活体肝移植的胆道重建技术及并发症分析

目的 探讨活体肝移植的胆道重建方法及并发症防治措施.方法 回顾性分析77例活体肝移植临床资料,其中74例行右半肝移植(带肝中静脉29例,不带肝中静脉45例),左半肝带肝中静脉1例,左外叶切取2例.胆道重建采用胆肠吻合或供肝肝管与受体肝管端端吻合.结果 供肝断面1个胆管开口为54例,多个胆管开口为23例;胆肠吻合2例,胆管端端吻合75例,63例留置T管;术后总体胆道并发症发生率为36.4%(28/77),其中胆漏为10.4%(8/77),胆道狭窄为26.0%(20/77).供肝单支胆道以及单个吻合口术后胆道狭窄的发生率明显低于多支胆道及多个吻合口(P<0.05).8例胆漏病人经过B超指引穿刺引流全部治愈,20例吻合口狭窄病人经T管窦道放置支撑管或通过ERCP进行扩张,肝功能全部或部分好转.结论 活体肝移植供肝切取术中注意对断面胆管血供的保护以及尽可能获得单一的肝管开口可有效减少术后胆道并发症的发生;内镜和放射介入技术是治疗胆道并发症的有效手段.     

活体肝移植的胆道重建与胆道并发症

To systematically summarize the current status of surgical techniques in biliary reconstruction and biliary complications following living donor liver transplantation and analyze the biliary reconstruction techniques and difficulties in the prevention of biliary complications.The refinements of surgical techniques and successful prevention and therapeutic strategies for reducing biliary complications after living donor liver transplantation are discussed.     

Biliary reconstruction and complications of right lobe live donor liver transplantation

OBJECTIVE: To identify the possible reasons of failure of biliary reconstruction in right lobe live donor liver transplantation (LDLT) and to devise the best method of reconstruction and treatment strategy for the complications. SUMMARY BACKGROUND DATA: Right lobe LDLT was associated with a high biliary complication rate (15-64%) in the reported series. The causes of failure were not completely understood and the best treatment strategy has not been defined. METHODS: From 1996 to 2001, 74 patients received right lobe LDLT. The operative procedures of the first 37 patients were critically reviewed to identify the possible reasons of leakage or stenosis from the anastomosis. The causes included right hepatic duct ischemia, double or triple hepaticojejunostomies, unrecognized branch of right hepatic duct, jejunal opening smaller than the size of right hepatic duct, and ductal plasty without division of newly created septum. The second 37 patients had biliary reconstruction by a modified technique that preserved blood supply to the right hepatic duct and aimed at avoidance of risk factors. RESULTS: The overall complication rate decreased from 43% in the first 37 patients to 8% in the second 37 patients. There was no leakage from the anastomosis in the second group of patients. Percutaneous transhepatic biliary drainage (PTBD) for the biliary complications resulted in right portal vein and hepatic artery injury in four patients and accounted for mortality in three of them. To avoid complications from PTBD, three patients in the second group developing stenosis of hepaticojejunostomy had repeated hepaticojejunostomy without preoperative PTBD and recovered. CONCLUSIONS: With identification of risk factors and modification of the surgical technique, the complication rate of biliary reconstruction of right lobe LDLT could be reduced. Repeated hepaticojejunostomy without preoperative PTBD is the preferred approach once a complication develops.     

Biliary complications after adult living donor liver transplantation

We evaluated the causes and outcomes of biliary complications occurring after adult living donor liver transplantation (ALDLT) in a large patient cohort. Among 46 patients who underwent ALDLT at two different centers early bile duct complications occurred in 11 recipients (23.9%), consisting of leakage from the anastomotic site or from the cut surface of the liver. T-tube-associated biliary complications occurred in four patients. Late complications, primarily anastomotic strictures, occurred in 15 patients (32.6%) at 6.7+/-3.5 months after transplantation. Surgical intervention was generally required for early biliary complications but rarely necessary for late complications. No graft loss was caused by biliary complications. Thus, ALDLT is accompanied by a high rate of biliary complications, which in our series have been of low severity. However, long-term effects on graft function are not yet known.     

成人右半肝活体肝移植胆道重建探讨

目的探讨成人右半肝活体肝移植胆道重建的技术问题.方法回顾性分析我院2007年4月至2009年5月完成的21例成人右半肝活体肝移植资料.供肝右肝管与受者肝总管单个吻合10例;供肝两支胆管开口分别与受者两支胆管吻合5例;供肝胆管整形成一个开口与受者胆管吻合5例,其中采用T管支撑2例,Y型管支撑1例;右肝管空肠Roux-en-Y吻合1例.结果4例受者术后1个月内死亡,1例因术后急性肝坏死行再次肝移植.其余受者存活至今,1年存活率为77.65%.受者术后发生胆道并发症7例,其中胆漏5例,胆道狭窄2例,均经外科手术处理痊愈.胆管与胆管单个吻合口组、胆管整形成一个开口与受者胆管吻合组和两支胆管开口分别与受者胆管吻合组比较,胆道并发症发生率差异无统计学意义(x2=0.659,P=0.719).结论根据供受者胆管情况,可以灵活采用单根胆管吻合、胆管整形、分别吻合和肝管空肠吻合等不同重建方式.后壁连续、前壁间断以及显微外科技术的采用可能有助于降低胆道并发症的发生率.     

Biliary complications after living donor adult liver transplantation.

The highest rate of complications characterizing the adult living donor liver transplantation (ALDLT) are due to biliary problems with a reported negative incidence of 22-64%. We performed 23 ALDLT grafting segments V-VIII without the middle hepatic vein from March 2001 to September 2005. Biliary anatomy was investigated using intraoperative cholangiography alone in the first five cases and magnetic resonance cholangiography in the remaining 18 cases. In 13 cases we found a single right biliary duct (56.5%) and in 10 we found multiple biliary ducts (43.7%). We performed single biliary anastomosis in 17 cases (73.91%) and double anastomosis in the remaining six (26%) cases. With a mean follow up of 644 days (8-1598 days), patient and graft survivals are 86.95% and 78.26%, respectively. The following biliary complications were observed: biliary leak from the cutting surface: three, anastomotic leak: two, late anastomotic strictures: five, early kinking of the choledochus: one. These 11 biliary complications (47.82%) occurred in eight patients (34.78%). Three of these patients developed two consecutive and different biliary complications. Biliary complications affected our series of ALDLT with a high percentage, but none of the grafts transplanted was lost because of biliary problems. Multiple biliary reconstructions are strongly related with a high risk of complication.     

Biliary anastomosis and biliary complications following living donor liver transplantation

Biliary complications are one of the most important problems in liver transplantation. Regardless of various improvements of surgical technique, liver transplantation is associated with significant biliary problems. In this article, we have described a biliary anastomosis method with a continuous suture (CS) technique in the posterior wall and interrupted suture (IS) technique for the anterior wall. We performed this biliary reconstruction in 28 adult patients between September 2003 and August 2007. Prior to that time our procedure was a CS anastomosis for both the anterior and posterior walls. A 5-Fr catheter is inserted into the biliary system. The current biliary complication was 3 cases (13.0%) of stenosis at the anastomosis, which is lower than that for a CS anastomosis. This anastomosis reduced biliary complications and is simple.     

建立经腹腔镜切取活体猪左半供肝的动物模型

目的 评价经腹腔镜切取活体猪左半供肝的可行性.方法 建立经腹腔镜切取活体猪左半供肝的动物模型,其技术包括CO2气腹的建立与戳孔布局,解剖肝十二指肠韧带,腹腔镜术中超声辅助确定断肝平面,肝脏的游离,离断肝实质,肝内管道的处理.将切取的左半供肝进行冷灌注及修整,并取少量肝组织块行病理学检查.结果 10头猪接受了手术,除1头因下腔静脉出血后发生气栓死亡外,其余均成功建立模型.手术时间为(208±25)min,热缺血时间为(8±2.3)min,手术出血量为(313±75)ml.供肝切取后,残肝重要结构保留完好;供肝管道结构及组织学形态正常.结论 经腹腔镜切取活体猪左半供肝的技术是安全可行的.     

Impact of biliary complications in right lobe living donor liver transplantation

Biliary reconstruction is one of the most challenging parts of right lobe living donor liver transplantation (RL LDLT), and biliary complications have been reported as the first source of surgical complications of this procedure. We reviewed biliary reconstruction and complications in 27 consecutive RL LDLTs. We compared the first 14 procedures (group 1) to the last 13 (group 2). Seven patients (25.9%) experienced a biliary complication (five leaks and two strictures). The incidence of biliary complications was 11.1% in RL grafts with a single duct and 55.5% in graft presenting multiple bile ducts (P = 0.03). Four of the 18 patients with a duct-to-duct reconstruction (22.2%) and three of the 11 patients with a Roux-en-Y reconstruction (27.3%) developed a biliary complication (P = ns). The incidence of biliary complications significantly decreased from 42.9% (n = 6) in the first group to 7.6% (n = 1) in the second group (P = 0.05). The overall 1-year graft and patient survival were 57.1% and 64.3% in group 1 versus 100.0% and 100% in group 2 (P = 0.01; P = 0.006). Biliary complications remain one of the most important technical complications affecting RL LDLT. Nevertheless, attention and surgical refinement can lead to a significant reduction of the biliary complication rate, improving graft and patient survival.     

Biliary complications in adult living donor liver transplantation with duct-to-duct hepaticocholedochostomy or Roux-en-Y hepaticojejunostomy biliary reconstruction

BACKGROUND: The aim of this study was to compare the incidence of biliary complications after adult living donor liver transplantation (ALDLT) with Roux-en-Y hepaticojejunostomy (R-Y HJ) or duct-to-duct hepaticocholedochostomy (D-D HC). METHODS: Biliary complications were reviewed in 20 consecutive ALDLT recipients surviving more than 1 month, including 10 patients who underwent R-Y HJ and 10 patients who underwent D-D HC reconstructions. RESULTS: Ten biliary complications were seen in 8 patients (40%) from the study group. Specifically, 1 case of biliary leakage and 1 case of biliary hemorrhage were observed in the R-Y HJ group (20%), and 2 biliary leakages, 4 biliary strictures, and 2 C-tube related biliary leakages were seen in 6 patients from the D-D HC group (60%). Three of the 5 patients (60%) who underwent right lobe graft ALDLTs experienced biliary stricture. All cases of biliary leakage and biliary hemorrhage were stopped spontaneously by continuous drainage. Three patients in the D-D HC group with anastomotic strictures were successfully treated with percutaneous interventions. Only 1 patient with anastomotic stricture in the D-D HC group with left lobe graft required intrahepatic R-Y HJ reanastomosis. Two cases of C-tube related biliary leakages were treated with endoscopic management. CONCLUSIONS: Biliary complications such as anastomotic strictures were common in the D-D HC group rather than in the R-Y HJ group. D-D HC reconstruction should be applied cautiously, especially in the right lobe graft ALDLT cases.     

成人间右半肝活体肝移植的肝动脉重建

Objective To summarize our experience in hepatic artery reconstruction in adult-to-adult right lobe living donor liver transplantation(LDLT).Methods A retrospective analysis was made for 17 cases undergoing LDLT in our center from May 2007 to Oct 2008.Results All the 17 right lobe graft of the liver was supplied by single right hepatic artery and the mean diameter of right hepatic artery was 3.1 mm.The hepatic artery for segment 4 was mainly originated from left hepatic artery(12/17,70.1%).The recipient right or left hepatic artery was used in 14 cases of reconstruction,proper hepatic artery was used in 2 cases,and gastroduodenal artery was used in one case.Anastomosis was performed with interrupted 8-0 prolene and 12-16 stitches were made on the posterior wall first and then the anterior wall to avoid turning over the vessel.The mean anastomosis time was(51±26) minutes and all hepatic arteries were patent immediately after anastomosis.Hepatic arterial complications including hepatic artery thrombosis (HAT)did not occur after LDLT.Conclusions Detailed evaluation and careful protection of the hepatic artery of segment 4 are the key to successful reconstruction of hepatic artery in LDLT.Anastomosis was performed without flipping the artery wall helped to reduce the difficulty of operation remarkably and with a good result.     

成人间右半肝活体肝移植的肝动脉重建

目的 探讨成人间右半肝活体肝移植的肝动脉重建的相关问题.方法 我院移植中心2007年5月至2008年10月,共完成17例成人活体右半肝肝移植,结合此组病例的临床资料,就肝动脉重建的术前评估、手术技巧和并发症防治进行回顾性分析.结果 17例右半肝供体均为单一肝右动脉供血,动脉平均直径3.1 mm,S4段主要由左肝动脉供血有12例(12/17,70.1%),由肝右动脉供血4例(4/17,23.5%),肝右和肝左动脉均发出动脉分支供血的1例.利用胆囊动脉扩大供肝肝右动脉吻合口径2例.供肝肝右动脉与受体肝右动脉吻合10例(10/17,60%),与受体肝左动脉吻合4例,与受体肝固有动脉吻合2例.吻合方式均为间断吻合,先吻合动脉后壁再吻合前壁,缝合针数12～16针.均为一次吻合成功,平均吻合时间(51±26)min,术后未出现肝动脉相关并发症.结论 对供肝S4段肝动脉的详细评估和保护是活体肝移植肝动脉重建的重点,不翻转供受体动脉的吻合方法可以有效降低手术难度,减少动脉并发症的发生.     

Technique of bile duct reconstruction and management of biliary complications in right lobe living donor liver transplantation

From December 1999 to January 2002, 50 right lobe living donor liver transplantations were performed. The donor operations included an intraoperative cholangiography to elicit variations in bile duct anatomy. The biliary reconstruction was done whenever possible as an end-to-end microanastomosis of the donor right hepatic duct with the recipient's bile duct. As a result of the early segmental branching of the donor biliary tree, two segment bile ducts had to be anastomosed in 20 patients and three segment bile ducts in three patients. In 12 patients, a Roux-en-Y hepaticojejunostomy was performed. All anastomoses were drained externally. We observed two leakages at the resection surface which could be treated successfully by an external drainage. Six leaks occurred at the site of end-to-end biliary anastomoses. Twice the problem could be conservatively solved placing a stent percutaneously. In two patients a hepaticojejunostomy was performed after a bile duct necrosis. In two patients with an anastomotic leak, occurring 3 d, respectively, 3 month after the original transplantation, the bile duct could be directly reconstructed over a T-tube. Two anastomotic stenoses were observed, one in combination with a leak treated by percutaneous stent implantation and the second, 3 month after transplantation which was treated surgically. Biliary reconstruction after living donor liver transplantation requires microsurgical techniques and can be performed as a direct end-to-end anastomosis in most cases. Biliary complications were treated by percutaneous drainage or surgical revision in all cases.     

成人间右半肝活体肝移植的肝动脉重建

Objective To summarize our experience in hepatic artery reconstruction in adult-to-adult right lobe living donor liver transplantation(LDLT).Methods A retrospective analysis was made for 17 cases undergoing LDLT in our center from May 2007 to Oct 2008.Results All the 17 right lobe graft of the liver was supplied by single right hepatic artery and the mean diameter of right hepatic artery was 3.1 mm.The hepatic artery for segment 4 was mainly originated from left hepatic artery(12/17,70.1%).The recipient right or left hepatic artery was used in 14 cases of reconstruction,proper hepatic artery was used in 2 cases,and gastroduodenal artery was used in one case.Anastomosis was performed with interrupted 8-0 prolene and 12-16 stitches were made on the posterior wall first and then the anterior wall to avoid turning over the vessel.The mean anastomosis time was(51±26) minutes and all hepatic arteries were patent immediately after anastomosis.Hepatic arterial complications including hepatic artery thrombosis (HAT)did not occur after LDLT.Conclusions Detailed evaluation and careful protection of the hepatic artery of segment 4 are the key to successful reconstruction of hepatic artery in LDLT.Anastomosis was performed without flipping the artery wall helped to reduce the difficulty of operation remarkably and with a good result.     

活体肝移植中利用受者胆囊管完成供肝多支胆管的重建五例

目的 研究在活体肝移植中利用受者胆囊管完成供肝多支胆管重建的可行性.方法 回顾分析2008年1月至2011年9月期间利用受者胆囊管与供肝多支胆管中的一支进行吻合的5例病例的临床资料,其余供肝胆管与受者肝总管或右肝管相吻合,从而完成供肝多支胆道的重建.术后定期复查肝功能,所有受者均于术后2周和术后3个月时接受胆道造影检查.结果 术后2周时,5例受者的胆道造影均显示肝内、外胆道无明显狭窄及外漏.3例受者术后恢复顺利,未出现肝功能异常,术后3个月时接受胆道造影检查见肝内外胆道良好,无明显狭窄及外漏,胆道排空良好.1例受者术后肝功能持续正常,因未满3个月,尚未接受第2次胆道造影检查.1例受者术后早期恢复顺利,术后3个月时胆道造影检查见右前支胆管见胆囊管迂曲,吻合口狭窄,因肝功能正常,给予拔除T管;术后9个月时出现肝功能异常,表现为胆红素及转氨酶的轻度升高,行胆道磁共振水成像检查发现胆总管中段管腔略窄,较前无明显变化,副右肝管近端较前扩张,将免疫抑制剂由他克莫司更换为西罗莫司后,肝功能恢复正常.结论 在活体肝移植中,如果供肝具有多支胆管开口,利用受者胆囊管进行吻合的方法是安全可行的.     

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.)     

Right lobe living donor liver transplantation.

BACKGROUND: The shortage of livers for transplantation has prompted transplant centers to seek alternatives to conventional cadaveric liver transplantation. Left lateral segmentectomy from living donors has proven to be a safe operation for the donor with excellent results in the pediatric population. Left lobectomy, conceived to supply more tissue, still provides insufficient liver mass for an average size adult patient. Right lobectomy could supply a graft of adequate size. METHODS: Donors were considered only after recipients were listed according to United Network for Organ Sharing (UNOS) criteria. Donor evaluation included liver biopsy, magnetic resonance imaging, and celiac and mesenteric angiography. The donor operation consisted of a right lobectomy uniformly performed throughout the series as described herein. RESULTS: Twenty-five right lobe living donor liver transplants were performed between adults, with no significant complications in donors. Recipient and graft survival was 88%, with three recipient deaths secondary to uncontrolled sepsis in patients at high risk for liver transplant; all three had functioning grafts. CONCLUSIONS: Right lobe living donor liver transplantation poses challenges that require a meticulous surgical technique to minimize morbidity in the recipient. Right lobectomies for living donation can be performed safely with minimal risk to both donor and recipient although providing adequate liver mass for an average size adult patient.     

Hepatic artery reconstruction and successful management of its complications in living donor liver transplantation using a right lobe

Kim S‐J, Yoon Y‐C, Park J‐H, Oh D‐Y, Yoo Y‐K, Kim D‐G. Hepatic artery reconstruction and successful management of its complications in living donor liver transplantation using a right lobe.
Clin Transplant 2011: 25: 929–938. © 2010 John Wiley & Sons A/S. Abstract: Background: The aim of the present study was to improve the techniques of hepatic artery (HA) reconstruction and to properly manage arterial complications after living donor liver transplantation (LDLT). Methods: Prospectively collected data collected from 371 patients who underwent adult LDLT using a right lobe from January 2000 to August 2009 were retrospectively reviewed. Results: Of 17 patients (4.6%, 17/371) with double HA stumps in the graft, 12 patients (70.6%) received dual HA reconstruction. HA complications were composed of thrombosis (n = 6), pseudoaneurysm (n = 2), and stenosis (n = 4), showing 3.2% (12/371) of incidence. In patients with HA thrombosis, whereas operative thrombectomies with re‐anastomosis rescued all the grafts in early attack (n = 3, ≤1 wk), angiographic thrombolysis successfully reestablished the flow in patients with late attack (n = 3, >1 wk). In all patients with HA complications, except for one, all of our treatment modalities – operation and angiographic intervention – resulted in successful rescue of grafts and no patient received re‐transplantation because of HA complications. Conclusion: Prompt diagnosis of HA complications by serial post‐operative Doppler ultrasound and corresponding treatment strategies, including operative and radiological intervention, can rescue both grafts and patients without necessitating re‐transplantation.