同种原位肝移植肝脉重建技巧

目的：探讨和总结同种原位肝移植术中肝动脉重建技术。方法：回顾性分析我院近一年来所施行18例原位肝移植术中肝动脉重建方式和技巧。结果15例行供受体肝固有动脉端端吻合,2例供体肝总动脉与受体肝固有动脉吻合,1例供体总动脉与受体脾动脉吻合。术后彩色色普勒超声监测显示肝动脉血流通畅,均未发现有血栓菜成或肝动脉狭窄,全部病例未发生胆道并发症。结论：成功的肝动脉重建技术防止肝移植术后肝动脉血栓形成或肝动脉狭窄的关键。     

改良的套叠缝合重建肝动脉的大鼠原位肝移植模型

目的 介绍1种简便的套叠缝合重建肝动脉的大鼠原位肝移植模型。方法 采用套叠缝合重建肝动脉的大鼠原位肝移植模型20例。肝移植采用二袖套法，动脉重建利用供肝的肝总动脉与受体的肝固有动脉根部二针套叠缝合方法。结果 本方法建立大鼠原位肝移植模型的手术时间（包括供体手术）和重建动脉的时间明显缩短。大鼠30d存活率和肝动脉的通畅率均为100％。无胆道并发症发生。结论 套叠缝合重建肝动脉的大鼠原位肝移植模型简便、省时、成功率高，且对组织损伤小、更符合受体解剖生理。     

单肝段移植

部分肝移植目前已成为儿童晚期肝病的治疗方法.最常用的部分肝是左外段(Ⅱ、Ⅲ段)和左半肝(Ⅰ、Ⅱ、Ⅲ、Ⅳ段),但对小儿腹腔上述缩小的供肝仍过大,故作者采用单肝段原位移植术.病例报道 1992年10月为一4个月的男孩行单肝段原位肝移植术.病儿出生后76天时因肝外胆道闭锁而行门肠吻合术,肝活检示广泛的门静脉纤维化伴胆管增生.术后因无胆汁而深度黄疸、肝肿大.超声探查见门静脉通畅.同年10月28日获一供肝,保留左外侧肝段(Ⅱ、Ⅲ段)及左肝静脉和肝门完整的血管胆道结构.受体肝切除时保留下腔静脉.术中发现受体肝右动脉起始于肠系膜上动脉,有两支细小的肝主动脉供应左半肝.将供体肝静脉与受体下腔静脉行端侧吻合.供肝的左门静脉与受体左、右门静脉汇合部吻合.肝动脉重建则以供肝肝总动脉与胃十二指肠动脉汇合部和受体肝右动脉吻合.胆道重建方式为左肝管与第一次手术建立Roux—Y空肠攀吻合.术后第3天肝转氨酶急剧增高,多谱勒超声探查提示肝动脉无血流,动脉CT证实为肝动脉血栓.故行急症再次移植术.术中见移植肝对小儿腹腔仍嫌体积过大,故行肝Ⅱ殷切除,仅留肝Ⅲ段.     

活体肝移植术后胆管并发症的处理与预防

目的 探讨活体肝移植术后胆管并发症的防治.方法 84例活体肝移植,成人56例.小儿28例;良性终末期肝病66例,肝细胞肝癌18例.供受体胆管端端吻合重建50例,供体肝管与受体肝管端端和胆总管端侧吻合重建1例,供体肝管与受体肝管和胆囊管吻合1例,供体胆管与受体空肠Roux-en-Y吻合重建32例,所有胆管莺建后均置入4Fr或6Fr内支架管从受体胆总管前壁或空肠袢肓端侧肠壁引出体外.结果 术后发生胆管并发症24例,发生率为28.5%,胆管胆管吻合与肝管空肠Roux-en-Y吻合胆漏发牛率差异显著(8.3%νs16.7%,P＜0.05).胆管胆管吻合与肝管空肠Roux-en-Y吻合胆管狭窄发生率差异显著(50%νs 16.7%,P＜0.05).单支胆管与多支胆管发生胆管并发症差异湿著(20.8%νs 79.2%,P＜0.05).胆漏者保守治疗治愈4例,再次手术治疗治愈4例;胆管狭窄内镜下球囊扩张和鼻胆管引流治疗治愈4例,好转2例,再次手术胆管空肠Roux-en-Y吻合治疗治愈6例,经皮肝脏穿刺胆管狭窄球囊扩张治疗支架管引流治疗好转4例.该组资料无因胆管并发症死亡病例.结论 良好的胆管血供和吻合技术,选择恰当的胆管重建方式,是降低活体肝移植术后胆管并发症的重要措施.     

肝动脉变异与肝移植

目的总结肝移植中供体及受体肝动脉变异情况与重建方式。方法回顾我院2002年3月～2005年12月107例肝移植供体与107例受体肝动脉变异情况及重建方式。术后应用Doppler超声、胆道镜及介入方法监测肝动脉及胆道并发症的发生情况。结果107例肝移植之供、受体肝动脉(214例肝动脉),3例术中、术后死于多器官功能衰竭,有20例次肝动脉变异,经过术中良好的重建,其结果显示肝动脉及胆道并发症3例(3/19),较正常肝动脉吻合者(15/85)无显著性差异(P>0.05)。结论肝动脉变异发生率约9.35%左右,肝移植时供肝切取、修整及受体病肝切除应引起高度重视,术中良好的重建能取得好的效果。     

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目的：分析10例活体肝移植术中的血管变异，总结其外科处理经验，进一步提高手术成功率，减少并发症。方法：2001年1月至12月，行活体肝移植10例，其中左半肝8例，左外叶1例，右半肝1例，供肝者均为其母，经术中B超及胆管造影以确定肝切线。供体单支肝动脉分支与受体肝动脉吻合，两支肝动脉分别与受体肝左、右动脉吻合。门静脉分支与受体门静脉主干吻合。供体肝静脉与受体下腔静脉行端侧吻合。胆管重建均采用肝管分支与受体胆总管端端吻合，置T管引流。结果：10例活体肝移植，1例因肝动脉血栓形成，术后5天需次肝移植；1例发生排斥；其余8例均康复出院，5例已上学。结论：活体肝移植术中血管重建技术是其重要环节，术前和术中了解供受体解剖变异并正确处理，可减少术后血管和胆道的并发症。     

重建肝动脉血供大鼠原位肝移植模型的术式探讨

目的　探讨重建肝动脉血供的大鼠原位肝移植 (OLT)模型的手术操作方法 ,并对几种术式的效果进行了比较。方法　采用重建肝动脉血供的大鼠原位肝移植 60例 ,其中动脉“袖管式微血管缝合法”2 0例 ,动脉“套管法”2 0例和动脉“支架法”2 0例。同期行不吻合肝动脉的经典“二袖套法”96例。结果　各组手术时间 (包括供体手术 ) :“袖管式缝合法”(118.3± 12 .9)min ,“套管法”(10 6.2± 11.6)min ,“支架法”(93 .8± 10 .2 )min ,经典“二袖套法”(88.2± 9.6)min。无肝期均控制在 (2 0 .0± 2 .5 )min。经典“二袖套法”大鼠 1周存活率为 86.5 % (83 /96) ,重建肝动脉血供的大鼠 1周存活率为 86.7% (5 2 /60 )。胆道并发症发生率分别为 17.7% (17/96)和 6.7% (4 /60 )。结论　肝动脉重建的OLT本身并不能延长肝移植大鼠的生存时间 ,而肝动脉重建后可以减少术后胆道并发症的发生率。     

原位肝移植中受体血管异常时的肝动脉重建

摘要：目的 探讨原位肝移植中动脉异位重建的方法及效果。 方法 回顾性分析我院10年来的440例肝移植中36例因受体血管异常而行异位重建的方法及术后处理措施等。 结果 36例中行供肝动脉与受体肾下腹主动脉吻合20例，与肾上腹主动脉吻合10例，与胃左动脉吻合4例，与脾动脉吻合2例。5例围手术期死亡，但吻合口通畅，31例存活3个月至4年无血管相关并发症，仅1例术后2个月因胆道缺血坏死行再次肝移植。 结论 肝移植时受体肝动脉有病变或异常改变时，应将受体肾下或肾上腹主动脉、脾动脉、胃左动脉与供肝动脉进行异位重建，可取得满意效果。     

肝移植中使用受体脾动脉行肝动脉重建

目的探讨在肝移植中受体肝动脉存在病变的情况下肝动脉重建的方法。方法在二例肝移植病人中,选用受体脾动脉与供体肝动脉端端吻合以重建肝动脉。结果术后分别随访5个月和2年,肝动脉通畅,肝功能正常,无胆管并发症,无脾梗塞和脾功能异常。结论肝移植中受体的脾动脉可以用来行肝动脉重建。     

直视下袖套法加套入式吻合大鼠全血供肝移植模型建立

目的　直视下应用套入式吻合方法重建大鼠移植肝的动脉血供。　方法　SD- SD大鼠肝移植30只,SD- Wistar大鼠肝移植5 0只。供体从腹腔干动脉开始分别结扎脾动脉、胃左动脉、胃右动脉及胃十二指肠动脉,保留肝固有动脉。以8- 0无损伤缝线作袖套法加套入式方法行供体的腹腔干动脉和受体的右肾动脉吻合,恢复移植肝动脉血供。　结果　无肝期最短13min,最长2 1min。套入式吻合肝动脉时间平均4 .0 0±1.31min;手术成功率96 .3% ;SD- SD大鼠成功2 9只,术后不使用免疫抑制剂均健康存活,最长目前已超过2个月。SD- Wistar大鼠成功4 8只,一般术后3～5 d出现急性排斥反应,不用免疫抑制剂于9d后死于排斥反应所致的肝功能衰竭。　结论　直视下袖套法加套入式吻合方法重建大鼠移植肝的动脉血供是一种稳定、可靠及易行的全血供肝移植模型     

原位肝移植肝动脉血栓形成的预防和治疗

目的 总结原位肝移植肝动脉重建及其并发症的防治经验，以提高肝移植疗效和受体存活率。方法 分析9年间实施的85例原位肝移植患者的临床资料。肝动脉重建采用供者腹腔动脉干Carrell’s袖片或肝总动脉-脾动脉汇合部与受者肝左-右动脉部吻合16例(18．82％)，与受者胃十二指肠-肝固有动脉汇合部吻合61例(71．76％)，采用髂动脉-腹主动脉搭桥8例(9．42％)。术后根据凝血酶原时间(PT)，使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肝动脉血供。结果 1例术中发生肝动脉血栓形成(HAT)，立即行血栓切除，重新吻合动脉，现已随访13个月，肝动脉保持通畅。其余84例随访2～54个月，未见HAT发生。全组HAT发生率为1．2％。结论 正确选择肝动脉重建吻合的部位和术后有效的抗凝治疗可以减少HAT的发生；多普勒超声监测能早期发现HAT，挽救移植物，避免再移植。     

An improved model for rat liver transplantation including arterial reconstruction and simplified microvascular suture techniques.

For experimental liver transplantation in the rat, the models that have been used most frequently do not include reconstruction of the arterial blood supply to the liver. In these procedures, specially developed cuff anastomoses rather than the conventional microvascular suture technique are used almost exclusively in the recipient operation, so that the anhepatic time is minimized. In this study the technical details of an improved rat model for orthotopic liver transplantation are described. During the donor operation in this experimental method, the liver is prepared with an arterial pedicle that includes the abdominal segment of the aorta, permitting perfusion in situ of the portal vein as well as the hepatic artery. The transplantation of the excised donor organ into the recipient site is carried out with simplified microvascular suture techniques and includes reconstruction of the arterial supply to the liver. Anastomosis of the bile duct is accomplished by choledocho-choledochostomy with a splint technique and supplemental suturing. For the entire procedure, magnifying glasses with 2- to 2.5-fold magnification are sufficient. When this technique has been mastered, the average duration of the anhepatic phase is about 20 min, well below the critical 30-min limit for survival of the experimental animals. As proficiency increased, the perioperative mortality was reduced to 9.2% (n = 130). With the combination of portal and arterial in situ flushing during the donor operation and the rearterialization of the transplant during the recipient operation, the clinical conditions can be approximated more closely than is possible when the transplanted rat liver is supplied only by the portal vein. Use of microvascular suture techniques, without cuff anastomoses, reduces the need for ex situ handling of the donor organ.     

Surgical management of anatomical variations of the right lobe in living donor liver transplantation

OBJECTIVE: To review the anatomical variations of the right lobe encountered in 40 living liver donors, describe the surgical management of these variations, and summarize the results of these procedures. SUMMARY BACKGROUND DATA: Anatomical variability is the rule rather than the exception in liver and biliary surgery. To make effective use of liver segments from living donors for transplantation, surgical techniques must be adapted to the anomalies. METHODS: Donor evaluation included celiac and mesenteric angiography with portal phase, magnetic resonance angiography, and intraoperative ultrasonography and cholangiography. Arterial anastomoses were generally between the donor right hepatic artery and the recipient main hepatic artery. Jump-grafts were constructed for recipients with hepatic artery thrombosis, and double donor arteries were joined to the bifurcation of the recipient hepatic artery. The branches of a trifurcated donor portal vein were isolated during the parenchymal transection, joined in a common cuff, and anastomosed to the recipient main portal vein. Significant accessory hepatic veins were preserved, brought together in a common cuff if multiple, and anastomosed to the recipient cava. The bile ducts were individually drained through a Roux-en-Y limb, and stents were placed in most patients. RESULTS: Forty right lobe liver transplants were performed between adults. No donor was excluded because of prohibitive anatomy. Seven recipients had a prior transplant and five had a transjugular intrahepatic portosystemic shunt (TIPS). Arterial anomalies were noted in six donors and portal anomalies in four. Arterial jump-grafts were required in three. Sixteen had at least one significant accessory hepatic vein, and one had a double right hepatic vein. There were no vascular complications. Multiple bile ducts were found in 27 donors. Biliary complications occurred in 33% of patients without stents and 4% with stents. CONCLUSIONS: Anatomical variations of the right lobe can be accommodated without donor complications or complex reconstruction. Previous transplantation and TIPS do not significantly complicate right lobe transplantation. Microvascular arterial anastomosis is not necessary, and vascular complications should be infrequent. Biliary complications can be minimized with stenting.     

成人间活体肝移植肝动脉重建方法和并发症的处理

目的 探讨成人间活体肝移植的肝动脉重建和并发症处理的经验.方法 自2002年1月至2006年7月,共施行50例成人间右半肝活体肝移植.在供受者间肝动脉的重建中,供者右肝动脉与受者右肝动脉吻合24例,与受者肝固有动脉吻合12例,与受者左肝动脉吻合3例,与受者肝总动脉吻合2例,与受者肠系膜上动脉发出的副右肝动脉吻合2例,与受者肝总动脉自体大隐静脉间置搭桥3例.受者腹主动脉与供者右肝动脉自体大隐静脉搭桥2例,用保存的尸体髂血管行受者腹主动脉与供者右肝动脉搭桥2例.供者肝动脉直径1.5～2.5 mm,采用显微外科技术在3.5倍手术放大镜和5～10倍手术显微镜下完成肝动脉重建.结果 50例成人间右半肝活体肝移植中,有2例(4%)分别于术后1d、7d发生肝动脉血栓形成,立即采用自体大隐静脉从肾下腹主动脉至供者右肝动脉搭桥术,恢复供肝血流,痊愈出院.1例术后1.5个月后发生肝动脉血栓形成,随访期无临床症状未行处理.术后和随访期未发现肝动脉狭窄、肝动脉假性动脉瘤等并发症.围手术期未有与肝动脉并发症有关的死亡病例.全部病例获得随访,随访时间2～52个月(中位随访时间9个月),1年实际生存率为92%.结论 选择恰当的肝动脉重建方式和应用显微外科技术可显著降低肝动脉并发症,及时处理肝动脉并发症是保证供肝存活的关键.     

同种异体原位肝移植的肝动脉重建

目的 总结同种异体原位肝移植术中肝动脉吻合的经验。方法 回顾悸分析20例原位肝移植术中影响肝动脉吻合的因素和处理技巧。结果 16例行供、受者肝固有动脉端端吻合，3例供者肝总动脉与受者肝固有动脉吻合，1例供者肝总动脉与受者脾动脉吻合；术后彩色多普勒超声监测显示肝动脉血流通畅，均未发现有血栓形成或肝动脉狭窄，全部病例未发生胆道并发症，现存活15例。结论 合理选择吻合用血管是避免术后发生血栓形成和动脉狭窄的关键。     

Branch patch reconstruction in living donor liver transplantation: arterialization of grafts with replaced type arteries

We developed a hepatic arterialization technique in living donor liver transplantation. The technique was indicated in patients with a left graft from donors with a right hepatic artery originated from superior mesenteric artery or a right graft from donors with a left hepatic artery from left gastric artery. The donor common hepatic and gastroduodenal arteries were split. On the recipient side, left and right hepatic arteries or branches of the right hepatic artery were split, received patch plasty, and anastomosed with the graft arteries under loupe observation. Livers from 25 donors were procured (16 right livers and 9 left livers) using this technique. There were no vascular complications in the donors. Three recipients died due to infectious disease with arterial patency. The remaining 22 recipients survived without hepatic arterial thrombosis. In limited situations, this technique can be adapted for living donor liver transplantation without increasing donor complications.     

Maintenance of the celiac trunk with the left-sided liver allograft for in situ split-liver transplantation

BACKGROUND: It has been shown that in situ split-liver transplantation (SLT) expands the cadaveric donor pool, decreases recipient waiting time, and decreases pretransplant morbidity. However, the technique as previously described requires a microvascular left hepatic artery anastomosis. In an attempt to decrease the incidence of hepatic artery thrombosis and to increase collaboration among transplant teams, in the current report, we describe a modification of the in situ SLT technique that maintains the celiac trunk with the left-sided liver allograft. METHODS: Twelve in situ split-liver procurements resulted in 24 segmental liver allografts; 11 right trisegments, 11 left lateral segments, 1 right lobe, and 1 left lobe. The common bile duct and main portal vein were maintained with the right-sided liver allograft in all cases. The right hepatic artery was divided, and the celiac trunk was maintained with the left-sided liver allograft in nine cases. In one case the left hepatic artery was divided and the celiac trunk was maintained with the right-sided allograft. Two of the 12 donors had a completely replaced left hepatic artery originating from the left gastric artery, which was divided at its origin from the celiac trunk. When the celiac trunk was maintained with the left-sided allografts, arterial reconstruction of the right-sided allograft was performed with an external iliac arterial interposition graft. Nineteen of the 24 split-liver allografts were transplanted at our center. The remaining five liver allografts were shared with regional liver transplant centers. RESULTS: In this series, 1-year actuarial patient and allograft survival rates are 100% and 96%, respectively. Hepatic artery thrombosis (HAT) did not occur in any patient receiving a left-sided split allograft in which the celiac trunk or left gastric artery was maintained; in addition, HAT did not occur in any of the right-sided allografts. HAT did occur immediately after transplantation in the one patient who was transplanted with a left lateral segment without the celiac trunk. This allograft was salvaged by early thrombectomy and interposition grafting. One patient required retransplantation, owing to portal vein thrombosis. Hepatic venous outflow obstruction did not occur in any of the patients. Two patients required reexploration in the posttransplant period because of arterial anastomotic site bleeding, and one of the left lateral segment allograft recipients had a cut-surface bile leak, which was managed nonoperatively. All of the patients are alive and well, including the five patients who received their transplants at other centers, with a median follow-up of 10 months (range, 1-27 months). CONCLUSIONS: In summary, our data demonstrate that maintaining the celiac trunk with the left-sided allograft in SLT provides excellent early survival results with low complication rates. This technical modification obviates the need for a left hepatic artery microvascular anastomosis and should lower the incidence of hepatic artery thrombosis in the small-caliber left hepatic artery. We have also shown that this technique allows sharing among liver transplant centers without compromise in patient or allograft survival rates. It is hoped that this modification in SLT will increase the number of livers split, and will promote sharing among transplant centers to truly optimize the number of liver allografts available from the cadaveric pool.     

重建肝动脉血供的小鼠原位肝移植模型的建立

目的 构建稳定的重建肝动脉血供的小鼠原位肝移植模型,初步探讨重建肝动脉血供在小鼠肝移植中的意义.方法 66只小鼠分为实验组(n=33)和对照组(n=33).实验组行重建肝动脉血供的原位肝移植术,在经典"双袖套法"的基础上,采用支架法重建肝动脉血供;对照组行非动脉化的原位肝移植.结果 共施行小鼠原位肝移植共66只.术后2周实验组生存率为84.85%(28/33),对照组生存率为81.82%(27/33);实验组的血清γ-GT和ALP水平显著低于对照组;病理学证据亦提示实验组胆管上皮细胞受损较对照组为轻. 结论肝动脉血供重建有助于减轻移植肝胆道冷保存-再灌注损伤.该模型可能成为肝移植分子生物学研究的理想动物模型.