附加腔静脉成形的背驮式原位肝移植术

目的　探讨腔静脉成形术在背驮式原位肝移植中的应用价值及在防止移植肝流出道阻塞并发症中的作用。方法　 3例终末期肝病病人选为肝移植受者。供肝的下腔静脉及受体的肝后下腔静脉 (包括肝静脉 )均作了成形术 ,在单独股 -腋静脉转流术下行改良背驮式肝移植术。结果　 3例病人术中均较平稳 ,手术时间和无肝期缩短 ,出血量减少 ,术后肝功能恢复快 ,恢复顺利 ,无并发症发生。结论　腔静脉成形术可防止背驮式肝移植肝静脉流出道阻塞 ,术中对受体的血流动力学干扰小 ,并可缩短无肝期和减少腔静脉梗阻并发症的发生。     

Replacement of the retrohepatic vena cava in segmental liver transplantation

Reduced grafts represent an important technical development in paediatric liver transplantation. The use of a left lateral segment graft has required preservation of the native inferior vena cava to “piggy-back” the graft onto it. We report four children who underwent left lateral segment transplantation with caval replacement using the donor iliac vein because the native retrohepatic inferior vena cava was small, friable or difficult to preserve. There were no caval or hepatic vein complications post-transplant and the donor iliac vein proved to be a satisfactory interpositional graft. The technique offers the advantages of a wider retrohepatic cava avoiding venous outflow or caval obstruction, provides good tissue to suture and is well suited for the triangulation technique of the left hepatic vein. Received: 24 January 1997 Received after revision: 20 June 1997 Accepted: 30 June 1997     

Liver transplantation: experience with our first 100 cases

OBJECTIVES: Our goal was to evaluate the results of the first 100 liver transplants performed in our institution. METHODS: We retrospectively analyzed the first 100 liver transplants undertaken in adults from November 2001 to August 2005. RESULTS: The mean age of the recipients was 50 years (20 to 69) and 73% were men. The mean waiting time was 35 days. The mean age of the donors was 60 years (15 to 87), and 60% were men. One-year patient and graft survival rates were 93% and 90%, respectively. Three-year patient and graft survival rates were 85% and 82%, respectively. The need for retransplantation was 3%. Surgical complications included hepatic artery stenoses, 2%; hepatic artery thromboses, 2%; biliary leaks, 6%; and biliary stenoses, 14%. CONCLUSIONS: These results are no different from the overall results for liver transplantation in Spain during the same period.     

乌司他丁对腔静脉成形肝移植术肾功能的保护作用

目的观察腔静脉成形肝移植术患者肾功能的变化与乌司他丁对肾功能的保护作用。方法71例腔静脉成形肝移植术患者,随机给予乌司他丁30万IU或等量生理盐水,持续静脉输注1h,新肝期再重复一次。根据腔静脉平均阻断时间分成≤62min组,其中用乌司他丁23例(U1组)、生理盐水18例(C1组);>62min组,其中用乌司他丁13例(U2组)、生理盐水17例(C2组)。监测血流动力学、血气、生化指标、肾功能指标、凝血功能、体温、尿量及出血量等。结果下腔静脉阻断(IVC)时间为(62.3±11.2)min。与术前相比,所有患者术后24h血尿素氮(BUN)明显升高(P<0.01),血肌酐(Cr)在新肝期1h、术毕、术后24h均明显升高(P<0.01)。术后24hBUN、CrU1组明显低于C1组(P<0.01),U2组亦明显低于C2组(P<0.01)。而U1与U2组、C1与C2组BUN、Cr差异无统计学意义。结论腔静脉成形术肝移植术对肾功能有明显损伤,术中使用乌司他丁对肾脏有一定程度的保护作用。     

Resection and reconstruction of the retrohepatic vena cava in combination with liver resections

Liver resection combined with the resection and reconstruction of the vena cava represents the only potential curative therapy for malignant hepatic tumors with invasion of the vena cava. We performed a liver resection with segmental replacement of the retrohepatic vena cava by synthetic grafts in 29 patients. In three cases, the additional presence of central involvement of all three hepatic veins required ex situ tumor resection. Four patients underwent a simultaneous exstirpation of the primary tumor (kidney or suprarenals). The remaining hepatic veins were reimplanted into the graft in three cases, and in two cases the renal veins were reimplanted. There was no perioperative mortality. A distal arteriovenous fistula was not applied. Five patients revealed postoperative transient liver insufficiency, requiring temporary dialysis in three cases. Two of these patients developed a transient multiorgan failure with the need of mechanical ventilation. 18 patients died during the course of follow-up, 17 of these cases due to recurrent metastases of the primary disease. Infection or thrombosis of the prosthetic vascular graft have not been observed. Beside tumor exstirpation, extended liver resection and concomitant vena cava replacement may prevent embolism as well as the obstruction of the vena cava with lower extremity swelling and the possibility of developing a Budd Chiari syndrome. We were able to achieve a long-term survival for surgically treated patients even in cases with advanced tumor stages.     

游离肝后下腔静脉行右肝切除77例体会

目的 探讨肝后下腔静脉手术游离方法.方法 解剖暴露77例肝后下腔静脉右侧壁并游离其后壁.结果 77例右肝均部分翻转于切口外,术后顺利恢复.结论 切断右肾上腺是游离肝后下腔静脉的关键;暴露肝后下腔静脉右侧壁是充分游离右肝的技术标准之一.     

The first clinical experience with orthotopic transplantation of the liver

The article deals with material concerning the performance of 4 operations for orthotopic liver transplantation (OLT). The operations were carried out on 2 males and 2 females whose ages ranged from 20 to 52 years. The indications for OLT were as follows: ++hemangioendothelioma of the liver, hepatocellular carcinoma, cirrhosis-carcinoma of the liver, and metastatic affection of the liver. One male patient died immediately after the end of the operation, another patient died 3 days after the operation due to nonfunctioning of the transplant. In 2 female patients the operations were carried out successfully. One of them was discharged from the clinic in 62 days in a satisfactory conditions and a well functioning transplant. The other patient died from a complication which was not connected with the operation--perforation of the small intestine 69 days after OLT. The technical aspects of and the provision for the operation and the postoperative management of patients are discussed. The encountered complications are analysed.     

Hepatic artery graft in pediatric liver transplantation: single-center experience with 58 cases

Introduction

The use of arterial grafts (AG) in pediatric orthotopic liver transplantation (OLT) is an alternative in cases of poor hepatic arterial inflow, small or anomalous recipient hepatic arteries, and retransplantations (re-OLT) due to hepatic artery thrombosis (HAT). AG have been crucial to the success of the procedure among younger children. Herein we have reported our experience with AG.

Methods

We retrospectively reviewed data from June 1989 to June 2010 among OLT in which we used AG, analyzing indications, short-term complications, and long-term outcomes.

Results

Among 437 pediatric OLT, 58 children required an AG. A common iliac artery interposition graft was used in 57 cases and a donor carotid artery in 1 case. In 38 children the graft was used primarily, including 94% (36/38) in which it was due to poor hepatic arterial inflow. Ductopenia syndromes (n = 14), biliary atresia (BA; n = 11), and fulminant hepatitis (n = 8) were the main preoperative diagnoses among these children. Their mean weight was 18.4 kg and mean age was 68 months. At the mean follow-up of 27 months, multiple-organ failure and primary graft nonfunction (PNF) were the short-term causes of death in 9 children (26.5%). Among the remaining 29 patients, 2 (6,8%) developed early graft thrombosis requiring re-OLT; 5 (17%) developed biliary complications, and 1 (3.4%) had asymptomatic arterial stenosis. In 20 children, a graft was used during retransplantation. The main indication was HAT (75%). BA (n = 15), ductopenia syndromes (n = 2), and primary sclerosing cholangitis (n = 2) were the main diagnoses. Their mean weight was 16.7 kg and age was 65 months. At a mean follow-up of 53 months, 7 children died due to multiple-organ failure or PNF. Among the remaining 13 patients, 3 developed biliary complications and 1 had arterial stenosis. No thrombosis was observed.

Conclusion

The data suggested that use of an AG is useful alternative in pediatric OLT. The technique is safe with a low risk of thrombosis.     

肝上腔静脉成形术联合肝后腔静脉扩展术在肝移植中的应用:首次115例经验报道

目的：本文介绍原位肝移植中腔静脉成形术的方法并评估其结果。方法：1994年11月至2000年9月，我们对连续115例原位肝移植9包括6例左外侧叶及2例右叶移植）病人采用了腔静脉成形术。在起初的4年里，53例（66．3％）移植病人需行股－腋静脉体外转流，而以后的2年内该比例降至8例（22．9）％。无一例病人需中转为背驮式或经典术式。结果：中位手术时间4.5h，中位热缺血时间25min，中位输血量6U浓缩红细胞。上述结果在首次移植及再次移植间无差异。本组无与腔静脉成形技术相关的围手术期死亡。包括活体原位肝移植在内，均未观察到肝静脉流比道梗阻。没有病人因急性肾功能衰竭而需术后血透。病人留置于ICU的中位天数2d，中位住院天数为10d。结论：腔静脉成形术无需解剖肝后腔静脉，肝静脉或肝短静脉，肝下腔静脉也得以保留，并因此更有利于肝切除术维持稳定的血流动力学，在再次移植中优势更为明显。大开口的三角形腔静脉吻合容易操作，能在较三时间内完成供肝植入，且易与吻合血管口径的匹配，并可避免流出道阻塞。操作时间的缩短头了静脉体外转流的可能。我们认为腔静脉成形技术能适用于所有病人，且相应手术的并发症少。     

Isolated azygos continuation of the inferior vena cava. (Absence of the retrohepatic segment of the inferior vena cava)

The isolated azygos continuation of the inferior vena cave is a very rare variation of this organ. It is accompanied by the absence of the retrohepatic segment of the vena cava with two new observations, the literature is revised and the origin discussed.     

Comparison of surgical methods in liver transplantation: retrohepatic caval resection with venovenous bypass (VVB) versus piggyback (PB) with VVB versus PB without VVB

Use of piggyback technique (PB) and elimination of venovenous bypass (VVB) have been advocated in adult liver transplantation (LT). However, individual contribution of these two modifications on clinical outcomes has not been fully investigated. We performed a retrospective review of 426 LTs within a 3‐year period, when three different surgical techniques were employed per the surgeons’ preference: retrohepatic caval resection with VVB (RCR + VVB) in 104 patients, PB with VVB (PB + VVB) in 148, and PB without VVB (PB‐Only) in 174. The primary outcomes were intraoperative blood transfusion and the patient and graft survivals. Demographic profiles were similar, except younger recipient age in RCR + VVB and fewer number of grafts with cold ischemic time over 16 h in PB‐Only. PB‐Only required lesser intraoperative red blood cells (P = 0.006), fresh frozen plasma (P = 0.005), and cell saver return (P = 0.007); had less incidence of acute renal failure (P = 0.001), better patient survival (P = 0.039), and graft survival (P = 0.003). The benefits of PB + VVB were only found in shortened total surgical time (P = 0.0001) and warm ischemic time (P = 0.0001), and less incidence of acute renal failure (P = 0.001) than RCR + VVB. PB‐Only method seemed to provide the best clinical outcome. The benefit of PB was not fully achieved when it was used with VVB.     

Orthotopic liver transplantation with preservation of the inferior vena cava.

Piggyback orthotopic liver transplantation was performed in 24 patients during a period of 4 months. This represented 19% of the liver transplantation at our institution during that time. The piggyback method of liver insertion compared favorably with the standard operation in terms of patient survival, blood loss, incidence of vascular and biliary complications, and rate of retransplantation. The piggyback operation cannot be used in all cases, but when indicated and feasible its advantages are important enough to warrant its inclusion in the armamentarium of the liver transplant surgeon.     

ABO血型不合肝移植20例单中心经验

目的 总结我院开展的共20例ABO血型不符的肝移植病例,并探讨同类患者可能的治疗方案.方法 2009年1月至2011年7月,我院共实施ABO血型不符肝移植20例,其中ABO血型不相容(ABO-incompatible,ABO-Ⅰ)16例,ABO血型相容(ABO-compatible,ABO-C)4例,中位随访时间为(13.3±9.2)m.结果 除术前MELD评分外,ABO-C及ABO-Ⅰ组围手术期其他资料、术后并发症发生率及累积生存率比较差异无统计学意义.20例患者中死亡5例(ABO-C组2例,ABO-Ⅰ组3例),1年生存率75％.死亡原因为围手术期多器官衰竭2例,肝癌复发2例,脑出血1例.ABO-Ⅰ组术后发生排斥反应2例,术后远期出现胆道并发症3例,术后发生门静脉血栓3例.20例患者中,术后早期发生血肌酐升高共11例,发生率55％,其中6例术前即有血肌酐升高,此6例患者术后血肌酐升高时间均超过7d,其余7例患者血肌酐水平均在术后7d内降至正常.结论 门静脉血流复通前行脾脏切除术,应用巴利昔单抗+他克莫司+霉酚酸酯+皮质激素的四联免疫抑制方案,术后静脉应用前列地尔的治疗方案,对于有选择性的ABO血型不合肝移植患者可取得较好疗效.     

肾癌并发下腔静脉癌栓的诊断与治疗

目的：提高对肾癌并发下腔静脉癌栓的诊断及治疗经验。方法：分析8例肾癌并发下腔静脉癌栓的诊断方法及治疗措施。结果：术前已明确诊断6例,8例均经手术治疗,1例术中死亡,余7例手术成功。结论：手术切除肾癌并取出癌栓是目前有望治愈的方法之一,手术方式的选择取决于癌栓的大小及部位。手术风险大、难度大,必须警惕癌栓的脱落。     

活体供肝肝移植成功的初步经验--附3例报告

目的 报告3例活体供肝肝移植成功的初步经验。方法 回顾性分析1例肝细胞癌伴肝硬化、1例先天性肝内胆汁淤积症及1例药物性肝炎病人活体供肝肝移植经过和供受体恢复情况。结果 供肝均取自病人父亲，1例为右半肝，另2例为扩大左外叶，供肝重量分别为835g、295g及320g。第1例供体术后有一过性黄疸，且有轻度胆漏，另2例供体术后恢复顺利，无手术并发症。3例病人手术均顺利，1例成人一成人活体供肝肝移植胆道重建为胆管端端吻合，术后定期行全身化疗预防肿瘤复发。2例成人-儿童活体供肝肝移植胆道重建为胆管、空肠Roux-en-Y吻合。3例病人均行肝静脉整形以保证静脉回流通畅。随访至今，供受体已分别健康生存16、14、13个月。结论 严格的病例选择，完善的术前准备，精细的手术操作及正确的术后处理是活体供肝肝移植成功的关键。