门静脉血栓的肝移植术中处理

目的 探讨门静脉血栓(PVT)的肝移植术中外科处理方法及其效果.方法 肝移植患者2508例,共行肝移植2614次,其中253例术前并发PVT.并发PVT者的Yerdel分级为,Ⅰ级者104例,Ⅱ级者114例,Ⅲ级者29例,Ⅳ级者6例.根据具体情况对并发Ⅰ、Ⅱ级PVT者施行静脉血栓切除术、外翻血栓切除术或外翻式门静脉内膜剥脱切除术;并发Ⅲ级PVT者,18例行外翻式门静脉内膜剥脱切除术,11例行外翻血栓切除术;并发Ⅳ级PVT者行外翻式门静脉内膜剥脱切除术.结果 218例并发Ⅰ、Ⅱ级PVT者中,32例行静脉血栓切除术,52例行外翻血栓切除术,134例行外翻式门静脉内膜剥脱切除术,均获得成功.29例并发Ⅲ级PVT者中,18例行外翻式门静脉内膜剥脱切除术,均获得成功;11例行外翻血栓切除术,其中5例获得成功,6例失败.6例并发Ⅳ级PVT者中,3例行外翻式门静脉内膜剥脱切除术,获得成功,3例取栓失败.253例并发PVT者肝移植术后6个月的存活率为93.7%,与同期无PVT的肝移植患者相比较(94.4%),差异无统计学意义(P>0.05).结论 并发PVT者可接受肝移植,术中应根据PVT的Yerdel分级情况,采取适合的外科处理方式.     

Primary permanent arterialization of the portal vein in liver transplantation

Permanent total arterialization of the portal vein in liver transplantation has been described as a method of providing portal inflow after insufficient thrombectomy due to chronic occlusion of the portal-vein system. A specific problem is the restriction of the arterial inflow and its long-term adaptation after transplantation. We describe here the surgical techniques and clinical course of three patients who underwent portal-vein arterialization for liver transplantation. Two patients had an uneventful course. In one patient, a flow reduction by means of coil embolization of one arterial inflow branch was performed; thereafter, the patient recuperated well. Analysing the microcirculation of an arterialized graft in comparison with liver grafts with normal non-arterialized portal-vein inflow, we observed an increase in inter-sinusoidal distance and a decrease in sinusoidal red blood cell velocity. From a technical point of view, we recommend permanent portal-vein arterialization by an iliac artery graft interposition from the subdiaphragmatic aorta. The inflow to the portal vein can easily be reduced by the banding of the arterial graft interposition.     

肝移植术中复杂门静脉机化血栓的处理

目的：探讨存在复杂门静脉机化血栓者肝移植术中门静脉的处理要点。方法：为17例机化血栓超过门静脉内径50％的患者施行肝移植，术中9例在切除血栓段门静脉或取栓后，将受者的门静脉与供肝门静脉行端端吻合；5例将供肝门静脉与受者的曲张冠状静脉行端侧吻合；1例切除闭塞段门静脉，利用供者的髂静脉于供肝门静脉与受者肠系膜上静脉间搭桥；1例供肝门静脉与受者的胆总管前曲张静脉行端侧吻合；1例采用供者的髂静脉在供肝门静脉和受者的脾门旁曲张静脉间搭桥，行端侧吻合。结果：17例患者，死亡2例，1例死于感染，1例死于肝动脉出血，但此2例患者的门静脉血流一直通畅。存活的15例随访2～12个月，其中1例术后因门静脉血流量不足，而行二次肝移植，在缝扎分流的侧支后，门静脉血流恢复正常，其他患者的门静脉血流均通畅。结论：存在复杂门静脉机化血栓时首选栓塞段门静脉切除或取栓后门静脉重建，不能取栓或取栓后血流量不足时，可改行供肝门静脉与受者曲张内脏静脉的端侧吻合，也可取得较好效果。     

肝移植中门静脉-内脏曲张静脉吻合在门静脉机化血栓患者的应用

目的:探讨门静脉-内脏曲张静脉吻合在门静脉机化血栓患者肝移植中的应用。方法:对门静脉和肠系膜上静脉均完全被机化血栓阻塞的7例患者实施肝移植,其中3例供体门静脉-曲张冠状静脉吻合;2例髂静脉搭桥供体门静脉和脾门旁曲张的静脉吻合;1例采用供体门静脉-胆总管前曲张静脉吻合;1例供体门静脉—曲张的胃网膜右静脉吻合。结果:7例手术全部成功。1例术后7d死于多脏器功能衰竭,但是门静脉血流一直通畅。1例术后6个月发现吻合口狭窄,术后9个月采用经皮肝穿刺门静脉支架置入治愈;其余患者分别随访12～22个月,门静脉血流均通畅,无狭窄或血栓形成,肝、肾功能正常。结论:肝移植中对门静脉和肠系膜上静脉均完全被机化血栓阻塞的患者,行供体门静脉-曲张内脏静脉吻合可取得良好疗效。     

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目的　探讨肝移植围手术期门静脉血栓的处理。方法　回顾性分析 2 0 0 3年 10月至 2 0 0 4年 6月 14 0例原位肝移植病人的临床资料。结果　通过彩色多普勒、螺旋CT加三维血管成像和间接门脉造影共确诊肝移植术前门静脉血栓 5例。其中螺旋CT加三维血管成像 (CTA)对门静脉血栓的诊断特异性为 10 0 % ,彩色多普勒的诊断特异性为 80 % ,间接门脉造影的诊断特异性为 2 0 %。肝移植术中采用门静脉血栓切除术治疗成功率为10 0 %。结论　肝移植术中门静脉血栓切除术是治疗门静脉血栓的有效方法。CTA检查能准确判断门静脉血栓的程度。肝移植术后预防性抗凝能有效预防门静脉血栓复发。     

Arterialization of the portal vein in pediatric liver transplantation

Portal vein arterialization (PVA) is an acquired concept in shunt surgery for portal hypertension. This technique, recently described as both a temporary and permanent procedure in adult liver transplantation, is reported by the authors in two cases of pediatric transplantation. The indication was low portal blood flow after reperfusion with poor graft function due to persistence of spontaneous retroperitoneal venous shunts. In both cases described, PVA allowed for satisfactory macroscopic liver reperfusion. The increase in portal blood flow from 150 to 500 ml/min in the second patient enabled the liver to be reperfused correctly and led to successful transplantation. The graft function in both cases improved in the 1st postoperative week, but thrombosis of the PVA occurred in the 1st patient 2 months after transplantation. Signs of hepatic hyperarterialization occurred in the second patient and this necessitated a dearterialization of the portal vein 2 weeks later. Although the benefit of this procedure appears to be beyond doubt in the immediate postoperative period, we have no data on long-term arterialization. We do think that PVA can be performed in pediatric liver transplantation, but it may need to be done only in special, individual situations when no valid alternative can be proposed, such as in the absence of a mesenteric vein and/or the presence of spontaneous retroperitoneal venous shunts. Received: 24 June 1997 Received after revision: 27 November 1997 Accepted: 28 November 1997     

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。     

Auxiliary liver transplantation with arterialization of the portal vein for acute hepatic failure

Six adult patients suffering from acute hepatic failure and with a high urgent status underwent heterotopic auxiliary liver transplantation. In four of these patients, the portal vein of the liver graft was arterialized in order to leave the native liver and the liver hilum untouched and to be able to place the liver graft wherever space was available in the abdomen. The arterial blood flow via the portal vein was tapered by the width of the anastomosis. Two patients died, one of sepsis on postoperative day 17 (POD), the other after 3 months due to a severe CMV pneumonia. There were no technically related deaths. The native liver showed early regeneration in all cases. In one patient, the auxiliary graft was removed 6 weeks after transplantation. Four weeks later, he had to undergo orthotopic retransplantation due to a recurrent fulminant failure of the recovered native liver. This patient is alive more than 1 year after the operation. We conclude that heterotopic auxiliary liver transplantation with portal vein arterialization is a suitable approach to bridging the recovery of the acute failing native liver. Received: 15 September 1997 Received after revision: 4 February 1998 Accepted: 2 March 1998     

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。     

门静脉血栓对终末期肝硬化病人行肝移植手术的影响

目的探讨合并门静脉血栓(portal vein thrombosis,PVT)的终末期肝硬化病人行肝移植手术的处理方法及其疗效。方法回顾性分析2010年1月至2015年12月在中山大学附属第一医院器官移植中心接受肝移植手术的152例终末期肝硬化病人的临床资料。32例合并PVT的病人作为PVT组,其中Ⅰ级10例、Ⅱ级13例、Ⅲ级8例、Ⅳ级1例。其余120例无PVT的病人作为对照组。结果PV/T组术前脾切除史的比例明显高于对照组(46.8%比18.3%,P0.05),差异有统计学意义。PVT组较对照组明显延长无肝期时间[(72.5±25.3)min比(57.6±18.4)min,P0.05]和总手术时间[(622.4±183.5)min比(503.2±123.6)min],差异均有统计学意义。2组病人在术中出血量、ICU住院时间、术后并发症发生率、围手术期病死率、1年及3年生存率的比较上差异均无统计学意义(P0.05)。PVT组术后再栓塞率高于对照组(9.4%比1.7%,P0.05)。结论门静脉血栓一定程度上增加了终末期肝硬化病人肝移植手术的难度,Ⅰ~Ⅲ级PVT不影响病人的预后,仍可通过肝移植手术取得良好的疗效。Ⅳ级PVT肝移植手术的难度和风险会明显增加,应谨慎对待。     

Improved technique of heterotopic auxiliary rat liver transplantation with portal vein arterialization

BACKGROUND AND AIMS: In acute, potentially reversible hepatic failure, auxiliary liver transplantation is a promising alternative approach. Using the auxiliary partial orthotopic liver transplantation (APOLT) method--the orthotopic implantation of auxiliary segments--most of the technical problems (lack of space for the additional liver mass, the portal vein reconstruction, and the venous outflow) are avoided, but extensive resections of the native liver and the graft are necessary. Erhard described the heterotopic auxiliary liver transplantation (HALT) with portal vein arterialization (PVA). Initial clinical results demonstrated that an adequate liver function can be achieved using this technique. We developed and improved a technique of HALT with flow-regulated PVA in the rat to perform further investigations. The aim of this paper is to explain in detail this improved experimental surgical technique. MATERIALS AND METHODS: Liver transplantations were performed in 122 male Lewis rats: After a right nephrectomy, the liver graft, which was reduced to about 30% of the original size, was implanted into the right upper quadrant of the recipient's abdomen. The infrahepatic caval vein was anastomosed end-to-side. The donor's portal vein was completely arterialized to the recipient's right renal artery in stent technique. Using a stent with an internal diameter of 0.3 mm, the flow in the arterialized portal vein was regulated to achieve physiologic parameters. The celiac trunk of the graft was anastomosed to the recipient's aorta, end-to-side. The bile duct was implanted into the duodenum. RESULTS: After improvements of the surgical technique, we achieved a perioperative survival of 90% and a 6-week survival of 80% in the last 112 transplantations. CONCLUSION: We developed a standardized and improved technique, which can be used for experiments of regeneration and inter-liver competition in auxiliary liver transplantation. Furthermore, this technique is suitable for the investigation of the influence of portal vein arterialization and portal hyperperfusion on liver microcirculation, function, and morphology.     

肝移植术中门静脉血栓和瘤栓的处理

目的 探讨肝移植时门静脉血栓和瘤栓的处理方法和临床效果.方法 2000年8月至2004年底我院施行的150例肝移植患者中5例为肝硬化伴门静脉血栓形成,21例为肝癌伴门静脉瘤栓及/或血栓形成,共26例.这些病例在术中清除了门静脉内的栓子,3例又行门静脉壁部分切除及低位门静脉对端吻合术,1例行门腔静脉半转位吻合术.结果 26例中1例术后门静脉又再发血栓形成.21例肝癌合并门静脉瘤栓者,术后近期死亡3例,分别死于：门静脉继发性血栓形成,移植肝原发性无功能和多器官衰竭.18例得到长期随访,术后1、2、3年生存率分别为：66.7%,38.9%,27.8%.结论 肝移植时受体门静脉合并血栓/瘤栓者在清除栓子后再行肝移植仍然可取得较好的疗效.     

Reconstructing the portal vein through a posterior pancreatic tunnel: New choice for portal vein thrombosis during liver transplantation

BACKGROUNDThrombectomy and anatomical anastomosis (TAA) has long been considered the optimal approach to portal vein thrombosis (PVT) in liver transplantation (LT). However, TAA and the current approach for non-physiological portal reconstructions are associated with a higher rate of complications and mortality in some cases.AIMTo describe a new choice for reconstructing the portal vein through a posterior pancreatic tunnel (RPVPPT) to address cases of unresectable PVT.METHODSBetween August 2019 and August 2021, 245 adult LTs were performed. Forty-five (18.4%) patients were confirmed to have PVT before surgery, among which seven underwent PV reconstruction via the RPVPPT approach. We retrospectively analyzed the surgical procedure and postoperative complications of these seven recipients that underwent PV reconstruction due to PVT.RESULTSDuring the procedure, PVT was found in all the seven cases with significant adhesion to the vascular wall and could not be dissected. The portal vein proximal to the superior mesenteric vein was damaged in one case when attempting thrombolectomy, resulting in massive bleeding. LT was successfully performed in all patients with a mean duration of 585 min (range 491-756 min) and mean intraoperative blood loss of 800 mL (range 500-3000 mL). Postoperative complications consisted of chylous leakage (n = 3), insufficient portal venous flow to the graft (n = 1), intra-abdominal hemorrhage (n = 1), pulmonary infection (n = 1), and perioperative death (n = 1). The remaining six patients survived at 12-17 mo follow-up.CONCLUSIONThe RPVPPT technique might be a safe and effective surgical procedure during LT for complex PVT. However, follow-up studies with large samples are still warranted due to the relatively small number of cases.     

门静脉血栓形成对肝移植手术相关参数的影响

目的 探讨术前合并门静脉血栓(PVT)对原位肝移植(OLT)受者手术和术后相关参数的影响.方法 回顾性分析2002年2月至2007年2月武警总医院836例成人OLT病人中71例术前合并门静脉血栓(PVT组)和765例无门静脉血栓(对照组)病人的临床资料.比较两组手术时间、无肝期时间、输血量等手术参数以及ICU时间、住院时间、PVT复发、移植物功能、门静脉血流量、围手术期病死率和1、3、5年生存率等术后参数.结果 PVT组手术时间(min)和无肝期时间(min)明显长于对照组(分别为792.47±162.29和516.18±186.30,P<0.01;77.53±24.76和48.55±31.20;P<0.05).两组间术中输血量、平均ICU时间、住院时间没有显著差异(P>0.05).PVT组术后再栓塞率显著高于对照组(分别为9.86%和1.44%,P<0.01).除90 d时PVT组门静脉血流(PVF,cm/s)较高(41.43±17.19和19.85±11.39,P<0.05)外,两组间各随访时段移植物功能和PVF没有显著性差异.PVT组围手术期病死率略高于对照组而1、3、5年生存率稍低于对照组,但是差异均没有显著性.结论 术前PVT可能会增加肝移植手术复杂程度,但并不影响肝移植效果.     

Outcome of modified portal vein anastomosis for recipients with portal vein thrombosis or stenosis before living donor liver transplantation

Background

Portal vein thrombosis (PVT) or stenosis (PVS) often requires challenging techniques for reconstruction in living donor liver transplantation (LDLT).

Materials and Methods

A total of 57 LDLTs were performed between October 1996 and December 2010. There were 16 cases (28%) with PVT/PVS that underwent modified portal vein anastomosis (m-PVa). The m-PVa techniques were classified into 3 groups: patch graft (Type-1), interposition graft (Type-2), and using huge shunt vessels (Type-3). The reconstruction patterns were evaluated with regard to age, graft vessels, PV flow, and complication rate.

Results

The m-PVas were Type-1 in 10 cases, Type-2 in 3 cases, and Type-3 in 3 cases. The vessel graft in Type-1 was the inferior mesenteric vein (IMV) in 8 and the jugular vein in 2 cases, whereas the vessel graft in Type-2 was IMV in 2 and the saphenous vein in 1 case; in Type-3, the vessel grafts were renoportal, gonadal-portal, and coronary-portal anastomoses, respectively. The postoperative PV flow was sufficient in all types and slightly higher in Type-3. The postoperative complications occurred in 20% of the patients who underwent Type-1, in 33% who underwent Type-2, and in 0% who underwent Type-3.

Conclusion

The m-PVa was effective to overcome the surgical difficulty during transplantation. Pretransplant planning for the selection of the type of reconstruction is important for recipients with PVT/PVS.     

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.     

肝移植术后门静脉并发症的诊断和治疗(附6例分析)

目的 探讨肝移植术后门静脉并发症的诊断和治疗。方法 回顾性分析160例原位肝移植临床资料。结果 肝移植术后门静脉并发症发生率为3．75％,与门静脉并发症相关死亡率为0。门静脉狭窄发生率为1．25％,门静脉栓塞发生率为2．5％,需治疗的门静脉并发症占33．3％。结论 术前有门脉高压症手术治疗史、移植术前门静脉血栓、门静脉手术史以及严重感染病史等是门静脉并发症的高危因素;彩色多普勒超声检查是监测门静脉并发症的有效方法,确诊门静脉并发症依赖门静脉造影;有症状的门静脉并发症需及时行再血管化手术。     

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。     

门静脉血栓与肝移植

门静脉血栓形成(PVT)是指门静脉主干以及门静脉属支内血栓形成。由于PVT常缺乏特征性表现,主要依赖于术前影像学检查发现,甚至在术中偶然发现PVT。随着我国肝移植事业的不断发展,移植过程中发现PVT的案例越来越多,PVT已不再是肝移植禁忌证。因此,针对PVT的诊断、治疗以及移植过程中的处理方法显得尤为重要。本文根据国内外最新研究进展及经典文献报道,对肝移植中PVT展开综述。     

肝移植术后迟发性门静脉血栓形成12例

目的 总结肝移植术后迟发性门静脉血栓形成的治疗方法,并分析其预后.方法 单中心3100例次尸体全肝移植中发生迟发性门静脉血栓形成12例,发生时间平均为移植术后29.8个月.12例中,2例合并严重胆道并发症(肝内胆道狭窄),2例表现为移植肝功能衰竭,1例影像学检查可见肝门部肿物致门静脉受压,均接受再次肝移植;2例表现为急性上消化道出血,分别行经胃镜下套扎、注射硬化剂治疗;余5例无任何临床表现,口服抗凝或抗血小板药物治疗.结果 12例中,除1例失访外,其他患者至随访结束时存活8例,包括2例行再次肝移植者.存活者肝功能检查结果均正常.结论 肝移植术后发生迟发性门静脉血栓形成,应根据患者的临床表现不同采用不同的治疗方法.

Abstract：

Objective To summary therapeutic method for delayed portal vein thrombosis after liver transplantation. Methods In 3100 cases undergoing cadaveric whole liver transplantation in a single center, there were 12 cases of delayed portal vein thrombosis after liver transplantation.Average occurring time was 29. 8 months after liver transplantation. Among these 12 patients, 2 cases were complicated with severe biliary complication (intrahepatic stricture) , 2 cases presented with liver failure of transplanted liver, and one case had portal vein compression by hepatic hilum tumor under the image examination, who received liver re-transplantation; two patients presented upper gastrointestinal bleeding, and they experienced endoscopic ligation and sclerotherapy respectively; the rest five patients without any clinical presentation were subjected to anticoagulation and antiplatelet therapy. Results Among 12 cases, 8 patients survived by the time of follow-up, including two patients undergoing re-transplantation; one patient lost follow-up. The liver function tests of the patients who survived were all normal. Conclusion The individualized therapeutic methods should be adopted for the patients with delayed portal vein thrombosis after liver transplantation.