影像学检查在成人活体肝移植术后小肝综合征中的应用

小肝综合征（SFSS）是成人活体肝移植术后一种发病率和死亡率都很高的临床并发症。目前如何有效防治SFSS已成为研究热点。除改进外科技术外,影像学检查在成人活体肝移植术后SFSS的预防、检测及治疗方面也发挥着越来越重要的作用。本文对影像学检查在成人活体肝移植术后小肝综合征中的应用作一综述。     

预防活体肝移植后肝小体积综合征的综合措施

目的 通过术前选择合适的供肝、术中建立充分的流出道及术后调整门静脉压等综合措施预防活体肝移植术后肝小体积综合征.方法 总结2007年12月至2009年11月的113例活体肝移植的临床资料,术前通过影像系统评估供肝体积,测算供肝体积与受者体重比(GRWR),根据供肝解剖及GRWR确定采用的供体类型(含肝中静脉右半肝,不含肝中静脉右半肝,含肝中静脉左半肝等),术中通过建立充分的流出道,根据GRWR、术前脾功能亢进情况、肝动脉开放后门静脉血流量及门静脉压力,确定是否采用脾动脉结扎等方法将门静脉压力控制在＜20 mm Hg(2.67 kPa),门静脉血流量控制在＜250 ml·min-1·100 g-1,观察采取上述措施后肝小体积综合征的发生情况.结果 75例受者接受含肝中静脉的右半肝,37例接受不含肝中静脉的右半肝,1例接受含肝中静脉左半肝.随访6个月,所有受者均未出现持续黄疸、败血症等严重的肝小体积综合征表现,1例受者于术后42 d死于脑卒中及呼吸衰竭,受者术后6个月存活率为99.1％(112/113).结论 术前根据供肝血管解剖及GRWR选择适当的供肝类型,术中建立充分的流出道,通过脾动脉结扎等方式调整门静脉血流及压力的综合方法可有效预防肝小体积综合征.     

Posterior cavoplasty: a new approach to avoid venous outflow obstruction and symptoms for small-for-size syndrome in right lobe living donor liver transplantation

Purpose  

A common and serious problem after living donor liver transplantation (LDLT) of small grafts is small-for-size syndrome (SFSS). Although hyperdynamic portal inflow and portal hypertension are cornerstones in the development of SFSS, inadequate outflow may aggravate SFSS. Therefore, enlargement of the portal outflow tract by incision of the anterior rim of the orifice of the right hepatic vein (RHV) has been advocated for right lobe LDLT. But backwards tilt of a small graft into a large abdominal cavity may lead to a choking of the otherwise large anastomosis and thus we propose posterior enlargement of the orifice of the RHV.     

选择性脾切除调整门静脉血流预防活体肝移植小肝综合征

目的 探讨选择性脾切除对活体肝移植(LDLT)受者术中门静脉血流(PVF)及术后小肝综合征(SFSS)发生率的影响.方法 回顾性分析2007年9月至2008年3月26例LDLT术中PVF监测资料.对PVF ＞250 ml/(min·100 g)者,术中同期行脾切除术;PVF＜250 ml/min(100 g)者不行脾切除,分析选择性脾切除对PVF的影响及是否可以预防SFSS的发生.结果 脾切除8例,切脾后PVF较切脾前明显降低(P＜0.01).脾切除及未行脾切除的患者均无SFSS发生.其中脾切除患者(8例)供肝重占受者体重比显著低于未行脾切除患者(18例)(P＝0.044),PVF显著高于未行脾切除患者(P＜0.01).结论 根据LDLT术中PVF监测数据,选择性脾切除可显著降低高门静脉灌注患者的PVF,对术后SFSS有预防作用.     

Chronic atelectasis of the left lower lobe: a clinicopathological condition equivalent to middle lobe syndrome

OBJECTIVES Middle lobe syndrome is a well-known clinical condition. In this retrospective study, we report our experience with a similar clinicopathological condition affecting the left lower lobe. METHODS The data of 17 patients with atelectasis or bronchiectasis of the left lower lobe who underwent lobectomy during the period from January 2000 to December 2011 were reviewed. Demographic, clinical, radiological and surgical data were collected. RESULTS Seventeen patients were included in this study, only one adult male patient of 52 years and 16 children. The paediatric patients were 10 boys and 6 girls, their age ranged from 2 to 11 years, mean 6.19?±?2.6 years. Most patients presented with recurrent respiratory infection 15/17 (88.2%). The lag time before referral to surgery ranged from 3 to 48 months, mean 17.59?±?13.1 months. Radiological signs of bronchiectasis were found in 11 (64.7%) patients. Bronchoscopy showed patent lower lobe bronchus in all patients. The criteria for lobectomy were evidence of bronchiectasis [11 (64.71%) patients], persistent atelectasis of the lobe after bronchoscopy and intensive medical therapy for a maximum of 2 months [6 (35.29%) patients]. Histopathological examination showed bronchiectasis in 11 (64.71%) patients, fibrosing pneumonitis in 4 (23.53%) patients and peribronchial inflammation in 2 (11.76%) patients. Most patients were doing well 1 year after surgery. CONCLUSIONS Chronic atelectasis of the left lower lobe is a clinicopathological condition equivalent to middle lobe syndrome. Impaired collateral ventilation together with airway plugging with secretion is an accepted explanation. Surgical resection is indicated for bronchiectatic lobe or failure of 2-month intensive medical therapy to resolve lobar atelectasis.     

A thoracoabdominal approach in revision of the hepatic hilum after left lobe living donor liver transplantation

We present an approach to safely expose the hepatic hilum for revision procedures after left lobe living donor liver transplantation. A 14-year-old adolescent girl who had undergone left lobe living donor liver transplantation experienced repeated episodes of cholangitis. Because treatment with interventional techniques failed, surgical revision was indicated. The right thoracoabdominal approach was selected to minimize dissection. Intraoperative findings showed adhesive kinking of the Roux-Y limb just distal to the bilioenteric anastomosis, and a side-to-side jejunojejunostomy was performed. The thoracoabdominal approach leads to easy and excellent reoperative exposure of the hilar site of a left lobe liver graft.     

The surgical approach to urological complications in renal allotransplant recipients.

Urinary extravasation or ureteral obstruction occurred in 22 patients who received 30 transplants in a series of 290 renal transplants. This incidence represent 10.3 per cent of the entire transplant experience at The Johns Hopkins Hospital and Baltimore City Hospitals from 1968 to the present time. Ureteroneocystostomy was used as the primary form of urinary tract reconstruction in all but 1 patient who had urinary complications. These 22 patients received 30 renal transplants: 6 from living related donors and 24 from cadaver sources. There were 15 instances of urinary extravasation and 14 instances of obstruction. All but 2 fistulas were diagnosed within 30 days of the original transplant. Obstruction occurred later, with 4 cases of ureterovesical obstruction being diagnosed 3 to 5 years after the transplant procedure. The ureterovesical junction or bladder was the site of complication in 17 of the 29 instances. Surgical management in these cases was highly individualized, with successful outcomes more commonly attained in those cases characterized by obstruction. Ureteral stents were used in all but 1 secondary procedure involving the ureter and these stents were not associated with an increased incidence of urinary tract infection. Death directly related to the urological complications occurred in 2 cases, 5 patients underwent transplant nephrectomy and 2 patients died of rejection and infection more than 6 months after the urinary fistulas were successfully managed. From the original series, there are 15 of the 22 patients who have stable renal function after secondary or tertiary urological procedures on the transplanted kidney. Four patients underwent surgical correction of hydronephrosis associated with infection or diminishing renal function more than 3 years after the transplantation and 3 of these had good results.     

New approach to the surgical treatment of Swyer-James-MacLeod syndrome

Three patients with Swyer-James-MacLeod syndrome underwent operation. Occlusion of the main bronchus, leaving the lung in place, was carried out with good long-term results.     

Reduction of left ventricular diameter and mass after surgical arteriovenous fistula closure in renal transplant recipients

BACKGROUND: Left ventricular hypertrophy and dilatation is a frequent finding in kidney transplant recipients, which may be favored by the persistent patency of arteriovenous fistula. The purpose of the current study was to prospectively investigate whether surgical closure of the fistula allows reduction of abnormalities of left ventricular morphology in stable renal transplant patients. Furthermore, we studied the ability of preoperative echocardiographic and noninvasive hemodynamic measurements, including the effects of a temporary occlusion of the fistula, to predict postoperative left ventricular diameter and mass reduction. METHODS: Seventeen kidney transplant recipients referred for surgical arteriovenous fistula closure were prospectively studied. Standard echocardiographic parameters, heart rate, and blood pressure were assessed preoperatively at baseline and during an acute pneumatic fistula occlusion. These measurements were repeated 3 to 10 weeks after surgical closure. Six kidney transplant recipients with patent arteriovenous fistulas referred for routine echocardiographic follow-up served as a control group. RESULTS: Surgical fistula closure decreased left ventricular end-diastolic diameter and mass indexes (29.9+/-2.4 to 27.4+/-2.1 mm/m2, P<0.001, and 141+/-37 to 132+/-39 g/m2, P<0.05, respectively), whereas no changes were seen in controls after a similar delay. Postoperative left ventricular end-diastolic diameter and mass reductions correlated best with the increases in total peripheral resistance (r=0.85, P<0.0001) and mean arterial blood pressure (r=0.64, P=0.006) during pneumatic occlusion, respectively. CONCLUSIONS: Surgical closure of arteriovenous fistula reduces left ventricular diameter and mass in kidney transplant recipients. Increases in blood pressure and total peripheral resistance induced by temporary fistula occlusion are the best predictors of these morphological changes.     

A tailored anatomical approach to prevent complications during left atrial ablation

Atrial fibrillation ablation surgery has grown very popular in recent years. Modern techniques involve creation of linear scars on the left atrial wall using different ablation devices. That raises the concern about new major surgical complications that can be caused by the ablation procedure. Postablation coronary obstruction and esophageal injury have been described. We report our present strategy for left atrial ablation in which the lesion set is tailored to the specific coronary anatomy. Safeguards to prevent esophageal and bronchial injury are also outlined.     

Hepatic artery reconstruction and biliary stricture formation after living donor adult liver transplantation using the left lobe

Biliary complications, including bile leak, biliary stricture, and cholangitis, are seen in 15% to 29% of all cases after living related liver transplantation. We investigate risk factors and discuss the management of biliary complications after living related liver transplantation in adults using left-lobe grafts. We studied 37 adult patients who underwent living related liver transplantation using left-lobe grafts. Perioperative variables were evaluated as risk factors for biliary strictures. The overall incidence of biliary complications was 43.2% (16 of 37 patients). Anastomotic strictures occurred in 8 patients, whereas bile leaks and cholangitis occurred in 9 and 8 patients, respectively. Anastomotic stricture was strongly related to a partial artery reconstruction (P < .02) and cholangitis (P < .01). Anastomotic biliary stricture was not associated with bile leak, acute cellular rejection, or infection. Our results suggest that an important risk factor for biliary anastomotic biliary strictures is a partial artery reconstruction. To minimize the risk for biliary anastomotic strictures, we will reconstruct both the middle and left hepatic artery. (Liver Transpl 2002;8:495-495.)     

Surgical approach to left subclavian artery aneurysm in Marfan syndrome

We present a case of left subclavian artery aneurysm in a 48-year-old man with Marfan syndrome. Aneurysmectomy and interposition with an artificial graft were successfully performed through an infraclavicular incision by dividing the clavicle at its midshaft. The clavicle bone was reconstructed with a steel plate, and the postoperative course was uneventful. Because the arterial wall is fragile in cases of connective tissue disorders such as Marfan syndrome, our surgical approach was considered to be helpful for gentle maneuvering in an adequate operative field.     

Hepatocellular proliferation and changes in microarchitecture of right lobe allografts in adult transplant recipients.

Imaging studies show complete restoration of liver volume in adult recipients of right lobe allografts within 2-3 weeks of living donor transplantation (LDLT). However, it is not known if this growth is associated with restoration of hepatic microarchitecture. We compared 21 biopsies without significant pathology from LDLT recipients with 23 biopsies from adult recipients of cadaveric donor liver transplantation (CDLT) performed within 3 months of transplantation. The difference in the number of portal tracts per cm was statistically significant (P < .0001) between CDLT (9.08 +/- 1.74) and LDLT recipients within 3 months (6.26 +/- 1.62), as well as after 3 months following transplantation (6.56 +/- 1.44). The coefficient of correlation between length of biopsy specimens and the number of portal tracts in these 3 groups was .94, .93, and .85, respectively. Proliferative activity demonstrated by immunohistochemical staining for MIB-1 was seen predominantly in hepatocytes in both groups; bile ducts only occasionally stained positive. The difference between labeling indices of hepatocytes was statistically significant (P = .00056) between CDLT and LDLT recipients within 3 months of transplantation (.82 +/- .63 and 4.53 +/- 3.72), and between LDLT recipients within 3 weeks and after 3 weeks of transplantation (5.97 +/- 3.78 and 1.80 +/- 1.37, P = .0074). In conclusion, restoration of liver volume following LDLT occurs by proliferation of hepatocytes in the immediate posttransplant period. There is a decrease in number of portal tracts in these volume-restored allografts. Volume restoration is therefore, not accompanied by restoration of hepatic microarchitecture.