外翻式门静脉血栓切除术在肝移植术中的应用

目的 探讨肝移植术中门静脉血栓切除技术的改进.方法 回顾性分析天津市第一中心医院移植外科收治的合并门静脉血栓(PVT)的198例肝移植患者的临床资料,根据术中PVT的处理方法不同分为两组:A组为常规外翻式门静脉血栓切除术组(n=43),B组为不切断PVT的外翻式门静脉血栓切除术组(n=155).分别比较两组患者术中一般情况、失血量、血栓切除成功率、PVT复发率及患者生存情况等指标.结果 两组手术时间无明显差异(P>0.05).两组Yerdel Ⅰ级及Ⅱ级患者血栓切除成功率均为100%;B组中Yerdel Ⅲ级患者血栓切除成功率较A组高(100%比45.4%;X~2=12.38,P<0.01).B组失血量较A组明显减少[(4315.4±630.5)ml比(3509.2±862.7)ml,P<0.05].B组Yerdel Ⅰ～Ⅱ级PVT患者术后血栓复发率与A组相比差异无统计学意义(P>0.05),而Yerdel Ⅲ级患者术后血栓复发率低于A组(5.6%比2/5;X~2=4.09,P<0.05);两组Yerdel Ⅰ～Ⅲ级PVT患者围手术期病死率均为0,差异无统计学意义(P>0.05).两组YerdelⅠ～Ⅲ级PVT患者1年生存率的差异无统计学意义(86.5%比89.O%,P>0.05).结论 不切断PVT的外翻式门静脉血栓切除术可以简化手术操作,减少术中出血量,扩大应用范围,提高血栓切除的成功率,降低术后血栓复发率.     

肝移植治疗终末期肝病合并门静脉血栓的临床研究

目的 总结分析肝移植中门静脉血栓(PVT)的处理经验以及PVT对肝移植术后疗效的影响.方法 总结1995年5月至2007年9月194例接受肝移植手术的患者的临床资料,其中术前存在PVT 24例(12.4%),Ⅰ级12例、Ⅱ级9例、Ⅲ级2例、Ⅳ级1例.根据血栓程度分级采取不同的方式进行门静脉重建.术后根据凝血酶原时间(PT),应用普通肝素或低分子肝素预防性抗凝.术后应用多普勒超声监测门静脉血供.选取同期接受肝移植手术的无PVT的170例患者作为对照组,比较两组手术过程和预后的差别.结果 21例Ⅰ级、Ⅱ级血栓患者行血栓切除术,2例Ⅲ级血栓患者行髂静脉-肠系膜上静脉搭桥,1例Ⅳ级血栓患者将供肝门静脉和受者粗大的门静脉属支吻合.有PVT组比无PVT组手术时间和住院时间长,输血量多,术后PVT的再发率高(P<0.05),但并发症发生率、围手术期病死率和术后1年生存率两组间无差别(P>0.05).PVT组有2例术后血栓再发,经放射介入治疗治愈.结论 术前PVT的存在增加了肝移植手术的难度和术后PVT的再发率,但对肝移植的预后没有影响.     

术前门静脉血栓对终末期肝硬化患者行肝移植手术的影响

目的探讨术前门静脉血栓对终末期肝硬化患者行肝移植的影响。方法回顾性分析2007年1月至2011年12月在中山大学附属第三医院器官移植中心接受肝移植手术的182例终末期肝硬化患者的临床资料。将合并门静脉血栓的13例(Yerdel分级Ⅰ级3例,Ⅱ级6例,Ⅲ级2例,Ⅳ级2例)患者作为门静脉血栓组,其余169例无门静脉血栓的患者作为对照组。比较两组患者肝移植术中和术后情况。结果与对照组比较,门静脉血栓组的手术时间和术中出血量较多(均为P0.05),Ⅲ~Ⅳ级血栓者的手术时间和术中出血量亦较多(均为P0.05)。术后1个月,门静脉血栓组发生门静脉血栓1例(8%),对照组发生3例(2%),两组比较差异有统计学意义(P0.05)。门静脉血栓组术后3年存活率为46%(6/13),对照组相应为84%(142/169),两组比较差异有统计学意义(P0.05)。结论Ⅲ~Ⅳ级门静脉血栓会明显增加肝移植手术难度和风险,但只要术前严格评估门静脉血栓情况,术中采用合理的门静脉重建方式,依然可以取得良好的疗效。     

肝移植中合并门静脉血栓的诊断及处理

目的 探讨肝移植中合并门静脉血栓的诊断和处理。方法 采用回顾性分析的方法分析了我院自2001年6月1日至2003年1月30日的158例肝移植病例。结果 158例肝移植病人中26例(16.5%)术中确认有门静脉血栓形成。其中9例Ⅰ级;11例Ⅱ级;5例Ⅲ级;1例Ⅳ级。对Ⅰ、Ⅱ级的门静脉血栓中3例施行了血栓切除术、16例施行取栓术、1例行门静脉左支吻合;5例Ⅲ级血栓中,远端肠系膜上静脉作为流入道,通过利用供体的髂静脉进行了搭桥术;对Ⅳ级血栓,尝试利用其他的内脏静脉进行吻合。病人术后6个月存活率:门静脉血栓组24／26,对照组114／132(P>0.05)。结论 对于肝移植合并门脉血栓的病人,准确的术前诊断、合理的术式选择在很大程度上影响病人的预后。     

肝移植时门静脉的血栓内膜剥脱术

门静脉血栓 (PVT)形成是原位肝移植的禁忌证 ,但终末期肝病的患者有 2 %～ 19%并发此症 ,随着技术的提高 ,使有 PVT患者的肝移植成为可能。作者单位于 1984 .12～ 1999.10共行 15 46例原位肝移植 ,其中 85例行肝门静脉血栓内膜剥脱术。手术方式 :结扎切断胆总管及肝动脉后 ,将门静脉显露清楚 ,确定门静脉内血栓的范围及门体分流的开口 ,近肝门结扎门静脉左右支 ,用两把扁桃体钳撑开门静脉 ,分离血栓及静脉内膜 ,然后钳夹住血栓近端 ,左右转动 ,尽可能将远处的血栓取出 ,使门静脉、肝静脉、肠系膜上静脉血流通畅。门静脉吻合时 ,尽可能多…     

肝移植中门静脉血栓的处理经验

目的 探讨肝移植术中门静脉血栓的几种处理方法及其疗效.方法 回顾性分析773例次肝移植临床资料.773例中,107例病人有门静脉血栓,其中59例Ⅰ级;33例Ⅱ级;12例Ⅲ级;3例Ⅳ级.Ⅰ、Ⅱ级组行血栓切除或取栓术;Ⅲ级采用取栓术或肠系膜上静脉架桥的方式重建供肝门静脉;对Ⅳ级采用改良门腔静脉半转位术和门静脉胃冠状静脉吻合重建供肝门静脉.结果 Ⅰ、Ⅱ级组移植肝功能恢复良好,围手术期病死率为4.3%.Ⅲ级取栓组5例肝功能恢复良好,围手术期无死亡.静脉架桥组7例中有2例肝功能恢复不佳,围手术期病死率为28.6%.Ⅳ级组肝功能恢复良好,围手术期无死亡.结论 门静脉血栓已非肝移植禁忌证,根据血栓的不同情况采取合理的手术方式重建门脉系统可以获得良好的治疗效果.     

77例肝移植门静脉血栓处理经验

目的探讨肝移植术中门静脉血栓的处理方法及其对肝移植疗效的影响。方法回顾性分析598例次肝移植临床资料,77例（占12．9％）患者有门静脉血栓,其中39例系Ⅰ级,24例系Ⅱ级,12例系Ⅲ级,2例系Ⅳ级。对Ⅰ,Ⅱ级的门静脉血栓患者施行血栓切除或取栓术;Ⅲ级血栓患者采用取栓术或肠系膜上静脉架桥的方式重建供肝门静脉;对Ⅳ级血栓采用改良的门腔静脉半转流术。结果Ⅰ,Ⅱ级血栓组移植肝功能恢复良好,围手术期死亡率为6．3％（4／63）,Ⅲ级血栓组取栓5例肝功能恢复良好,围手术期无死亡（0／5）,静脉架桥组7例中有2例肝功能恢复不佳,围手术期死亡率为28．6％（2／7）,Ⅳ级血栓组肝功能恢复良好,围手术期无死亡（0／2）。结论门静脉血栓已非肝移植的禁忌证,根据血栓的不同情况采取合理的手术方式可以使患者获得良好的治疗效果。     

肝移植门静脉血栓形成的预防和治疗

目的总结原位肝移植门静脉血栓形成（PVT）的预防和治疗经验，提高肝移植疗效和受者存活率。方法分析1995年5月至2005年9月实施的137例肝移植临床资料，肝移植术前存在门静脉血栓10例，其中Ⅰ级5例，Ⅱ级4例，Ⅲ级1例，肝移植术中均行门静脉血栓切除术，结扎术前存在的门腔分流和粗大的侧支循环。术后根据凝血酶原时间（PT），应用普通肝素或低分子肝素预防性抗凝。术中、术后应用多普勒超声监测门静脉血供。结果137例患者肝移植术后PVT发生率为2．92％（4／137）。1例PVT经外科门静脉取栓、重新吻合治愈，2例经皮肝穿刺门静脉造影置管溶栓、支架植人治愈，另1例仅表现肝功能轻度异常，未经特殊处理。与PVT相关的死亡率为0。其余患者随访2～66个月，未发生PVT。结论肝移植术中完整地切除门静脉存在的血栓、结扎门腔存在的分流以及术后有效的抗凝治疗可以减少PVT的发生；多普勒超声监测能早期发现PVT，挽救移植物的功能，避免再次移植。     

术前脾切除对原位肝移植的影响及对策

目的 探讨术前脾切除对原位肝移植的影响及对策.方法 上海交通大学医学院附属瑞金医院2002年6月至2005年12月共行肝移植185例,其中术前有脾切除史者14例,对该14例病人的临床资料进行回顾性分析.结果 14例病人中单纯脾切除1例,脾切除加断流术9例,脾切除加脾肾分流3例,脾切除加脾腔分流1例.14例病人中,并发门静脉血栓(PVT)5例,占35.7%,明显高于其它171例病人的7.1%(P＜0.01),其中Ⅱ级2例,Ⅲ级3例.术中行血栓切除术1例,血栓剥脱术4例;4例门体分流者中,分流阻断3例,另1例未能阻断.术后2例病人PVT复发,经溶栓治疗血栓消失,但其中1例术后30个月PVT再次复发.结论 术前脾切除易导致PVT的形成,给原位肝移植手术及术后处理带来困难,准确的术前评估、正确的术中及术后处理是减少不利因素的关键.     

肝移植中门静脉血栓形成的处理

目的：探讨肝移植术中门静脉血栓形成的处理方法并评价其对肝移植疗效的影响。方法：回顾性分析246例良性终末期肝病行肝移植的临床资料，并结合文献进行讨论。结果：31例（12．6％）病人术中确认有门静脉血栓形成。其中14例I级；8例Ⅱ级；7例Ⅲ级；2例Ⅳ级。I、Ⅱ级的门静脉血栓病人施行了血栓切除或取栓术：Ⅲ级血栓病人采取供者髂静脉在供肝门静脉与受者肠系膜上静脉间架桥的方式重建供肝门静脉循环：对Ⅳ级血栓，采用了改良的门腔静脉半转流术。病人术后6个月死亡率：门静脉血栓组6．5％，无门静脉血栓组7．4％（P＞0．05）。结论：术前存在的门静脉血栓已非肝移植的绝对禁忌证，根据血栓的不同情况采取合理的手术方式可以使病人获得良好的治疗效果。     

肝移植围手术期门静脉血栓的处理

目的 探讨肝移植围手术期门静脉血栓（PVT）的处理。方法 回顾性分析中国医科大学附属第一医院1995年5月至2008年6月实施的194例肝移植病人临床资料,术前存在PVT 24例,其中Ⅰ级12例,Ⅱ级9例,Ⅲ级2例,Ⅳ级1例。术中采取不同门静脉重建方式,结扎术前存在的门腔分流和粗大的侧支循环。术后根据凝血酶原时间（PT）,应用普通肝素或低分子质量肝素预防性抗凝。术中、术后应用多普勒超声监测门静脉血供。结果 术后PVT发生率2.58%（5/194）。1例PVT经外科门静脉取栓、重新吻合治愈,3例置管溶栓、支架植入治愈,另1例仅表现肝功能轻度异常,未特殊处理。与PVT相关病死率为0。其余病例随访6~ 104个月,未见PVT。结论 理想的门静脉重建方式、结扎门腔存在的分流和术后有效的抗凝可以减少PVT的发生,多普勒超声监测能早期发现PVT,挽救移植物,避免再移植。     

Single-Center Experience of 253 Portal Vein Thrombosis Patients Undergoing Liver Transplantation in China

Objective

We sought to review the etiopathogenesis, diagnosis, and surgical options for 253 patients with portal vein thrombosis (PVT) undergoing orthotopic liver transplantation (OLT) to assess the the impact of PVT on outcomes.

Methods

We retrospectively analyzed the data from 2508 adult patients undergoing 2614 OLTs in our center from September 1998 to July 2007. PVT was scorded according to the operative findings and Yerdel grading of PVT. No prisoners were used as donors for this study.

Results

Two hundred fifty-three patients were diagnosed with PVT (10.09%): there were 104 grade I; 114, grade II; 29, grade III; and 6, grade IV PVT. Sex and previous splenectomy increased the risk for PVT. In grade I and II cases, we performed simple thrombectomy, eversion thrombectomy, or improved eversion thrombectomy (IET, innovated by our center), producing smooth postoperative recoveries with a 0% in-hospitality mortality. In grade III cases, 18 underwent successful IET. Of 11 subjects who had eversion thrombectomy, six failed, and the distal superior mesentery vein or dilated splanchnic collateral tributary had to be used as the inflow vessel in four patients, and portal vein arterialization were performed in the other two patients, all of whom experienced a smooth postoperative recovery except one who died of hepatic failure and pulmonary infection 2 weeks after the operation. The in-hospitality mortality was 3.45%. In grade IV cases, three underwent successful IET, but another three cases failed, with two of them requiring a renal vein as the inflow vessel, and other one undergoing portocaval hemitransposition, with one postoperative death due to hepatic failure and another of cancer recurrence, an in-hospitality mortality rate of 33.33%. The transfusion requirement among PVT patients was significantly higher than that in non-PVT patients (9.32 ± 3.12 U vs 6.02 ± 2.40 U; P < .01). Blood loss in PVT patients who underwent the IET technique was significantly lower than that for an eversion thrombectomy (2800.36 ± 930.52 mL vs 5700.21 ± 162.50 mL P < .05). The overall actuarial 1-year survival rate in PVT patients was similar to the controls (86.56% vs 89.40%; P > .05).

Conclusion

OLT was successfully performed for PVT patients. The grade of PVT decided the surgical strategy. Similar 1-year survival rates were attained between PVT patients and controls undergoing OLT.     

Intraoperative ultrasound guided portal venous thrombectomy in living donor liver transplantation recipient surgery.

Portal vein reconstruction in liver transplantation from live donor grafts has major challenging factors in cases with portal venous thrombosis (PVT). To overcome this critical surgical challenge, we devised a novel technique, intraoperative ultrasonography (IOUS)-guided thrombectomy of the portal vein. IOUS-guided thrombectomy was applied to the 10 patients whose PVT extended to the splenomesenteric junction. In these patients, closed thin scissors were inserted from the stump of the recipient portal vein under ultrasound guidance and the thrombus was dissected from the venous wall. The application of IOUS-guided thrombectomy in patients with moderate to severe PVT led to a 3-year patency rate of 83%, comparable to that of simple thrombectomy applied to partial or minimal (grade I-II) PVT (83%). IOUS-guided thrombectomy is helpful to adequately remove severe thrombi from the deep lumen of the portal vein, provided the procedure was carried out by an experienced surgeon with adequate preparation for unexpected venous injuries.     

终末期肝病合并门静脉血栓患者的肝移植术(附四例报告)

目的 探讨终末期肝病合并门静脉血栓(PVT)患者的肝移植术。方法 对准备肝移植的受者常规应用CT和彩色多普勒检查，发现共有4例受者伴有PVT。此4例受者进行了原位肝移植术和门静脉血栓摘除治疗。术中对残留有附壁血栓的1例受者，在肠系膜上静脉分支处插入一带有肝素帽的导管，术后用于注入尿激酶进行溶栓治疗。术后所有受者均应用了低分子肝素、华法令和前列腺素E1等抗凝治疗。结果 术中一次性取尽血栓3例；1例受者PVT延及脾静脉人口和门脉左右支，术后门静脉残留有血栓，经溶栓和抗凝治疗，术后28d血栓消失。有3例受者在术后2个月内痊愈出院，随访至今情况良好；1例受者因胸腔穿刺并发出血，后发生多房性积液和肺部感染，于术后48d死亡。结论(1)PVT不是肝移植的绝对禁忌证；(2)外科摘除血栓、溶栓和抗凝治疗能对PVT进行根治；(3)出血是肝移植门静脉血栓治疗后的主要并发症，要加强预防和治疗。     

癌栓分型对肝癌伴门静脉癌栓病人肝移植术预后的指导意义

目的 探讨门静脉癌栓分型对肝细胞性肝癌合并门静脉癌栓病人行肝移植手术治疗及预后的指导意义.方法 选择2003年1月至2005年12月长征医院肝移植科收治的149肝癌病人,其中肝癌伴门静脉癌栓病人74例,根据Ⅰ～Ⅳ癌栓分型标准相应分为Ⅰ～Ⅳ组,回顾分析各组病人生存时间及接受肝移植手术后的疗效.结果 无门静脉癌栓组0组(75例)、Ⅰ组(33例)、Ⅱ组(17例)、Ⅲ组(12例)、Ⅳ组(12例)的1年生存率分别为86.66%、84.84%、82.35%、66.66%和41.66%,1.5年生存率为68.00%、75.75%、70.58%,58.33%和16.66%,0～Ⅱ组各组间无明显区别(P＞0.05),Ⅲ、Ⅳ组和其他组差异有显著性意义(P＜0.05).癌栓Ⅰ型、Ⅱ型,肝移植手术疗效与无癌栓组相近,明显优于Ⅲ、Ⅳ组.结论 癌栓分型有助于肝癌合并门静脉癌栓病人肝移植手术适应证的选择及判断预后.     

Modified Cavoportal Hemitransposition for Severe Portal Vein Thrombosis Contributed to Long-term Survival After Deceased Donor Liver Transplantation—Insight Into Portal Modulation for Improving Survival: A Case Report

BackgroundSevere/massive portal vein thrombosis (PVT) deteriorates peri-liver transplantation outcomes. Cavoportal hemitransposition (CPHT) is a rescue procedure for severe PVT, and short-term outcomes have been well studied. However, CPHT is associated with some long-term issues caused by portal flow modulation via extraordinary reconstruction. We describe a patient with Yerdel grade 4 PVT who underwent a liver transplant and achieved long-term survival with CPHT and a portosystemic shunt.Case ReportA 50-year-old man with liver cirrhosis underwent a deceased donor liver transplant. Preoperative examinations indicated Yerdel grade 4 PVT; thus, we planned a CPHT. In liver transplant surgery, we confirmed diffusely complete PVT and removed them as possible. After placing a liver graft, we performed CPHT and confirmed that the graft received sufficient portal vein flow. However, the gastroepiploic vein pressure increased significantly. Therefore, we added a portosystemic shunt between the splenic vein and the inferior vena cava, and the pressure improved. The patient was discharged after an uneventful hospital stay, and he reported no unfavorable events for over 12 years.ConclusionsThis case study suggested that a modified CPHT with a portosystemic shunt for Grade 4 PVT was useful in preventing post–liver transplant PVT development and improved the outcome.     

Portal Vein Thrombosis and Liver Transplantation: Long Term

Obstruction of the portal vein may be related to constriction by malignant tumors or thrombosis associated with liver disease. We herein have reported our experience with patients undergoing liver transplantation with portal vein thrombosis (PVT) whose diagnosis was made intraoperatively. From September 1991 to May 2009, we studied 27/419 (6.4%) patients with PVT who were evaluated according to the presence of esophagogastric varices, underlying disease, malignancy, and if there was previous surgery, review of medical records on data collected prospectively. We observed 24 (88.9%) patients with PVT grade 1, 2 (7.4%) with grade 2, and 1 (3.7%) with grade 3. The average age of the PVT patients was 47.5 years; the average model for End-Stage Liver Discase score was 18.3, and the predominant diagnosis, hepatitis C cirrhosis. Eighteen underwent a sclerotherapy/ligature. The sensitivity of ultrasound for grade 1 thrombosis was 39.1%; for grade 2, 50%; and for grade 3, 100%. Portal vein thrombectomy was performed in 24 patients. In other patients (grade 2), we performed an anastomosis of the donor portal vein to the recipient gastric vein or to a greater splanchnic collateral vein. In only 1 patient was the graft performed using the donor portal vein-donor iliac vein-recipient superior mesenteric vein. None of the patients displayed PVT in the immediate postoperative period. Actuarial survivals at the years 1, 3, and 5 were 85%, 74%, and 63%, respectively. We concluded that PVT cannot be considered to be a contraindication for liver transplantation.