成人活体肝移植肝动脉重建50例

目的 总结成人活体肝移植的肝动脉重建经验.方法 我院2002年1月至2006年7月施行了50例成人右半肝活体肝移植,供、受者肝动脉的重建采用显微外科技术成形端端连续缝合方式完成.结果 术后肝动脉血栓形成2例(4%).随访时间2～52个月(中位随访时间9个月),术后和随访期未发现肝动脉狭窄、肝动脉假性动脉瘤等并发症.1年实际生存率为92%(46/50).结论 根据供、受者肝动脉解剖及变异情况,选择适宜的长度和匹配的口径,采用显微外科吻合技术重建肝动脉,是减少肝移植围手术期并发症发生的关键.     

Reconstruction of the Replaced Right Hepatic Artery at the Time of Pancreaticoduodenectomy

Background  The arterial anatomy supplying the liver is highly variable. One of the most common variants is a completely replaced right hepatic artery which is seen in about 11% of the population. Interruption of arterial flow to the right hepatic artery at the time of pancreaticoduodenectomy has been associated with biliary fistula and the consequent complications, as well as stenosis of the biliary enteric anastomosis. Malignancies of the posterior aspect of the head of the pancreas can encase a replaced right hepatic artery without involvement of other vascular structures. In this situation, it is possible to resect and reconstruct the replaced right hepatic artery to maintain oxygen delivery to the biliary enteric anastomosis. Summary  Herein we describe a technique to reconstruct a replaced right hepatic artery following resection of the vessel en bloc with the tumor during a pancreaticoduodenectomy, using inflow from the gastroduodenal artery.     

肝动脉-腹主动脉架桥重建移植肝肝动脉74例报告

探讨原位肝移植术中采用肝动脉-腹主动脉架桥重建移植肝肝动脉的疗效.方法 回顾分析2003年10月至2009年8月在中山大学附属第三医院肝移植中心行肝动脉-腹主动脉架桥重建移植肝肝动脉的74例患者的临床资料.全部患者采用供肝动脉通过供者髂动脉间置架桥与受者腹主动脉(肾动脉下方腹主动脉)行端侧吻合.总结手术治疗方法和术后并发症发生情况.所有患者均签署知情同意书,符合医学伦理学规定.结果 74例采用肝动脉-腹主动脉架桥重建肝动脉的患者中,68例治愈,6例术后早期死亡,治愈率为92%.术后急性排斥反应的发生率为18%(13/74),胆道并发症发生率为11%(8/74),肝动脉并发症发生率为14%(10/74),其中5例为架桥动脉血栓形成,5例为肝动脉(含架桥动脉)狭窄,行动脉支架置入溶栓术或动脉支架置入术,除1例上述治疗无效后行再次肝移植外,其余9例血管恢复通畅.结论 肝移植术中若无法行供、受者肝动脉端端吻合术重建肝动脉,间置髂动脉的肝动脉-腹主动脉架桥术是一种安全可靠的肝动脉重建方法.     

A technique for hepatic artery anastomosis during orthotopic liver transplantation

Hepatic artery thrombosis remains the most common technical complication that causes graft failure following orthotopic liver transplantation. The Hepatic artery anastomosis should be performed using meticulous technique and adequate magnification. We report a very low incidence of Hepatic artery thrombosis (1.3%) utilising a modified microvascular 120° triangulating technique in 150 adult liver transplants.     

Alternative procedure for failed reconstruction of a right replaced hepatic artery in liver transplantation

A right replaced hepatic artery (RRHA) arising from the superior mesenteric artery (SMA) is the most frequent variation of the hepatic arterial supply requiring backtable reconstruction. There are several widely used techniques for backtable reconstruction of the RRHA to a single conduit. If these reconstructions fail, due to technical reasons or size discrepancies, an alternative method of rearterialization is needed. We describe six cases in which an RRHA was anastomosed to the donor's gastroduodenal artery (GDA) stump utilizing a loupe magnification technique. In four cases the reconstruction was performed at the time of the backtable procedure and in two after reperfusion and failure of the original RRHA to splenic artery (SA) reconstruction. In all cases, the anastomoses remained patent. All patients had Doppler sonography and two had subsequent arteriograms that verified anastomotic patency. This method of reconstruction is more demanding technically but obviates the awkward 90-degree twist of the hepatic artery when an RRHA is anastomosed to the SA stump.     

肝移植术后肝动脉血栓的处理及预后

目的了解肝移植术后肝动脉血栓（HAT）的处理方法及预后。方法收集2004年至2010年在北京佑安医院肝移植中心施行的427例肝移植病例的临床资料,分析HAT的临床处理方法及预后情况。结果 427例肝移植患者中,共发生HAT5例（1.2%）,发生时间为4～91d（中位时间28d）。经尿激酶介入溶栓、血栓取出、肝动脉重建、再次肝移植及高压氧等治疗后,5例患者中死亡3例。移植物存活时间为8～690d（中位时间298d）,患者存活时间为13～1005d（中位时间298d）。结论肝移植术后HAT发生率较低,但预后极差。一旦确诊及时采用尿激酶介入溶栓、血栓取出、肝动脉重建、再次肝移植及高压氧等治疗,以降低病死率。     

肝移植中使用受体脾动脉行肝动脉重建

目的探讨在肝移植中受体肝动脉存在病变的情况下肝动脉重建的方法。方法在二例肝移植病人中,选用受体脾动脉与供体肝动脉端端吻合以重建肝动脉。结果术后分别随访5个月和2年,肝动脉通畅,肝功能正常,无胆管并发症,无脾梗塞和脾功能异常。结论肝移植中受体的脾动脉可以用来行肝动脉重建。     

肝移植术后肝动脉血栓形成的溶栓治疗3例报道

目的 探讨肝移植术后肝动脉血栓形成的溶栓治疗价值。方法对50例同种异体肝移植病例，术后以彩色多普勒超声(CDI)定期监测肝动脉血流，怀疑肝动脉血栓形成(HAT)行动脉造影，确诊3例，即刻行介入溶栓治疗，经导管分别在20分钟内予尿激酶12．5万单位、30分钟内予尿激酶25万单位和肝素50mg，及4小时内注入尿激酶60万单位。结果3例溶栓治疗后，肝动脉均再通。1例因二次血栓形成再次溶栓成功。但均发生不同程度的腹腔内出血，1例保守治疗痊愈，1例经开腹手术止血后痊愈，另1例死于多器官功能衰竭。结论对怀疑HAT病例，应尽早行动脉造影。改进后的溶栓疗法有可能成为治疗HAT的可选择方法。     

小鼠肝移植中两种肝动脉重建方法的比较

目的比较小鼠肝移植中两种不同肝动脉重建方法的效果。方法应用雄性C57BL/6小鼠建立小鼠肝脏移植模型,随机分为肠系膜上动脉重建组（14对）和腹主动脉重建组（16对）。手术采用异氟醚吸入麻醉。供肝经门静脉灌注4℃威斯康星大学保存液（UW液）。两组小鼠的肝动脉重建分别采用供体肠系膜上动脉或供体肾下腹主动脉与受体腹主动脉端侧吻合两种方法。移植肝血流恢复后重建肝动脉。胆管采用内支架管的方法重建。观察术后2周移植物的存活情况和肝动脉通畅与否。用组织病理学方法检查移植肝的组织形态变化,用免疫组织化学法观察肝脏再生功能。结果术中无小鼠死亡,手术成功率为100%。肠系膜上动脉重建组供体肝动脉游离时间为（12.1±2.5）min,腹主动脉重建组为（17.3±3.1）min,比较差异有统计学意义（P〈0.05）。腹主动脉重建组肝动脉吻合时间为（14.5±2.9）min,肠系膜上动脉重建组相应为（12.4±3.3）min,比较差异无统计学意义（P〉0.05）。肠系膜上动脉重建组移植物术后2周存活率为93%（1只死于吻合口血栓形成）,腹主动脉重建组为100%。肠系膜上动脉重建组术后2周肝动脉通畅率为86%,腹主动脉重建组为100%。组织病理学检查示两组的移植肝组织正常,肝脏再生反应不明显。结论小鼠肝移植中,与应用肠系膜上动脉重建比较,应用腹主动脉吻合重建肝动脉的效果更好且安全,建议首选供受体腹主动脉吻合重建小鼠肝动脉的方法。     

Cephalic pancreaticoduodenectomy with preservation of a right coronary artery bypass graft using the right gastro-epiploic artery: a case report

Introduction: Pancreatic cancer is a rare disease with a high mortality rate, for which complete surgical resection, when possible, is the preferred therapeutic. Pancreaticoduodenectomy represents the surgical technique of choice. Abdominal surgeons can be faced with the challenge of patients with a history of coronary artery bypass graft in which the right gastro-epiploic artery is used.

Case report: We report the case of a patient with an adenocarcinoma of the pancreatic head, stage IIA, having previously undergone a triple coronary artery bypass, one of which being a right gastro-epiploic graft. Our challenge was underlined by the necessity of a complete oncological resection through a cephalic pancreaticoduodenectomy while preserving the necessary cardiac perfusion via the right gastro-epiploic artery.

Conclusion: We have been able to preserve a right gastro-epiploic artery as a coronary bypass during a cephalic pancreaticoduodenectomy for a cephalic pancreatic adenocarcinoma. We have successfully been able to preserve and re-implant the right gastro-epiploic artery to the origin of the gastroduodenal artery while insuring R0 resection of the tumor. A coronary artery bypass using the right gastro-epiploic artery should therefore not be considered as an obstacle to a Whipple’s procedure if total oncological resection is obtainable.     

Clinical significance of reconstruction of the right hepatic artery for biliary malignancy

Background and aims The clinical significance of resectional surgery with reconstruction of the right hepatic artery for biliary malignancy remains unclear.Patients/methods Between 1990 and 2004, six patients (5%) with cholangiocarcinoma and five patients (3%) with gallbladder carcinoma with possible involvement of the right hepatic artery underwent resectional surgery with reconstruction of the right-sided hepatic artery. The surgical procedures included extended left hemihepatectomy (n=4), left trisectionectomy (n=1), central bisegmentectomy (n=1), resection of anterior segment and inferior area of segment 4 (n=2), resection of segment 5 and inferior area of segment 4 (n=1), and extrahepatic bile duct resection (n=2). Segmental resection and reconstruction of the right (n=7), anterior (n=1), or posterior (n=3) hepatic artery was performed by end-to-end anastomosis (n=5), using the right gastroepiploic artery (n=4), the gastroduodenal artery (n=1), or an autologous venous graft (n=1).Results There was no in-hospital mortality. Histopathological arterial involvement was present in seven patients, and the surgical margin was positive in five patients. The median survival was 23 months in R0 patients (n=6), while it was 13 months in R1 patients (n=5) (p=0.16).Conclusion Reconstruction of the right hepatic artery was safely performed in patients with biliary malignancy. Arterial reconstruction can be indicated when the arterial involvement is the only obstacle to obtain negative surgical margins.     

Accessory left hepatic artery arising from common hepatic artery

The knowledge of anatomical variations in hepatic artery are of importance to surgeons and radiologists while performing complicated procedures like liver transplantation and transarterial chemo-embolization for hepatic tumors. The incidence of accessory left hepatic artery is less common than the right accessory hepatic artery. Here we report an anomalous accessory left hepatic artery arising from common hepatic artery in a 55 year old male cadaver.     

成人肝移植中的肝动脉搭桥术——澳大利亚 Australia National Liver Transplant Unit的经验

目的 介绍澳大利亚国家肝移植中心在成人肝移植中应用肝动脉搭桥术的经验。方法 对澳大利亚国家肝移植中心（Australia National Liver Transplant Unit，ANLTU）1986—2003年的31例行肝动脉搭桥的成人肝移植结果进行回顾行分析。31例需行肝动脉搭桥的原因有微小受者肝动脉、肝动脉血栓症、肝门严重粘连、肝动脉壁间动脉瘤、真菌性肝动脉瘤及前次植入肝的肝动脉因胆道出血而结扎。18例为首次移植，13例为再次或多次肝移植。结果 术后15例（48．4％）存活，平均存活时间为4．1年，16例（51．6％）死亡，平均存活时间为34．56d。两次和多次肝移植者的死亡率为76．9％，首次肝移植者的死亡率为33．3％（P〈0．05）。因肝动脉血栓症而搭桥者的死亡率最高，其次为肝门严重粘连者。死亡原因依次为败血症、围手术期大出血、颅内出血、肝动脉血栓形成、排斥反应、原发病复发以及心跳骤停。结论 成人肝移植行肝动脉搭桥的适应证主要是各种原因导致的受者肝动脉不适用，或因肝门部严重粘连而无法解剖者；患者术后转归与肝移植的次数及患者的术前状况有关。     

原位肝移植术中肝动脉变异及术后肝动脉血栓形成的处理

目的探讨肝移植术中肝动脉变异及术后肝动脉血栓形成的处理。方法统计2000年8月至2002年12月期间进行肝移植术的67例次供、受者肝动脉的变异情况；分析肝动脉的重建方式，探讨肝动脉变异与手术后肝动脉血栓形成的关系、肝动脉血栓形成的危险因素及肝动脉血栓形成后的处理。结果67例次供者肝脏和65例受者肝脏共出现肝动脉变异12例次，发生频率最高的为右肝动脉起源于肠系膜上动脉(5例)及左肝动脉起源于胃左动脉(3例)。肝动脉的重建方式如下：供者及受者肝总动脉与胃十二指肠动脉分叉处成型后吻合58例；腹主动脉与肝动脉搭桥2例；利用变异的肝动脉分支吻合7例。手术后发生肝动脉血栓形成3例，均经腹股沟处股动脉插管行肝动脉溶栓治疗，此3例患者中死亡1例。结论避免变异的肝动脉损伤、选择适当的肝动脉吻合方式可以保证移植肝脏的动脉血供。肝动脉血栓形成与肝动脉变异无关。作为肝动脉血栓形成后的保守治疗方法，肝动脉内溶栓治疗有可能避免2次移植。     

Two-step hepatic artery reconstruction for a hepatic artery lacking in length for the use of a microclamp in living donor liver transplantation

IntroductionWe describe successful two-step hepatic artery reconstruction in a patient whose graft site hepatic artery was too short for the use of a microclamp in living donor liver transplantation.Presentation of caseA 57-year-old woman was diagnosed as having hepatitis C and liver cirrhosis. Her 26-year-old son was the living liver donor. The living donor underwent right lobectomy. The dissected graft hepatic artery was too short for the use of a microclamp. The recipient right hepatic artery was cut and used as an arterial graft. The graft right hepatic artery was sutured to the right hepatic artery of the arterial graft and the graft posterior branch of the right hepatic artery was sutured to the middle hepatic artery of the arterial graft. After reconstruction of the portal vein and hepatic vein was completed, anastomosis was performed between the graft right hepatic artery and right hepatic artery. The patency of the vessels was checked using color Doppler ultrasonography for 1 week postoperatively. No postoperative complications involving blood flow of the hepatic artery were observed.DiscussionIn our case, the recipient hepatic artery was cut and used as an arterial graft. Although the number of anastomotic sites of the hepatic artery increased, we could perform hepatic artery reconstruction safely and easily.ConclusionTwo-step hepatic artery reconstruction is a useful method in cases where the recipient hepatic artery does not have enough length.     

肝移植术后非肝动脉并发症的肝动脉彩色多普勒超声表现

目的研究肝移植术后非肝动脉并发症的肝动脉彩色多普勒血流显像（color Doppler flow imaging,CDFI）表现,并与肝动脉并发症的CDFI表现作比较。方法采用CDFI检测肝移植术后患者,将肝动脉血流动力学指标异常（肝动脉血流阻力指数〈0．50,收缩期加速时间≥0．08s）的98例患者分为非肝动脉并发症组（36例）和肝动脉并发症组（62例）。比较两组患者肝动脉的血流参数,包括阻力指数、收缩期加速时间、血流参数异常出现的时间及其治疗后的变化趋势等。结果非肝动脉并发症组患者肝动脉血流参数异常出现时间为7～284（中位数56）d,而肝动脉并发症组患者为1～588（中位数66）d,两组比较差异无统计学意义（P〉0．05）。与肝动脉并发症组患者比较,非肝动脉并发症组患者的肝动脉阻力指数较高,而收缩期加速时间较短（均为P〈0．01）。非肝动脉并发症组患者经抗炎、护肝、利胆、营养等保守对症处理,血流参数在（41±12）d内恢复至正常范围。肝动脉并发症组中有28例行肝动脉狭窄支架置入术,3例行肝动脉旁路移植术,4例行再次肝移植术,1例手术解除肝门部血肿压迫,术后患者肝动脉血流参数均恢复至正常,另有26例患者未做手术,血流参数持续异常。结论肝移植术后的非肝动脉并发症患者会出现轻度、一过性的肝动脉血流参数异常,表现为阻力指数降低和（或）收缩期加速时间延长,但异常程度明显轻于肝动脉并发症患者,这种异常可能与急性排斥反应等非肝动脉并发症有关,经过保守治疗后,血流参数可以恢复正常,而肝动脉并发症患者血流参数为持续性异常,需要手术纠正。     

肝移植术中供受者肝动脉夹层的防治策略

肝动脉重建是肝移植术中关键操作步骤之一,供受者因素及手术操作因素导致术中出现待重建动脉意外形成夹层的情况会打乱手术计划,增加动脉重建难度,明显延长手术时间,增加术后动脉狭窄及血栓的风险,也可能导致急性移植物失功而需要紧急手术干预甚至二次肝移植。探讨如何避免肝移植术中待吻合动脉形成夹层以及待吻合动脉出现夹层后的处理,将有助于预防肝移植术中动脉相关并发症,改善肝移植受者的预后。本文就肝移植术中供受者肝动脉夹层的成因、预防、处理及肝动脉重建方式经验介绍如下。     

Medial thickening of hepatic artery branches in biliary atresia. A morphometric study

Background/Purpose

Medial layer hypertrophy of hepatic arterial branches may be associated with biliary atresia (BA) pathogenesis. This study aimed at evaluating medial layer thickness in hepatic arterial branches at portoenterostomy and liver transplantation.

Methods

The authors evaluated 1274 arterial branches both in BA cases and in control subjects involving a total of 1108 arterioles and 166 arteries. Arterial branch characteristics were morphometrically evaluated in 47 BA patients at the time of portoenterostomy. Controls were patients with intrahepatic cholestasis (n = 3), immature neonates (n = 7), and infants (n = 7) without liver disease. Progression of medial layer thickening between the time of portoenterostomy and transplantation was evaluated in 7 BA patients. Biliary atresia patients at the time of transplantation were compared with non-BA-transplanted patients (n = 4).

Results

The arterial medial layer of BA cases at portoenterostomy was thicker than that of infants without liver disease (P = .03). The arterial medial thickness increased during the interval between portoenterostomy and transplantation (P = .05). Arterioles and arteries with thickened medial layers were found in transplanted BA patients but not in patients transplanted for other liver diseases (P = .05 and P = .01). Thickening of the medial layer of the hepatic arteries was associated with focal distribution of interlobular bile ducts in portal spaces in BA (P = .02).

Conclusions

In BA, there is a progressive thickening of the arterial medial layer, suggestive of vascular remodeling, which is associated to the disappearance of interlobular bile ducts.     

Central hepatic bisectionectomy with hepatic artery and biliary tracts reconstruction for the patient with nodular type intrahepatic hilar cholangiocarcinoma: A case report

Introduction and importanceA central hepatic bisectionectomy (CHBS) for a hilar cholangiocarcinoma (CCA) is technically challenging because bilateral biliary reconstruction is required after resection. On the other hand, hepatic artery resection and reconstruction in a major liver resection are also technical procedures. In this report, we describe our radical CHBS with hepatic artery and biliary tracts reconstruction for a patient with nodular type intrahepatic hilar CCA.Case presentationA 76-year-old man was referred for further investigation of an incidental hepatic tumor. The hepatic tumor was located from medial sector to anterior sector with encasement of the anterior branch of the right hepatic artery. Based on these findings, we performed a CHBS with right hepatic artery and biliary tracts reconstruction. The histopathological findings revealed that the tumor consisted of moderately differentiated tubular adenocarcinoma with tumor necrosis without a fibrous capsule. In this area, tumors cells had invaded branches of the hepatic vein; however, there was no destructive invasion to the hepatic artery. Consequently, he was diagnosed with a nodular type intrahepatic hilar CCA with pT2aN0M0.Clinical discussionA CHBS is usually performed with the intent of anatomically preserving a patient’s liver as much as possible. Concomitant resection and reconstruction of the hilar vessels and biliary tracts with CHBS is one of the most technically challenging procedures in liver resections.ConclusionA CHBS with hepatic artery and biliary reconstruction may be a promising alternative if expert surgeons perform it on strictly selected patients.