儿童肝移植术后肝静脉流出道梗阻三例报道

目的 探讨儿童肝移植术后肝静脉流出道梗阻(hapatic venous outflow obstruction,HVOO)的诊断及治疗经验.方法 对本院收治的3例儿童肝移植术后肝静脉流出道梗阻进行回顾性分析.3例中2例于本院接受肝移植手术,1例于外院接受肝移植手术.3例均经腹部彩色多普勒(color Doppler ultrasound,CDUS)、计算机断层扫描(computerized tomography,CT)及下腔静脉造影检查明确诊断为HVOO,并接受球囊扩张和/或支架置入治疗.治疗后对患儿进行定期监测及随访.结果 我院2000年1月至2009年12月共实施48例儿童肝移植,其中2例(4.17％)术后发生HVOO.3例患儿HVOO发生时间为术后2个月至1年不等.临床主要表现为腹胀、纳差等.下腔静脉造影测压(共4例次)显示肝静脉及右心房压力差值为6～30 mm Hg.经球囊扩张和/或支架置入后,静脉压力差值为4～10 mm Hg(1 mm Hg=0.133 kPa),血流恢复通畅,临床症状明显缓解.球囊扩张后,2例出现HVOO复发.其中1例经再次球囊扩张后,症状缓解;另外1例予以留置支架.术后无支架堵塞或脱落等并发症发生.治疗后随访2个月至9年.目前3例患者均存活良好.结论 虽然儿童肝移植术后肝静脉流出道梗阻的发生率不高,但后果严重,应引起临床医生重视.儿童肝移植术后肝静脉流出道梗阻采用球囊扩张或支架置入术治疗可获得满意疗效.     

儿童肝移植术后肝静脉流出道梗阻的血管腔内治疗进展

流出道梗阻是儿童肝移植术后的血管并发症。血管腔内介入治疗已成为治疗术后流出道梗阻的首选治疗方法。本文对近年来儿童肝移植术后流出道梗阻血管腔内治疗进展进行综述。     

Isolated right hepatic vein obstruction after piggyback liver transplantation.

The "piggyback" technique for liver transplantation has gained worldwide acceptance. Still, complications such as outflow obstruction have been observed, usually attributable to technical errors such as small-caliber anastomosis of the suprahepatic vena cava, twisting, or kinking. Iatrogenic Budd-Chiari syndrome after piggyback liver transplantation has been reported as a consequence of obstruction involving the entire anastomosis (usually the 3 hepatic veins). Here we describe technical issues, clinical presentation, diagnosis, and treatment of 3 cases in which outflow obstruction affected only the right hepatic vein. In conclusion, all 3 patients developed recurrent ascites requiring angioplasty and/or stent placement across the right hepatic vein to alleviate the symptoms.     

Long‐term follow‐up after endovascular treatment of hepatic venous outflow obstruction following liver transplantation

Hepatic venous outflow obstruction (HVOO) is a rare complication after liver transplantation (LT) associated with significant morbidity and reduced graft survival. Endovascular intervention has become the first‐line treatment for HVOO, but data on long‐term outcomes are lacking. We have analysed outcomes after endovascular intervention for HVOO in 905 consecutive patients who received 965 full‐size LT at our unit from January 2007 to June 2014. There were 27 (3%) patients who underwent hepatic venogram for suspected HVOO, with persistent ascites being the most common symptom triggering the investigation (n = 19, 70%). Of those, only 10 patients demonstrated either stricture or pressure gradient over 10 mmHg on venogram, which represents a 1% incidence of HVOO. The endovascular interventions were balloon dilatation (n = 3), hepatic vein stenting (n = 4) and stenting with dilatation (n = 3). Two patients required restenting due to stent migration. The symptoms of HVOO completely resolved in all but one patient, with a median follow‐up period of 74 (interquartile range 39–89) months. There were no procedure‐related complications or mortality. In conclusion, the incidence of HVOO in patients receiving full‐size LT is currently very low. Endovascular intervention is an effective and safe procedure providing symptom relief with long‐lasting primary patency.     

介入治疗在肝移植术后静脉流出道梗阻中的临床应用

目的探讨介入治疗在肝移植术后静脉流出道梗阻中的临床应用价值。方法回顾性分析27例肝移植术后患者的临床资料。患者肝移植术后出现胸、腹水和肝功能异常时，应用CT、磁共振（MR1）或超声波检查，若提示下腔静脉狭窄或肝静脉梗阻，则行静脉造影确定狭窄部位，并对其进行球囊扩张或支架治疗。治疗后随访1个月～5年，观察临床效果。结果静脉造影发现1例为单纯肝静脉狭窄；13例为下腔静脉狭窄，其中3例合并肝静脉狭窄。4例患者接受球囊扩张，10例接受支架治疗。接受治疗后患者多在短期内临床症状消失，未见明显并发症。1例肝静脉狭窄经球囊扩张8个月后再次出现狭窄，给于支架治疗；另1例球囊扩张2年后再次发生狭窄，接受再次球囊扩张，患者的临床症状缓解。结论下腔静脉狭窄或肝静脉流出道狭窄可通过球囊扩张或支架等介入治疗获得满意的临床效果。     

Surgical repair for late-onset hepatic venous outflow block after living-donor liver transplantation

The incidence of hepatic venous complications in partial liver transplantation is more frequent than that in whole liver transplantation. There are no reports of a surgical strategy for hepatic venous outflow block (HVOB) after living-donor liver transplantation. HVOB was diagnosed when the pull-through pressure gradient across the anastomotic site was over 5 mm Hg. Reoperation for venous anastomosis was performed if the angioplasty was unsuccessful. After dissection around the hepatic venous anastomotic site, a patch venoplasty of the anastomosis was performed. When the inferior vena cava was constricted, venoatrial anastomosis was performed. In 6 years, 5 of 223 patients experienced HVOB. Balloon angioplasty was successfully performed in two patients, a patch venoplasty of the anastomosis in two, and venoatrial anastomosis in one. In all patients, the ascites stopped. HVOB must be diagnosed as soon as possible with Doppler ultrasound and venography. Prompt surgical revision can salvage the grafts.     

原位肝移植术后静脉流出道梗阻的原因和处理

目的 探讨原位肝移植术后静脉流出道梗阻的原因和处理方法.方法 对2000年1月至2006年12月收治的776例同种原位肝移植患者的临床资料进行回顾性分析.总结原位肝移植术后静脉流出道梗阻的诊治经验.结果 776例肝移植患者中共发生术后静脉流出道梗阻10例,发生率为1.29%.其中肝上下腔静脉吻合口狭窄6例,肝后段下腔静脉狭窄2例,肝静脉流出道梗阻2例.10例均进行了下腔静脉造影而明确诊断,8例患者在下腔静脉造影的同时施行了气囊扩张或放置血管内支架术,2例介入治疗效果不佳而中转再次肝移植术;该组因术后静脉流出道梗阻而死亡3例,与静脉流出道梗阻相关的病死率为30%(3/10).结论 原位肝移植术后静脉流出道梗阻的发生与腔静脉的吻合技术,腔静脉吻合方式以及供肝体积与受者肝床不匹配有关;术后尽早发现流出道梗阻的存在,并及时做出正确的治疗选择如介入治疗或再次肝移植等是改善该并发症预后的关键.     

Maximizing venous outflow after right hepatic living donor liver transplantation with a venous graft patch

Between March 2002 and September 2004, 36 patients at Mie University Hospital underwent living donor liver transplantation (LDLT) of a right lobe graft without the middle hepatic vein. The patients were divided into two groups: group I (n = 25) received ordinary hepatic vein anastomoses, and group II (n = 11) received a venous graft patch in the subsequent procedure. Between groups, we compared hepatic vein blood flow (ultrasound), liver volume (CT scan), laboratory data, and ascitic fluid volume. Outflow block developed as a complication in 1 patient in group I. Hepatic vein blood flow on postoperative day (POD) 3 was significantly better in group II, and hepatic vein waveforms of most group II patients showed the triphasic pattern, especially on PODs 3 and 5. The total bilirubin and aspartate aminotransferase values on POD 1 were significantly better in group II, and daily ascitic fluid volume on PODs 3 and 5 was significantly lower in group II. Thus, modified venoplasty with a graft patch in the right hepatic LDLT not only improved hepatic vein hemodynamics (based on the ultrasound findings), but also improved liver function and decreased daily ascitic fluid volume.     

Selective management of hepatic venous outflow obstruction

To describe the outcome of selective management of hepatic venous outflow obstruction (HVOO), based on its presentation and liver function, we reviewed the records of 49 consecutive patients managed at our institution between 1984 and 1993. Twenty-six patients were managed surgically, 12 nonsurgically, and 11 were not treated. Portosystemic shunts (PSS) were performed in 18 patients (patency 83%). Two patients (11%) died postoperatively, 11 (61%) did well (mean follow-up 6.4 years), three (17%) required subsequent orthotopic liver transplantation, and two (11%) died of late liver failure. PSS remained patent if the preoperative pressure gradient between the portal vein and the infrahepatic inferior vena cava was greater than 10 mm Hg and across the intrahepatic inferior vena cava 18 mm Hg or less. All six orthotopic liver transplantations (three as primary treatment and three after failed PSS) were successful (mean follow-up 4.8 years). Five patients underwent other procedures. Nine (75%) of the 12 nonsurgically treated patients did well (mean follow-up 3.8 years). The most important predictor of successful out-come after PSS or medical management was the degree of liver function. All 11 untreated patients died either of end-stage liver failure (n=7; 63%) or of severe comorbid disease (n=4; 37%). In patients with preserved liver function, medical management of HVOO can be successful early in the course of the disease; a late presentation necessitates PSS. Orthotopic liver transplantation should be employed in patients with liver failure and may decrease the high mortality rate of HVOO. Presented at the Thirty-Seventh Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, Calif., May 19–22, 1996.     

儿童劈离式肝移植术后肝静脉流出道梗阻1例报道及文献复习

目的探讨儿童劈离式肝移植术后肝静脉流出道梗阻(hapatic venous outflow obstruction,HVOO)的病因、临床表现、诊断及治疗。方法回顾性分析1例儿童劈离式肝移植术后肝静脉流出道梗阻病例的临床资料并进行文献复习。结果患儿于术后8个月无明显诱因出现腹胀、纳差、双下肢水肿,经腹部B超、计算机断层摄影术(computed tomography,CT)增强扫描、下腔静脉及肝静脉造影确诊迟发型HVOO,遂行球囊扩张术,手术成功。球囊扩张术后10个月及15个月HVOO复发,均接受再次球囊扩张术,手术成功。随访至今患儿存活,未再发腹胀、纳差,肝功能正常。结论对于术后无明显诱因出现腹水、腹胀、纳差和双下肢水肿等表现的患儿,应重点排除HVOO,下腔静脉及肝静脉造影是诊断该病的金标准。对于迟发型的HVOO患儿,球囊扩张术和支架置入是理想的治疗方式,但支架置入的选择及时机仍存在争议。     

Endovascular treatment of hepatic artery thrombosis following liver transplantation

Hepatic artery thrombosis (HAT) is the most frequent vascular complication following orthotopic liver transplantation. Urgent retransplantation has been considered as the mainstay therapy. Surgical revascularization is an effective alternative in asymptomatic patients. Endovascular therapies including intra‐arterial thrombolysis, percutaneous transluminal angioplasty (PTA), and stent placement have shown encouraging results in recent years; however, their use remains controversial because of potential risk of hemorrhage. Until June 2009, 69 cases were published in 16 reports describing therapeutic potential of endovascular modalities. Interventions were performed as early as within 4 h to as late as 120 days in patients ranging from 4 months to 64 years of age. Majority of published reports suggested the use of urokinase. Thrombolysis was successful in 47 out of 69 (68%) patients. Bleeding was the most common complication including fatal intra‐abdominal hemorrhage in three patients. Twenty‐nine out of 47 (62%) patients underwent further intervention in the form of PTA, stenting, or both. The follow‐up patency ranged from 1 month to 26 months. In conclusion, whenever possible, efforts should be made to rescue the liver grafts through urgent revascularization (surgical and/or endovascular) depending on patient’s condition and interventional expertise at the transplant center; reserving the option of retransplantation for failure, complications, and cases with severe clinical symptoms or allograft dysfunction.     

背驮式原位肝移植流出道梗阻的原因分析及处理(附6例临床报告)

目的探讨背驮式肝移植流出道梗阻的原因及处理方法。方法回顾性分析我中心2002年1月至2003年9月实施的329例肝移植病例，其中经典非转流152例，经典转流31例，改良背驮式146例。6例出现明确的流出道梗阻，对这一并发症的临床表现及处理进行分析。结果这6例病人中，2例表现为急性Budd—Chiari综合征，其中1例剖腹探查，纠正吻合口扭转。另1例因同时伴有严重的肝功能障碍，急诊行二次肝移植；1例CT表现为左外侧叶淤血，未做特殊处理；另外3例手术关腹时血压、中心静脉压下降，右肝后加垫后缓解。结论背驮式肝移植流出道梗阻的发生与腔静脉吻合方式及供肝与受体是否匹配有关；术前详细地评估供受体条件并选择术式，术中及时发现并发症的存在并处理，可减少这一并发症带来的不良后果。     

成人活体肝移植术后肝静脉狭窄的诊断与介入治疗:2例报道并文献复习

肝静脉狭窄是肝移植术后的一种严重并发症,在活体肝移植术后发生率较高。本文通过回顾性分析2例成人活体肝移植术后肝静脉狭窄患者的相关资料,结合国内外相关文献,探讨肝移植术后肝静脉狭窄的诊断方法及介入治疗效果。经皮肝静脉造影术可确诊肝静脉流出道梗阻,经皮经肝球囊、支架成形术是治疗活体肝移植术后早期肝静脉狭窄的一种安全、简便、有效的方法。     

肝移植术后迟发性流出道梗阻的诊断和治疗

目的 探讨肝移植术后迟发性流出道梗阻的诊断和治疗方法.方法 2001年6月至2004年11月,共施行肝移植821例次,其中6例患者(背驮式原位肝移植1例,经典原位肝移植4例,减体积肝移植1例)在手术6个月之后出现流出道梗阻,均经彩色超声、计算机断层扫描(CT)检查及下腔静脉造影明确诊断.6例患者均接受经皮腔内血管成形术(PTA),并放置血管内支架治疗,每天口服肠溶阿斯匹林100 mg抗凝治疗半年.治疗期间对患者进行监测和定期随访.结果 肝移植术后迟发性流出道梗阻的发生率为0.73%.6例患者均为肝后下腔静脉及肝静脉狭窄,经PTA并放置血管内支架治疗后,血流恢复通畅,下肢水肿消失,肾功能恢复良好,长期随访无复发.结论 经彩色超声检查怀疑流出道梗阻的患者应行腹部强化CT检查,可以为诊断提供有力的证据;高度怀疑流出道梗阻的患者应进行下腔静脉造影,检测狭窄部位的压力梯度变化.经皮腔内血管成形术并放置血管内支架治疗肝移植术后迟发性流出道梗阻安全可靠,长期疗效满意.