肝移植术后脾动脉窃血综合征3例

肝移植术（liver transplantation,LT）是治疗各种原因引起的终末期肝病的有效手段。随着近年来肝移植术的广泛发展,肝移植术后的诸多并发症逐渐被认识。     

原位肝移植术后脾动脉窃血综合征的介入治疗

原位肝移植（orthotopic liver transplantation，OLT）术后脾动脉窃血综合征（splenic artery steal syndrome，SASS）可导致肝动脉血流量低、灌注不足、血栓形成、闭塞，进而出现肝功能异常，甚至移植物失功。因此，早期诊断并正确治疗是预防并发症的关键所在。回顾性分析天津东方器官移植中心2005年1月1日至2005年12月31日1年期间内完成的647例行OLT术患者的临床资料，其中有4例发生SASS，并对其行介入治疗，现报告如下：     

肝移植术后脾动脉窃血综合征的超声诊断

目的  探讨超声诊断肝移植术后脾动脉窃血综合征(SASS)的价值。方法  通过对肝移植术后10例并发SASS患者(研究组)及术后肝功能恢复正常的8例患者(对照组)进行常规超声及超声造影检查, 总结SASS的超声表现。将研究组患者的数字减影血管造影术(DSA)检查结果与超声造影进行对比。结果  研究组二维超声见肝脏回声正常或肝内见多发细小坏死灶, 彩色多普勒血流显像(CDFI)可见肝动脉内血流信号稀少或呈星点状, 超声造影见移植肝肝动脉内造影剂增强信号微弱。肝动脉内径偏细, 脾动脉内径明显增粗。超声造影与DSA的诊断结果一致。结论  常规超声及超声造影应常规作为肝移植术后的可疑移植肝血管系统异常的无创检查手段, 具有较高的应用价值。     

亲体部分肝移植术后肝动脉栓塞的防治

目的 探讨亲体部分肝移植（LRLT）术后肝动脉栓塞（HAT）的预防和治疗。方法 于2001年1月至6月成功的对6例肝豆状核变性患者进行了亲体部分肝移植。术中重视肝动脉吻合技术；根据红细胞压积（HCT）控制输血量；术后根据B超检查肝动脉血流及凝血相结果，选择不同的血浆输注,并采用低分子肝素、华法令和低分子右旋糖酐等联合抗凝治疗。结果 6例肝移植后均健康存活，1例发生HAT，经急诊取栓并行肝动脉重建术后无效，再次肝移植后存活。结论 理想的肝动脉吻合、适当控制血制品和正确使用抗凝治疗，是预防LRLT后HAT的重要手段，一旦发生HAT，应急诊取栓，进行肝动脉重建术，甚至进行再次肝移植。     

肝移植术后脾动脉窃血综合征的诊断和处理(附1例报道)

肝移植术后的动脉窃血综合征虽不多见,却会导致肝脏和胆管的缺血性损伤。临床上可表现为肝功能相关酶水平的显著变化、移植物功能异常、胆管炎或肝移植术后的肝动脉血栓形成。窃血综合征可引起缺血性胆道损伤或移植物功能丧失,但移植界尚未对窃血综合征引起足够的重视。本文报道1例肝移植术后发生脾动脉窃血综合征的诊断和处理方法。     

原位肝移植后并发脾动脉窃血综合征四例

原位肝移植后的脾动脉窃血综合征（SASS）可导致肝动脉血流量低，灌注不足，血栓形成、闭塞，进而出现肝功能异常，甚至移植物功能丧失。我中心在2005年共完成肝移植641例，其中有4例发生SASS，现报告如下。     

脾动脉栓塞治疗成人间活体右半肝移植术后小肝综合征一例

病例 受体男，32岁。1998年发现慢性乙型肝炎、肝硬化、反复黄疸、腹水及食管静脉曲张出血。于2002年行经颈静脉门体分流术（TIPS），但症状无明显缓解，于2005年12月入住我院拟行成人间活体肝移植（LDLT）。     

肝移植术后脾动脉盗血综合征

动脉并发症是肝移植后导致移植物失功能及受体死亡的主要原因之一。本文回顾性分析解放军总医院67例肝脏移植中发生的3例肝移植术后脾动脉盗血综合征（splenic artery steal syndrome,SASS）的临床资料，以总结SASS的诊治经验。     

肝移植术后脾动脉盗血综合征治疗选择及安全性评价（附5例报告）

目的 分析肝移植术后脾动脉盗血综合征（SASS）不同时机治疗方式选择的临床效果,评价脾动脉栓塞的疗效及其安全性。方法 回顾性分析2004年1月至2013年12月武警总医院191例肝硬化、脾脏增大,术前脾动脉直径/肝动脉直径≥1.5、但术中肝动脉血流≥30 cm/s的肝移植病人SASS发生率及临床表现。根据确诊时机和程度分别采取脾动脉栓塞、肝动脉与脾动脉或腹主动脉重新吻合、脾动脉结扎或脾脏切除,比较4种处理方式的临床效果及安全性。结果 17例（8.9%）病人确诊为SASS,绝大多数（16/17,94.1%）发生在术后15 d内。5例急诊行脾动脉栓塞后肝总动脉血流［栓塞前（16.6±3.0）cm/s vs. 栓塞后（39.3±7.7）cm/s,P＜0.001］立即改善,阻力指数全部恢复到正常水平（0.5～0.8）,未观察到相关并发症。12例继发肝动脉血栓形成病人取出血栓或溶栓后行肝动脉与腹主动脉吻合（4例）、脾动脉结扎（3例）或脾切除（5例）;其中3例接受再次肝移植;2例因肝功能衰竭死亡。结论 SASS是肝移植术后严重并发症,及时诊断并行脾动脉栓塞是有效的补救措施,具有可靠的疗效和安全性。     

肝移植术后肝动脉栓塞的防治

目的 探讨肝移植术后肝动脉栓塞的预防和治疗。方法 于１９９６年５月至１９９９年５月成功地进行了５例同种异原位肝移植术,２例存在供肝动脉变异,经整形后成功地进行了吻合;术后采用肠溶阿司匹林,潘生丁和低分子右旋糖酐联合抗凝治疗。结果 无一例肝动脉栓塞发生;除第１例肝炎后肝硬化病人于术后７个月死于急性肝坏合并急性出血坏死性胰腺炎外,其余４例健康存活３６,３２,１８和２个月。结论 妥善的血管吻合和合理的术     

Splenic Artery Embolization for Splenic Artery Steal Syndrome After Living Donor Liver Transplantation: A Case Report

Splenic artery steal syndrome (SASS) has been considered a life-threatening complication to liver transplant recipients. Herein we timely diagnosed a case of SASS with deteriorating liver function. SASS was screened by routine Doppler ultrasonography (DUS) and multidetector computed tomography and was ultimately diagnosed by selective celiac trunk angiography. The patient was rescued by splenic artery embolization. In this case, routine DUS was useful to screen SASS. Signs of high-resistance hepatic artery waveform and low diastolic flow were highly suspected of SASS. This case also indicated that portal hyperperfusion was a cause of graft dysfunction in SASS. The study was in accordance with the Helsinki Congress and the Declaration of Istanbul, no prisoners were used, and participants were neither paid nor coerced in this study. Furthermore, we reviewed the recent literatures on the advances in the diagnosis and treatment of SASS. These studies suggest that splenic artery embolization may be a safe and effective technique to treat SASS. In addition, identification of recipients at high risk of SASS with preoperative computed tomography scans and DUS is recommended. Banding or ligation the splenic artery may be useful to prevent SASS and other potential complications after liver transplantation.     

活体肝移植小肝综合征的研究进展

目的 探讨在活体肝移植中小肝综合征发生的原因、预防及治疗方法.方法 复习国内、外近几年活体肝移植术后有关小肝综合征的相关报道.结果 供体年龄、脂肪肝程度、受体术前疾病状态(MELD评分)、术后高门静脉灌注、流出道不畅及移植物大小和质量对活体肝移植术后小肝综合征的发生起着重要作用,术前选择最佳的供体,术中的脾脏切除或脾动脉结扎或对门静脉限流,保证流出道的绝对通畅,术后及早发现并积极治疗能显著减少小肝综合征的发生.结论 小肝综合征的危险因素是可以预测的,积极的应对措施可以用于小肝综合征的预防与治疗.     

Increasing Donor Body Weight to Prevent Small-for-Size Syndrome in Living Donor Liver Transplantation

Background  

This study was designed to evaluate the possibility of avoiding small-for-size syndrome (SFSS) in living donor liver transplantation (LDLT) by increasing the donor’s body weight (BW) before liver donation.     

Splenic Artery Transposition for Arterial Reconstruction in Living Donor Liver Transplantation

PurposeIn living donor liver transplantation, poor compatibility of the recipient hepatic artery remains a technical challenge. Here, we analyzed our 14 years of experience with extra-anatomic hepatic artery reconstruction.MethodsBetween July 2004 and December 2018, there were 1063 liver transplantations at our center. All patients with an extra-anatomic hepatic artery reconstruction were identified. The gastroduodenal artery and the transposed splenic artery were the primary options for extra-anatomic arterial reconstruction. Patient characteristics, operative data, and post-transplant outcome were reviewed retrospectively.ResultsThere were 22 patients with extra-anatomic hepatic artery reconstruction, 6 with gastroduodenal artery, and 16 with splenic artery. There were 2 major complications: 1 patient underwent early reoperation due to bleeding from the splenic artery trunk and another had an iatrogenic injury to the transposed splenic artery during conversion hepaticojejunostomy. Both were treated successfully with surgery. One patient died perioperatively due to sepsis. The 1- and 3-year graft survival rates of these 16 patients were 93.7% and 87.5%.ConclusionIf the hepatic arteries are not suitable for anastomosis, then we consider the gastroduodenal artery and the splenic artery to be the conduits of choice for extra-anatomic arterial reconstruction. The transposed splenic artery is very consistent, easily accessible, and offers adequate length and diameter for successful arterial anastomosis.     

Open Thoracic Drainage Followed by Proximal Splenic Artery Embolization for Massive Hydrothorax Before Living Donor Liver Transplantation

BackgroundHepatic hydrothorax is associated with postoperative infectious complications and mortality in patients undergoing living-donor liver transplantation (LDLT). Thus, preoperative management of massive hepatic hydrothorax is essential for improving the outcomes of LDLT. This study aimed to demonstrate our successful cases and strategy for treating massive hepatic hydrothorax.MethodsOur strategy for hepatic hydrothorax includes (a) mini-thoracotomy under general anesthesia for the drainage of hydrothorax, (b) preoperative hepatic inflow modulation by proximal splenic arterial embolization, and (c) nutritional and physical intervention to improve the general condition.ResultsTwo patients with massive hepatic hydrothorax were treated with our strategy. Both patients had end-stage liver disease secondary to primary biliary cholangitis. Their performance status deteriorated due to massive hydrothorax. After the intervention, their performance status significantly improved. After that, LDLTs with right lobe grafts were performed. The duration of the operation was 440 and 343 minutes, with an intraoperative blood loss of 1,700 and 1,600 g, respectively. Their postoperative courses were uneventful, and they were discharged on postoperative days 16 and 14.ConclusionOur pre-LDLT multimodal management strategy for massive hepatic hydrothorax, including preoperative open thoracic drainage, pre-LDLT portal inflow modulation, and nutritional intervention, improved the preoperative condition of patients undergoing LDLT, resulting in successful outcomes.     

肝移植术后肝动脉血栓的防治(附2例报告)

目的探讨肝移植术后肝动脉血栓的防治方法，以降低其发生率。方法对52例（53例次）肝移植手术后发生肝动脉血栓的2例患者的临床资料进行回顾性总结。结果该2例患者均为乙肝肝硬变合并巨块型肝癌，术中发现受体肝动脉内膜及外膜管壁硬化，血管弹性差，内外膜间隙较大，供、受体肝动脉直径稍有差距，致血管内膜对合不好，造成吻合口扭曲、皱折等，从而导致术后肝动脉血栓形成，2例患者术后均经彩超检查确诊。结论对肝移植术后肝动脉血栓的形成应以预防为主，肝移植术后应常规用彩超监测肝动脉血流，一旦发现肝动脉血栓，应立即行肝动脉溶栓、取栓和重新吻合术。     

成人原位活体部分肝移植4例报告

目的 :报道成人活体部分肝移植的临床经验。方法 :回顾性研究 4例临床资料。结果 :所有病人年龄均大于 18岁 ;2例施行左半肝移植术 ,2例施行右半肝移植术。供体平均手术时间大约 7h ,平均失血量为 40 0ml,无一发生术后并发症。受体平均手术时间是 6 .8h ,移植肝重量介于 34 0 g～ 870g ,移植肝重量与体重的比例介于 0 .80 %～ 0 .91%;1例发生肝动脉部分栓塞 ,3个月后因胆道并发症而再次行原位移植 ,无近期手术死亡率。结论 :无论左半肝还是右半肝移植术 ,均能达到较好疗效 ,为成年病人的肝移植提供了新的供肝来源和选择。     

Liver “Compliance”: A Previously Unrecognized Preoperative Predictor of Small-for-Size Syndrome in Adult Living Donor Liver Transplantation

Background

The purpose of this study was to investigate the effect of liver compliance on computed tomography (CT) volumetry and to determine its association with postoperative small-for-size syndrome (SFSS).

Patients and methods

Unenhanced, arterial, and venous phase CT images of 83 consecutive living liver donors who underwent graft hepatectomy for adult-to-adult living donor liver transplantation (ALDLT) were prospectively subjected to three-dimensional (3-D) CT liver volume calculations and virtual 3-D liver partitioning. Graft volume estimates based on 3-D volumetry, which subtracted intrahepatic vascular volume from the “smallest” (native) unenhanced and the “largest” (venous) CT phases, were subsequently compared with the intraoperative graft weights. Calculated (preoperative) graft volume-to-body weight ratios (GVBWR) and intraoperative measured graft weight-to-body weight ratios (GWBWR) were analyzed for postoperative SFSS.

Results

Significant differences in minimum versus maximum total liver volumes, graft volumes, and GVBWR calculations were observed among the largest (venous) and the smallest (unenhanced) CT phases. SFSS occurred in 6% (5/83) of recipients, with a mortality rate of 80% (4/5). In four cases with postoperative SFSS (n = 3 lethal, n = 1 reversible), we had transplanted a small-for-size graft (real GWBWR < 0.8). The three SFS grafts with lethal SFSS showed a nonsignificant volume “compliance” with a maximum GVBWR < 0.83. This observation contrasts with the seven recipients with small-for-size grafts and reversible versus no SFSS who showed a “safe” maximum GVBWR of 0.92 to 1.16.

Conclusion

The recognition and precise assessment of each individual's liver compliance displayed by the minimum and maximum GVBWR values is critical for the accurate prediction of functional liver mass and prevention of SFSS in ALDLT.     

En Bloc Liver Kidney Transplantation Using Donor Splenic Artery as Inflow to the Kidney: Report of Two Cases

The number of simultaneous liver–kidney transplants has been increasing. This surgery is associated with an increased risk of complications, longer duration of surgery and longer ischemia time for the renal allograft. Two patients listed for liver–kidney transplant at our center underwent en bloc combined liver–kidney transplantation using donor splenic artery as inflow. Patient 1 previously underwent cardiac catheterization that was complicated by a bleeding pseudoaneurysm of the right external iliac artery that required endovascular stenting of the external iliac artery and embolization of the inferior epigastric artery. Patient 2 was on vasopressor support and continuous renal replacement therapy at the time of transplant. In this paper, we described a novel technique of en bloc liver–kidney transplant with simultaneous reperfusion of both allografts using the donor splenic artery for renal inflow. This technique is useful for decreasing cold ischemia time and total operative time by simultaneous reperfusion of both allografts. It is a useful technical variant that can be used in patients with severe disease of the iliac arteries.     

Wilson Disease With Giant Splenic Artery Aneurysms Caused by Fibromuscular Dysplasia During Living Donor Liver Transplantation: A Case Report

Liver cirrhosis can cause splenic artery aneurysms (SAA) that pose a threat to patients undergoing liver transplantation. However, liver transplantation with multiple visceral artery aneurysms including giant SAA caused by arterial fragility has never been reported. We describe a 36-year-old man with decompensated liver cirrhosis due to Wilson disease that was complicated by giant SAA and multiple aneurysms in the bilateral renal arteries caused by fibromuscular dysplasia (FMD). The maximal diameter of the triple snowball-shaped SAA was 11 cm. We planned a 2-stage strategy consisting of a splenectomy with distal pancreatectomy to treat the SAA and subsequent living donor liver transplantation (LDLT) to address the liver cirrhosis. This strategy was selected to prevent fatal postoperative infectious complications caused by the potential development of pancreatic fistula during simultaneous procedures and to histopathologically diagnose the arterial lesion before LDLT to promote safe hepatic artery reconstruction. However, a postoperative pancreatic fistula did not develop after a splenectomy with distal pancreatectomy, and the pathologic findings of the artery indicated FMD. The patient underwent ABO-identical LDLT with a right lobe graft donated by his brother. Other than postoperative rupture of the aneurysm in the left renal artery requiring emergency interventional radiology, the patient has remained free of any other arterial complications and continues to do well at 2 years after LDLT.