颅内外高流量搭桥治疗海绵窦内动脉瘤

目的 探讨利用大隐静脉进行颅内外搭桥，治疗海绵窦内动脉瘤的疗效，并对手术指征及手术方法进行讨论。方法 利用大隐静脉进行颅内外搭桥手术治疗海绵窦内动脉瘤13例。手术中首先准备大隐静脉20～30cm，并用等渗盐水加肝素充盈。根据手术前血管造影显示的侧支循环及手术中试验性夹闭颈内动脉时的脑电图监测情况，选用颈部颈内动脉或颈外动脉，利用大隐静脉与大脑中动脉搭桥。手术后随访3～63个月，平均23个月。结果 除1例患者因术后基底核血肿造成一侧肢体轻度偏瘫外，其余12例患者均恢复良好，眼球后疼痛及三叉神经痛均消失，眼球运动功能完全恢复，也无新的脑出血或脑缺血发生。结论 在严格选择病例的前提下，利用大隐静脉行颅内外高流量搭桥，仍然为治疗海绵窦内动脉瘤的有效方法。     

成人活体肝移植治疗终末期肝病

目的探讨成人活体肝移植治疗终末期肝病的方法及技术要点。方法回顾性分析2000年9月至2005年6月的成人活体肝移植患者12例。其中,左半肝(Ⅱ、Ⅲ、Ⅳ段,包括肝中静脉)移植3例;右半肝(Ⅴ、Ⅵ、Ⅶ、Ⅷ段)不包括肝中静脉移植8例,包括肝中静脉1例。结果 12例供体无因手术死亡者。手术时间(6．20±1．40)h;术中出血量300-1 200 ml;1例术后并发胆瘘,1例切口脂肪液化;随访 6-12个月,无远期并发症发生,术后3-6个月恢复工作。受体手术时间5-11 h;采用改良方法重建移植肝流出道、显微外科技术重建肝动脉、端端吻合重建胆道;术中出血800-7000 ml;移植物冷缺血时间(1．90±0．50)h;无肝期时间(1．63±0．43)h;移植肝重量与受体体重比为1．20％±0．26％。1例受体术后并发腹腔内局限性胆瘘,1例病死,11例长期生存。结论成人活体肝移植是解决供肝短缺、治疗终末期肝病的有效方法,同时能相对保证供体的安全。     

腹壁下动脉移植用于冠状动脉搭桥术

冠状动脉搭桥术最常使用的材料是自体大隐静脉。其后有人利用自体胸廓内动脉、胃网膜右动脉等均获得满意效果。但后两者对需要作多支搭桥的病人在使用上常感困难。作者利用自身腹壁下动脉游离移植,配合胸廓内动脉、胃网膜右动脉作三支病变搭桥,获得满意效果。患者男性、64岁,因心肌梗塞入院,经冠脉造影证实有冠脉狭窄。作经皮冠状动脉扩张术(PTCA),术后情况尚可。三周后冠脉造影复查发现冠脉左前降支狭窄90%,回旋支狭窄90%,右冠狭窄90%而决定作冠脉搭桥。手术在体外循环下施行。利用左胸廓内动脉与     

供体肝脏附属肝右动脉变异肝移植术后肝假性动脉瘤形成伴胆漏胆管出血1例报告

<正>1 病例资料男性患者,56岁,因“门静脉血栓、门静脉海绵样变、食管胃底静脉曲张破裂出血”,2021年1月26日在山西医科大学第一医院行原位肝移植手术。供肝修整时在肝固有动脉右侧,游离出附属肝右动脉(图1)。肝移植手术中动脉重建时端对端吻合供受体肝固有动脉,端对端吻合受体胃十二指肠动脉与供体附属肝右动脉,使用7-0 prolene缝线分别连续缝合动脉前后壁。供受体肝固有动脉直径约为0.5 cm,     

肝右静脉多普勒波形及门静脉右支血流速度诊断脂肪肝的临床价值

探讨彩色多普勒血流显像(CDFI)门静脉右支血流速度及肝右静脉多普勒波形诊断脂肪肝的临床价值。通过CDFI对2 80例脂肪肝的门静脉右支血流速度测定,观察其肝右静脉多普勒波形,并与4 5例正常肝组进行对比分析。结果发现,脂肪肝组的门静脉右支血流速度比正常明显降低,两组间比较有显著性差异(P <0 .0 5 )。脂肪肝患者的肝右静脉多普勒波形出现三种不同类型,其异常波形共占76 % ;而4 5例健康者肝右静脉多普勒形均为三相波形。脂肪肝组与正常组比较,肝右静脉多普勒频谱异常有显著性差异(P <0 .0 5 )。肝门静脉血流速度变化及肝右静脉多普勒频谱图异常有助于脂肪肝的早期诊断及预后判断。     

冠状动脉搭桥围术期急性心肌梗死紧急再搭桥

目的：回顾性分析冠状动脉搭桥围术期急性心肌梗死急诊再搭桥的临床经验。方法：在510例冠状动脉搭桥患中，5例患在术后4h内因急性心肌梗死需急诊再搭桥，发生率0．98％。5例患中，男女比例为4：1，年龄56－77岁（平均63．6岁），均为冠状动脉三支血管病变（3例伴左主干病变），手术中搭桥3－5支（人均搭桥3．6支），左乳内动脉桥5根，其余为大隐静脉桥。2例在关胸后20min，3例在回重症监护病房后2－4h出现急性心肌缺血表现（明显心电图ST－T变化），伴室颤2例，5例血液动力学均不稳定，药物处理难以稳定血液动力学。全部患均立即送手术室（2例仍在手术室），急诊再次开胸。探查发现，2例患静脉桥（分别搭桥到回旋支第二钝缘支和右冠状动脉后降支）内急性血栓形成；另3例所有静脉桥良好，但左室前壁收缩运动明显减弱，结合心电图变化，诊断为左乳内动脉灌注不良。重新建立体外循环，清除桥内血栓重新搭桥2例（1例在非体外循环心脏跳动下进行）；另取一段静脉搭桥到左乳内动脉－左前降支吻合口远端的左前降支3例。结果：5例患顺利度过手术，均置入主动脉内球囊反搏，支持22－25h（平均42h）。手术后呼吸机支持4h－18d（平均7．3d）合并消化道出血4例，肾功能不全2例，肺部感染2例，切口感染1例。手术后住院时间12－35d，平均21d。全组均痊愈出院。结论：冠状动脉搭桥围术期急性心肌梗死应重在预防。如怀疑桥有问题，急诊再搭桥是良好选择，但手术后并发症发生率明显增加。     

颈外动脉-静脉-大脑中动脉吻合后孤立海绵窦段颈内动脉瘤手术技术的改进

目的探讨在颅内外高流量搭桥治疗海绵窦内动脉瘤过程中，保留颈外动脉远端分支及处理保存大隐静脉的方法。方法取下2例患者的大隐静脉显露后，利用压力扩张技术以解除血管痉挛，并存放于保护液中备用；颅内选用大脑中动脉M1、M2交界处或M2段作为受者血管，大隐静脉与受体血管端一侧吻合，而非端一端吻合。在颈部大隐静脉与颈外动脉也行端一侧吻合。结果2例患者手术后，血管造影显示颅内吻合口远端血流充盈良好，颈外动脉远端侧支保留完好，经颅彩色多普勒超声显示，搭桥血管内血流量分别为210ml/min及180ml/min。随访6～9个月，症状均有好转。结论压力扩张技术解除移植血管痉挛，可以简化手术操作；大隐静脉与颈外动脉端一侧吻合，可以保留颈外动脉远端侧支，同时也可达到高流量搭桥的目的。     

中国大陆亲属供体肝移植的临床经验

南京医科大学第一附属医院王学浩教授报告亲属供体肝移植的临床经验。中国大陆1995年施行了第一例亲属供体肝移植（LDLT），到目前为止，其数量已经超过80例，其中该中心施行了48例。回顾性分析48例患者的一些重要临床数据，包括供体术后长期随访、LDLT治疗Wilson氏病、移植物一供体重量比、成人～成人右叶LDLT肝中静脉保留或放弃、急诊LDLT和植入小体积移植物的关键技术。患者1年生存率超过93％，     

老年冠心病患者非体外循环冠状动脉搭桥术25例

目的 总结25例老年（≥70岁）冠心病患者非体外循环冠状动脉搭桥术（OPCABG）的临床体会.方法 回顾性分析我院2007年7月至2013年11月经OPCABG治疗的25例老年冠心病患者的临床资料.结果 全组手术均获成功.无手术死亡,无中转体外循环完成手术者,围手术期死亡率0,无围手术期心肌梗死及神经系统并发症.全组应用左乳内动脉（IMA）和大隐静脉（SVG）搭桥77支,平均（3.1±1.0）支,行左乳内动脉与前降支吻合20例（80％）,大隐静脉搭桥24例（96％）,共57支,包括左乳内动脉（IMA）和大隐静脉（SVG）搭桥19例（79％）41支,完全静脉桥5例（20％）16支,其中序贯静脉桥14例（56％）18支.术后低心排综合征3例,应用IABP 1例,术后出现肺部并发症5例,呼吸衰竭2例,开胸止血1例,伤口感染1例.不稳定型心绞痛者,除2例术后无缓解,后经PTCA治疗有所缓解外,大部分手术后完全缓解.心功能不全者术后逐渐得到纠正,心功能Ⅰ～Ⅱ级.术后随访3～60个月,随访期间除1例死于心肌再梗死,1例死于肝癌外,大部分患者生活质量明显改善.结论 老年冠心病患者行OPCABG是一种安全、有效的方法,特别是对一些左主干病变、三支病变、合并心功能及其他重要脏器功能不全患者是一种更具优势的方法.     

肝前性门脉高压合并脾动脉盗血综合征的诊治

1一般资料患儿男性,12岁。因间断性呕血4年而入院。钡餐X线检查示食管胃底静脉重度曲张。血常规：WBC 0.78×109/L,RBC 2.72×1012/L,PLT 40.4×109/L,Hb 68 g/L。肝功能Child分级A级。术前CT动脉造影示脾动脉粗大,肝动脉分支纤细。CT静脉造影示脾静脉粗大,汇合进入门静脉左支发出的粗大脐旁静脉下行与右髂静脉交通,     

Modified techniques for adult-to-adult living donor liver transplantation

BACKGROUND: Because of critical organ shortage, transplant professionals have utilized living donor liver transplantation (LDLT) in recent years. We summarized our experience in adult-to-adult LDLT with grafts of right liver lobe by a modified technique. METHODS: From January 2002 to August 2005, 24 adult patients underwent living donor liver transplantation with grafts of the right liver lobe at West China Hospital, Sichuan University, China. Twenty-two patients underwent modi-Bed procedures designed to improve the reconstruction of the right hepatic vein and the tributaries of the middle hepatic vein by interposing a great saphenous vein ( GSV) graft and the anastomosis of the hepatic arteries and bile ducts. RESULTS: No severe complications and death occurred in all donors. In the first 2 patients, (patients 1 and 2), operative procedure was not modified. One patient suffered from "small-for-size syndrome" and the other died of sepsis with progressive deterioration of graft function. In the rest 22 patients (patients 3 to 24), however, the procedure of venous reconstruction was modified, and better results were obtained. Complications occurred in 7 recipients including acute rejection (2 patients), hepatic artery thrombosis (1), bile leakage (1), intestinal bleeding (1), left sub-phrenic abscess (1), and pulmonary infection (1). One patient with pulmonary infection died of multiple organ failure (MOF). The 22 patients underwent direct anastomosis of the right hepatic vein to the inferior vena cava (IVC), 9 direct anastomosis plus the reconstruction of the right inferior hepatic vein, and 10 direct anastomosis plus the reconstruction of the tributaries of the middle hepatic vein by in-terpos-ing a GSV graft to provide sufficient venous outflow. Trifurcation of the portal vein was met in 3 patients. Venoplasty or separate anastomosis was performed. The ratio of graft to recipient body weight ranged from 0.72% to 1.17%. Among these patients, 19 had the ratio <1.0% and 4 <0.8%, and the ratio of graft weight to recipient standard liver volume was between 31.86% and 62.48%. Among these patients, 10 had the ratio <50% and 2 <40%. No "small-for-size syndrome" occurred in the 22 recipients who were subjected to modified procedures. CONCLUSIONS: With the modified surgical techniques for the reconstruction of the hepatic vein to obtain an adequate outflow and provide a sufficient functioning liver mass, living donor liver graft in adults using the right lobe can be safe to prevent the "small-for-size syndrome".     

Hepatic venous outflow reconstruction in right lobe graft without middle hepatic vein

Background: We explored the pattern of hepatic venous outflow reconstruction in adult right lobe (segments V5-8) living donor liver transplantation (LDLT) without the middle hepatic vein (MHV). The difficulty and challenge of LDLT without MHV is the outflow reconstruction of hepatic vein. We have modified the surgical procedure and here report the results. Methods: Retrospective analysis was made of the clinical data of 50 recipients who underwent LDLT using right lobe without MHV. Results: Forty-five recipients (90.0%, 45/50) are alive at median follow up of 10 months. The graft-to-recipient bodyweight ratio (GRWR) was 1.21% +/- 0.49% (range, 0.72% to 1.98%). The recipients of GRWR <0.8% (extra-small graft), 0.8% < GRWR < 1.2% (small graft) and GRWR > 1.2% (ideal graft) were 14, 27 and 9, respectively. Total ratio venous outflowreconstruction of V5, V8 and inferior right hepatic vein was 66.0% (33/50). The overall incidence of small-for-size syndrome was 10.0% (n = 5), the overall graft survival rate was 92.0% (46/50). Conclusions: Graft function and survival rates are not only influenced by graft size, but also by hepatic venous outflow reconstruction; the 'multiple-opening vertical anastomosis' for reconstruction of hepatic vein outflow was used when the GRWR was smaller than 1.2%. This technique alleviates surgical risk in living donors, ensures excellent venous drainage, and reduces the incidence of small-for-size syndrome.     

Middle hepatic vein reconstruction in adult right lobe living donor liver transplantation improves recipient survival

BackgroundThe efficacy and necessity of middle hepatic vein (MHV) reconstruction in adult-to-adult right lobe living donor liver transplantation (LDLT) remain controversial. The present study aimed to evaluate the survival beneficiary of MHV reconstructions in LDLT.MethodsWe compared the clinical outcomes of liver recipients with MHV reconstruction (n = 101) and without MHV reconstruction (n = 43) who underwent LDLT using right lobe grafts at our institution from January 2006 to May 2017.ResultsThe overall survival (OS) rate of recipients with MHV reconstruction was significantly higher than that of those without MHV reconstruction in liver transplantation (P = 0.022; 5-yr OS: 76.2% vs 58.1%). The survival of two segments (segments 5 and 8) hepatic vein reconstruction was better than that of the only one segment (segment 5 or segment 8) hepatic vein reconstruction (P = 0.034; 5-yr OS: 83.6% vs 67.4%). The survival of using two straight vascular reconstructions was better than that using Y-shaped vascular reconstruction in liver transplantation with two segments hepatic vein reconstruction (P = 0.020; 5-yr OS: 100% vs 75.0%). The multivariate analysis demonstrated that MHV tributary reconstructions were an independent beneficiary prognostic factor for OS (hazard ratio=0.519, 95% CI: 0.282–0.954, P = 0.035). Biliary complications were significantly increased in recipients with MHV reconstruction (28.7% vs 11.6%, P = 0.027).ConclusionsMHV reconstruction ensured excellent outflow drainage and favored recipient outcome. The MHV tributaries (segments 5 and 8) should be reconstructed as much as possible to enlarge the hepatic vein anastomosis and reduce congestion.     

The influence of accessory right inferior hepatic veins on the venous drainage in right graft living donor liver transplantation

BACKGROUND/AIMS: Proper venous outflow reconstruction is essential for the success of living donor liver transplantation (LDLT). It has also a decisive impact on postoperative graft dysfunction. The accessory right inferior hepatic veins (IHVs) usually drain parts of the lateral sector of the right hemiliver graft (RHL). The purpose of our study was to: (1) evaluate the drainage patterns of the IHVs in right hemiliver grafts; (2) analyze the influence of IHVs on the dominance relationships between the right and middle hepatic veins in RHL's; (3) evaluate some potential correlation between drainage patterns of IHVs and the portal vein anatomy. METHODOLOGY: We analyzed 3-dimensional CT-imaging reconstructions of 71 potential live liver donors evaluated at our Institution between January 2003 and October 2004. RESULTS: (1) Thirty-six (51%) donors had inferior hepatic veins (IHV) with detectable venous drainage territories, (2) the RHV/IHV-complex was dominant in 97% of cases, and the RHV as a single veinwithout anatomical IHV was dominant in 94% of right hemiliver grafts, (3) 27 of 71 livers (38%) showed a central (n=11) or peripheral (n=16) PV anomaly, (4) IHV provided a mean 32% of venous drainage in the right lateral sector, and in some cases drained up to 25% of the right medial sector irrespective of the PV anatomy, (5) such cases required IHV reconstruction to prevent severe tissue congestion in the right hemiliver graft. CONCLUSIONS: Accurate insight into the drainage patterns of the right and middle hepatic veins and precise knowledge of the functional volume drained by the IHV are essential when planning for the proper outflow reconstruction of right hemiliver grafts in LDLT.     

Techniques of reconstruction of hepatic veins in living-donor liver transplantation, especially for right hepatic vein and major short hepatic veins of right-lobe graft

Living-donor liver transplantation (LDLT) is now widely accepted as a therapeutic option for adult patients with acute and chronic end-stage liver disease. In the early period, the left lobe was the major liver graft used in adult LDLT to ensure donor safety, especially in Eastern countries. However, the frequent extremes of graft-size insufficiency in left-lobe LDLT represented a greater risk of small-for-size graft syndrome in the recipient, which has focused attention on transplantation of the right lobe from a living donor. The major concern of right-lobe LDLT has focused on its safety for the donor and the necessity for including the middle hepatic vein (MHV) in the graft to avoid congestion of the right anterior segment. The MHV carries out important venous drainage for the right anterior segment and is essential for perfect graft function. The decision of whether to take the MHV with the liver graft (extended right lobe graft) or whether to retain it in the donor, with reconstruction of the MHV tributaries in the liver graft (modified right lobe graft) has been extensively discussed in numerous studies. However, adequate right hepatic vein and major short hepatic vein (middle and inferior right hepatic vein [RHV]) drainage of the liver graft is perhaps equally important as MHV outflow drainage for the integrity of right-lobe graft function. Herein, the author describes various techniques of venoplasty of the right hepatic vein (RHV) and the major short hepatic veins to obviate venous outflow obstruction in these veins.     

Left trisegmentectomy and combined resection of the inferior vena cava, without reconstruction, for giant cystadenocarcinoma of the liver

A 54-year-old woman with giant liver cystadenocarcinoma underwent left trisegmentectomy with combined resection of the inferior vena cava (IVC) and the right hepatic vein. As a result, only the right inferior hepatic vein was preserved as a drainage vein. Because the perivertebral plexus and the azygos vein were both well developed, neither veno-venous bypass nor IVC reconstruction was performed. The developed collateral veins acted as the venous drainage pathway to maintain a stable systemic circulation. On the seventh postoperative day, portal vein flow dramatically decreased and the patient tended to liver failure. Prostaglandin E₁ (PGE₁) was administrated via the superior mesenteric artery. The portal flow then gradually increased and liver failure was avoided. Six months after the operation, she was re-admitted due to obstructive jaundice and presented with complete stenosis of the common bile duct (CBD). The jaundice persisted and liver dysfunction progressed. The patient died seven months after the operation. The confluence of the right inferior vein and the IVC could have been deformed, causing outflow blockade. The intrinsic shunt was not good enough to act as the drainage pathway, and IVC reconstruction may have been needed.     

Morphometric analysis of conformational changes in hepatic venous system after right lobe living donor liver transplantation

Aim: After living donor liver transplantation (LDLT), the graft liver regenerates to the standard liver volume. However, little is known about the influence of this phenomenon on the hepatic venous system. Methods: Fourteen right lobe LDLT without the middle hepatic vein were included in this study. Computed tomography before and 1 month after LDLT was performed to measure the inflow angle of the right hepatic vein (RHV), the aspect ratio of the inferior vena cava (IVC), the coordinate position of IVC and diameter of RHV. In addition, the regeneration index (RI) was determined on each liver segment. Results: RHV showed a clockwise rotation at early postoperative months, the average increase of the inflow angle being 14.5 ± 15.6 (mean ± standard deviation) degrees. IVC was shifted from right to left with a deformity to a long oval shape on horizontal sections. The center of IVC moved dorsally at an average of 0.55 ± 0.77 cm and leftward at an average of 0.82 ± 0.89 cm. Diameter of RHV decreased at an average of 0.65 ± 0.39 cm at its root. The extent of liver regeneration was more prominent in the posterior segment as compared to the anterior segment, the average RI values being 1.65 ± 0.65 and 1.17 ± 0.44, respectively (P < 0.05). Hepatic vein outflow block (HVOB) was encountered in two patients with a marked conformational deformity observed in the hepatic venous system at early postoperative months after LDLT. Conclusion: After right lobe LDLT, the hepatic venous system exhibits a profound conformational change, which most likely plays a role in the onset of HVOB.     

Extended central hepatectomy with preservation of segment 6 for patients with centrally located hepatocellular carcinoma

BACKGROUND: In order to preserve functional liver parenchyma, extended central hepatectomy (segments 4, 5, 7 and 8 resection) was proposed for the management of centrally located hepatocellular carcinoma invading the right and middle hepatic veins, reconstructing segment 6 outflow in the absence of the thick inferior right hepatic vein. The present study was to describe our surgical techniques of extended central hepatectomy.METHODS: Between 2008 and 2012, 5 patients with centrally located hepatocellular carcinoma invading or in the vicinity of the right and middle hepatic veins underwent extended central hepatectomy. The thick inferior right hepatic vein was preserved during dissection. Gore-Tex graft was used for segment 6 outflow reconstruction in the absence of the thick inferior right hepatic vein.RESULTS: The mean future remnant liver volume for segments 2 and 3 was 28% versus 45% on segment 6 preservation. The mean tumor diameter was 7.4 cm. The thick inferior right hepatic vein was found in 1 patient. Outflow reconstruction from segment 6 was performed in 4 patients. Postoperative complications included bile leakage (1 patient), pleural effusion (2) and liver failure (1). The rate of graft patency was 75%. There was no perioperative mortality.CONCLUSION: Extended central hepatectomy is a safe alternative for extended hepatic resection in selected patients attempting to preserve the functional liver parenchyma.     

Leiomyosarcoma of the inferior vena cava--an unusual case

Primary tumors arising from great vessels like the aorta, pulmonary artery or inferior vena cava (IVC) are rare. The latter is the commonest site of its occurrence. It arises from the smooth muscle cells of the vessel wall. Aggressive surgical management should be attempted to excise it whenever possible. We describe a case of primary inferior vena cava tumor involving all three segments of the abdominal inferior vena cava infrarenal, suprarenal and retrohepatic vena cava, along with right kidney, right adrenal as well as right hepatic vein and left renal vein. We resected it completely without reconstruction of the IVC. The patient is doing well seven months after surgery without having any renal insufficiency, hepatic insufficiency or leg edema and having optimum quality of life. To our knowledge, this is the first case of such a long segment IVC leiomyosarcoma treated without IVC reconstruction, and despite its extent and concomitant involvement of the right kidney, right adrenal, right hepatic vein and left renal vein, it had a favorable response combining prolongation of survival and satisfactory quality of life.     

Phrenic vein dissection in partial liver graft harvesting

BACKGROUND/AIMS: Despite the impressive results of living donor liver transplantation, hepatic venous reconstruction remains a controversial component. METHODOLOGY: A total of 211 consecutive donor hepatectomies were performed. The proximal route of the hepatic vein was exposed by dissection of the connective tissue around the hepatic vein and by dividing and ligating all of the inferior phrenic veins that open into the hepatic vein, into the confluence of the hepatic vein and inferior vena cava, or directly into the inferior vena cava. RESULTS: In the 114 left-side hepatectomy procedures, the number of divided left inferior phrenic veins ranged from 1 to 4 and the diameters of the left and middle hepatic veins ranged from 7 to 33mm. For the 97 right-side procedures, the number of divided right inferior phrenic veins ranged from 1 to 4 and the diameters of right hepatic veins ranged from 9 to 34mm. This maneuver safely allowed for the safe exposure of all trunks and routes of the hepatic veins and the suprahepatic portion of the inferior vena cava. CONCLUSIONS: Our technique is useful for obtaining a wide ostium and a sufficient length of the hepatic vein for grafts obtained from living donors.