取出肝外胆管结石,缝合左肝断面胆管。结果全部病例得以成功实施,平均手术时间133.6min(110.0~185.0)min,平均术中出血量169.7ml(85.0~355.0)ml,平均术后住院时间7.1 d(5.0~9.0)d,术后1例病人出现左肝断面感染,并轻度胆汁漏,带引流管出院,术后28天拔除引流管治愈,平均术后随访时间28.1 m(9.0~48.0)m,未见结石残留、复发。结论选择合适的病例开展腹腔镜切除肝左外叶联合术中胆道镜免T管治疗肝左外叶胆管结石合并(或不合并)胆囊结石、肝外胆管结石是安全、可行的。     

改进供肝处理方法减少肝移植术后早期胆道并发症

目的改进供肝处理方法，以减少肝移植术后的胆道并发症。方法供肝处理进行如下改进：（1）肝门游离仅达胃十二指肠动脉下缘，不游离其上方的肝蒂结构；（2）修整供肝时暂不结扎胃十二指肠动脉本身的断端；（3）修整供肝时暂不切除胆囊，待供肝植入、肝动脉重建后切除。共行99例肝移植，患者的原发病，58％为良性肝病，42％为肝癌。供肝热缺血和冷缺血时间分别控制在5min和16h以内。胆道重建方式均为胆总管-胆总管端端吻合，其中5例放置T管。观察术后早期胆道并发症的发生情况。结果4例（4％，4／99）肝移植术后发生胆道并发症，其中1例术后10d发现胆道吻合口漏；1例术后5个月胆道内有胆树形成；1例为胆道吻合口狭窄；1例为左肝管狭窄。改进前的肝移植术后早期胆道并发症发生率为11．6％（5／43）。结论通过改进供肝的处理方法，可最大限度地保留供肝胆道血液供应，显著减少术后胆道并发症。     

腹腔镜活体供肝切取术：回顾与展望

随着腹腔镜微创技术的不断普及,腹腔镜肝切除在肝脏良恶性疾病的治疗中已逐渐成为主流。全腔镜下活体供肝切取是最具吸引力也最具争议的应用之一,供者安全和受者移植后疗效是争议的主要焦点。自2002年首例全腹腔镜供肝切取报道以来,目前在部分移植中心,腹腔镜活体供肝切取已得到广泛应用。从早期的左肝、左外移植物到更复杂的右半肝移植物,从作为过渡形式的手辅助腹腔镜供肝切取到全腹腔镜供肝切取,目前全腹腔镜供肝切取已日臻成熟。笔者对腹腔镜供肝切取的发展历史进行了回顾,并基于个人经验对其技术细节进行了简要分析。     

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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。     

全频超声乳化吸引刀在活体肝移植供肝切取中的应用

目的评价全频超声乳化吸引刀在活体肝移植供肝切取中的应用价值。方法62例活体肝移植的供体行右叶切除术。静脉复合麻醉,常规行双侧肋缘下"人"字形切口,游离右侧肝脏,确定切肝线,不阻断入肝血流,采用全频超声乳化吸引刀切离肝脏组织,至右半肝仅留有右肝静脉、门静脉右干和右肝动脉连结。全身肝素化后,依次阻断并切断右肝动脉、门静脉右干、右肝静脉,动脉远端不结扎,移去切取的肝脏进行灌注及修整。结果62例供者手术均顺利,供体手术时间(279±29)min,失血量(210±55)ml,无1例输血,术后住院时间(12.5±3.4)d,住院费用(28822±2846)元。所有供体全部存活。术后发生肝脏断面胆漏者2例,经充分引流1周后治愈;1例供体术后伤口脂肪液化,经换药后治愈。结论在活体肝移植中应用全频超声乳化吸引刀切取供肝,可降低失血及胆漏的发生率,可最大限度地保护供肝和残肝功能,是肝脏横断技术的重大进步。     

Direct measurement of hepatic blood flow during living donor liver transplantation in children

Background

The changes in liver blood flow associated with living donor liver transplantation (LDLT) in children have not yet been studied. The aim of the present study was to investigate changes in hepatic hemodynamics before and after pediatric partial liver transplantation.

Methods

In 7 pediatric recipients with congenital cholestasis and native liver Child-Pugh classes B and C, portal vein flow (PVF) and hepatic arterial flow (HAF) were measured using an ultrasonic transit time flow meter before removal of the native liver and after transplantation and compared with donor left PVF and donor left HAF.

Results

The mean portal contribution to total hepatic blood flow was markedly decreased in the recipient native liver compared with that in the donor (69% ± 15% vs 32% ± 15%; P = .0003) and after reperfusion changed to almost the same ratio as that in the donor liver (73% ± 18%; P < .0001).

Conclusion

The extreme imbalance between PVF and HAF that is common in implanted partial liver in adult LDLT recipients was not observed in pediatric LDLT. After transplantation of an appropriately sized liver graft, the portal contribution to total liver blood flow normalized to the value for normal liver.     

Guidelines for donor selection and an overview of the donor operation in living related liver transplantation

Guidelines for donor selection and an overview of the donor operation are reported on the basis of our experience with 120 cases of living related liver transplantation (LRLT) in pediatric patients. Once the parents had clearly expressed their desire to serve as donors, tests were performed to functionally and anatomically screen the donor livers to determine whether or not the parents' general physical condition allowed them to serve as donors. We then evaluated which of the two parental candidates was more suitable as a donor. The wishes of the family as to which parent should serve as donor was considered secondary and taken into account only in a few cases in which certain functional and/or anatomical abnormalities were uncovered that made the prime candidate less suitable. For the 120 LRLTs, 135 candidates were evaluated as potential donors, 15 (11.1%) of whom were rejected for various reasons. The mean volume of blood loss during the donor operation decreased significantly from 489 g in the first 60 LRLTs to 390 g in the latter 60 LRLTs; this was accompanied by a significant decrease in the mean volume of autologous blood transfused from 449 g to 390 g. Mean cold ischemia time of the graft increased significantly from 71.4 to 128.0 min, while mean operation time conversely decreased from 6.7 to 6.2 h. Bile leakage from the cut surface of the remnant lver, which was the only postoperative surgical complication encountered, was noted in five cases. We conclude that donor candidates should be strictly selected according to basic guidelines, taking into account both the results of preoperative screening and the wishes of the family. With this accumuled experience, we have been able to simplify our LRLT operative procedure, resulting in decreases in blood loss volume, blood transfused, and operation time.     

活体肝移植术后供体胆漏的诊治体会

目的  总结活体肝移植术后供体胆漏的诊治经验。 方法  回顾性分析95例活体肝移植供体的临床资料,了解术后胆漏并发症发生情况,重点分析胆漏并发症供体的临床表现、处理方法及治疗效果。 结果  95例肝移植供体术后发生胆漏9例,胆漏的发生率为9%。9例胆漏供体的供肝部位均为左外叶,均为肝断面迟发型胆漏,临床表现无典型胆汁性腹膜炎表现,血清胆红素升高。给予经皮穿刺引流或保留引流管处理后均治愈,无二次手术及死亡病例。 结论  活体肝移植供体术后应注意监测供体肝功能及肝动脉血流动力学变化,对并发胆漏的供体予以积极治疗,预后良好。     

活体肝移植不同供肝切取方式对残肝再生的影响

目的 探讨活体肝移植不同方式供肝切取术后供者康复及肝脏再生情况.方法 回顾性分析2006年5月至2011年5月13例活体肝移植供者临床资料.对不同方式供肝切取手术方法、供者术后肝功能指标变化及残肝再生情况进行比较.结果 供者手术分为不包含肝中静脉右半肝切除8例,包含肝中静脉右半肝切除2例,左半肝切除3例.供者肝功能及凝血指标均于术后两周恢复正常,术后未见严重并发症,随访情况良好,无供者死亡.术前CT估算供肝体积与术中实际切取供肝重量呈正相关(r＝0.838,P＜0.01).术后复查CT测残肝体积示:右半肝供者残肝较左半肝供者残肝再生速度快,不带肝中静脉右半肝供者较带肝中静脉右半肝供者残肝再生速度略高,但供者肝脏功能恢复无明显差异.结论 不同术式活体肝移植供者在规范化围手术期处理、精细手术操作后肝功能均能得到较好的康复,而供肝切取术后残肝再生速度则受切取比例、残肝供血情况、细胞因子调控等多因素影响.     

Hepatic grafts from live donors: donor morbidity for 470 cases of live donation

Living donor-morbidity was evaluated in 470 consecutive cases of living donor liver transplantation carried out from June 1990 to May 1999 at Kyoto University. Grafting was categorized into 4 groups according to the resection lines; left lateral segmentectomy (S2 + 3, n = 282, R1), extended left lateral segmentectomy without middle hepatic vein (MHV) (S2 + 3 + part4, n = 45, R2), left lobectomy with MHV (S2 + 3 + 4, n = 99, R3) and right lobectomy without MHV (S5 + 6 + 7 + 8, n = 43, R4). Intraoperative blood loss and operation duration were less for left lateral segmentectomy, but no significant difference was observed between left lobectomy and right lobectomy. The length of postoperative hospital stays was comparable among all groups except for the group with right lobe grafting. The AST values at the peak and at POD 7 were significantly elevated for right lobectomy, but the AST value normalized within one month in the majority of the cases. The close follow-up of donors with more than 1000 ml intraoperative bleeding, and of those donors who stayed in hospital for more than 30 days, the close follow-up, furthermore, of those donors with AST values higher than 100 IU/L AST after one month, revealed complete recovery. Biliary leakage was the most common and annoying complication after donor operations, especially in for right lobe grafting, but all donors recovered completely with conservative or minimal invasive therapy. The two cases of re-operation due to adhesive mechanical ileus we encountered were resolved completely. Finally, no donor-operation related death was noted. In conclusion, the morbidity of living donors is low or minimal even for right lobectomy, the most extended procedure, and complete recovery can be expected in all cases. Received: 24 November 1999/Accepted: 13 March 2000     

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.     

Living donor liver transplantation with hyperreduced left lateral segments

Liver transplantation is now an established technique to treat children with end-stage liver disease. Implantation of left lateral segment grafts (Couidaud's segments II and III) can be a problem in small infants because of a large-for-size graft. Reduced left lateral segmental liver transplantation has been recently introduced for small infants to mitigate the problem of large-for-size graft. Further reduction of the left lateral segment graft increases the possibility of supplying an adequate hyperreduced left lateral segment graft as an alternative surgical technique. We report 3 cases of our experience of transplantation using hyperreduced left lateral segment grafts from living donors.     

Anatomical keys and pitfalls in living donor liver transplantation

The surgery of living donor liver transplantation is more technically challenging than cadaveric whole liver transplantation and liver resection for the treatment of various pathological conditions. It requires a thorough understanding of the intra- and extra-hepatic anatomical relationships between the portal vein, hepatic artery, biliary tract, and hepatic vein, and also their respective contributions to liver physiology. Although a precise understanding of general anatomical principles is the key to correctly performing living donor liver transplantation procedures, anatomic anomalies are often present, and the means of detecting them and the surgical methods of coping with them represent technical challenges. In this monograph, we describe the anatomical keys and pitfalls of living donor liver transplantation surgery based on our own experience with more than 1800 hepatectomies, and 150 living donor liver transplantations. We also elaborate on techniques of selective intermittent vascular occlusion and their teleological and practical background. Received: June 1, 2000 / Accepted: June 24, 2000