儿童活体部分肝移植

活体部分肝移植术现已成为儿童终末期肝病的有效治疗方法,本文就儿童活体部分肝移植的适应证、禁忌证、术前供受者评估、供者肝部分切取、受者手术要点以及术后并发症及预后方面进行综述.     

儿童亲属活体肝移植的麻醉处理

目的 总结儿童亲属活体肝移植的麻醉处理。方法 回顾11例肝豆状核变性患儿行亲属活体肝移植手术的麻醉处理过程，对一些重要生理指标如血压、心率、中心静脉压、体温、激活凝血酶原时间、血糖、血钾和血浆乳酸浓度进行分析。结果 术中，尤其是在无肝早期及新肝早期，血液动力学波动较大，体温在无肝后期及新肝期有不同程度下降，凝血功能随着手术的进行有一定程度的恶化，血浆乳酸水平在手术后期明显增高。11例患儿均健康生存，其中1例是于术后因肝动脉血栓形成而行再次异体肝移植术取得成功。结论 儿童亲属活体肝移植术中多项生理指标发生明显变化，加强各生理指标的监测、及时纠正循环和代谢紊乱是保证手术成功的关键。     

儿童活体肝移植42例临床报告

目的 总结成人活体部分供肝儿童肝移植的临床疗效和经验.方法 42例儿童患者,年龄80 d至14岁.小于1岁者28例;体重3.08～45 kg,小于10kg者27例.移植前有不同程度的黄疸、腹水、营养不良和肝功能严重损害.其中父母供肝36例,祖母供肝4例.舅父和表兄供肝各1例.供肝类型包括:左外叶31例.Ⅱ段肝组织1例,左半肝8例.右半肝2例.对供肝的肝静脉、肝动脉和受者的肝动脉、肝静脉、门静脉进行成形.以便吻合;供肝动脉较短者,以供者大隐静脉搭桥.免疫抑制方案:采用环孢素A(CsA)+糖皮质激素21例,CsA+吗替麦考酚酯(MMF)+糖皮质激素8例,他克莫司(Tac)+糖皮质激素7例,Tac+MMF+糖皮质激素6例.术后随访时问2～43个月.结果 移植物与受者质量比为0.91%～5.71%,移植物与受者标准肝体积比为40.7%～137.1%.术后早期32例(76.2%,32/42)出现并发症,死亡5例,其中4例死于血管并发症;随访期9例出现并发症,死亡4例,其中3例死于血管并发症;意外死亡2例.其余31例(73.8%,31/42)健康存活.结论 成人活体部分供肝儿童肝移植是治疗儿童终末期肝病的有效方法,术后血管并发症是主要的死亡原因.预防和治疗血管并发症能明显提高手术成功率.     

小儿活体部分肝移植现状

正肝移植目前已成为小儿终末期肝脏疾病的常规治疗手段。活体部分肝移植(livingrelated partial liver transplantation,LRLT或LRPLT)是近年来逐步发展起来的一种新的肝移植方法,已在小儿肝移植中广泛的应用。1988年,巴西Raia医生报道了人类历史上第一例儿童活体肝移植,随后1989年澳大利亚Strong医生等报道了世界上第一例真正获得临床存活的儿童活体肝移植。随着活体肝移植技术的引进和发展,中国也在1997年报道国内首例成功完成的     

儿童活体肝移植术后罕见并发症——右侧膈疝

目的  分析儿童活体肝移植术后发生右侧膈疝的临床特点、致病原因和治疗经验。方法  回顾性分析3例儿童活体肝移植术后发生右侧膈疝受者的临床资料,分析其临床特点和诊疗经过,总结治疗经验。结果  3例活体肝移植术后发生膈疝患儿的原发性疾病均是胆道闭锁。膈疝发生时间为肝移植术后4~6个月。膈疝内容物包括腹膜内位和腹膜间位的组织和器官。膈肌缺损均位于右膈后内侧区,术中行一期间断缝合修补,长期随访无膈疝复发。结论  儿童活体肝移植术后发生右侧膈疝的临床表现多样,危险因素包括营养不良状态、低体质量、手术创伤、胆漏导致的化学腐蚀、局灶性感染以及胸膜-腹腔内压力梯度等。手术干预是肝移植术后膈疝的首选治疗策略。     

亲属活体供肝移植治疗儿童终末期肝病六例

目的 探讨亲属活体供肝移植(LDLT)治疗儿童终末期肝病的效果,并总结治疗经验.方法 2005年9月至2007年1月对6例终末期肝病患儿进行了LDLT.6例患者中,原发病为肝内外胆管弥漫性囊性扩张症Ⅳ型伴肝硬化1例、肝豆状核变性2例、门静脉海绵样变性3例;供者为患儿的母亲3例、父亲2例及舅父1例,分别切取供者的右半肝1例和左半肝5例作为供肝;在切除受者全部病肝和保留下腔静脉后,对受者施行部分供肝的原位肝移植.术后依据供、受者的临床表现、血液学指标和影像学检查,对活体供肝移植的治疗效果进行评价.结果 术后对供、受者随访了6～21个月.6例供者均健康存活,未发生并发症.6例受者中,1例于术后第4天死于门静脉血栓形成,1例于术后5个月时死于肝内静脉血栓形成,其余4例均长期健康存活.结论 亲属活体供肝移植是治疗儿童终末期肝病的有效方法.术前进行仔细的供、受者选择和完善的影像学检查,术中应用精确的手术技术,术后给予严格的管理是儿童LDLT成功的关键.     

儿童活体肝移植术后住院期间细菌感染的临床研究

目的 研究儿童活体肝移植术后细菌感染的常见病原菌种类、分布特征及耐药性.方法 回顾性分析41例儿童活体肝移植的临床资料,对受者术后住院期间的细菌感染发生率、感染发生时间、感染部位、病原菌种类和分布以及药敏试验结果进行总结.结果 41例肝移植受者中,有33例受者发生细菌感染69次,细菌感染发生率为80.5％(33/41).主要的感染部位依次是下呼吸道32例次(占46.6％)、腹腔16例次(占23.3％)及胆道11例次(占15.9％).共检出致病菌101株,其中革兰阴性菌(G-菌)占73.3％(74/101),超广谱β-内酰胺酶(ESBL)检出率为81.1％ (60/74);革兰阳性菌(G+菌)占26.7％(27/101),耐甲氧西林凝固酶阴性葡萄球菌(MRCNS)检出率为59.3％(16/27),氨基糖苷类高耐药肠球菌(HLAR)检出率为11.1％(3/27).术后2周内检出致病菌72株(71.3％).常见致病菌为铜绿假单胞菌、表皮葡萄球菌和大肠埃希菌等.致病菌对β-内酰胺类加酶抑制剂和头孢类的耐药率超过60％,主要的产ESBL的G-菌对碳青霉烯类敏感,耐药率＜10％;碳青霉烯类药物亚胺培南/西司他丁、美罗培能对质粒介导的ESBL、染色体及质粒介导的头孢菌素酶(AmpC酶)均具有高度稳定性;铜绿假单胞菌对碳青霉烯类和儿科常用抗生素均高度耐药,仅对喹诺酮类敏感;凝固酶阴性葡萄球菌和肠球菌对万古霉素、利奈唑胺、奎奴普丁/达福普丁高度敏感.结论 肝移植术后细菌感染发生率高,耐药菌株检出率高,且具有多重耐药特点.有效地预防感染,术后早期确诊和合理选用抗生素是控制细菌感染的关键.     

儿童活体肝移植受者术后新发乙型肝炎病毒感染的临床研究

目的  探讨儿童活体肝移植术后新发乙型肝炎病毒(HBV)感染的临床特点及其防治策略。方法  2010年7月至2014年7月, 在首都医科大学附属北京友谊医院移植中心和天津一中心医院器官移植中心接受活体肝移植术的106例儿童受者纳入本研究, 所有手术由同一外科团队完成。根据供者术前HBV血清学标志物的结果, 将儿童受者分为供肝乙型肝炎核心抗体(抗-HBc)阳性组(45例)和供肝抗-HBc阴性组(61例)。了解两组儿童受者的新发HBV感染情况, 分析供肝抗-HBc阳性组儿童受者新发HBV感染的危险因素, 了解新发HBV感染患儿的特征。结果  供肝抗-HBc阳性组和阴性组新发HBV感染发生率分别为18%(8/45)和2%(1/61)。受者术前抗-HBs阴性、术后无抗病毒治疗是抗-HBc阳性供肝受者新发HBV感染的危险因素(均为P < 0.05)。发病距移植手术的中位数时间12个月(8~48个月)。9例儿童受者中, 接受拉米夫定治疗7例, 未予抗病毒治疗2例, 均全部存活。结论  应用抗-HBc阳性供肝的儿童肝移植受者, 其术后存在感染HBV的风险。受者术前抗-HBs阴性、术后未给予预防性核苷类似物治疗是抗-HBc阳性供肝受者新发HBV感染的危险因素。接受供体抗-HBc阳性的肝移植儿童受体应使用核苷类似物预防新发HBV感染, 移植术前亦要加强对其接种乙肝疫苗。     

活体肝移植治疗儿童胆道闭锁44例

目的 观察活体肝移植治疗儿童胆道闭锁的效果,总结其临床经验.方法 2006年10月至2010年12月间共有44例胆道闭锁患儿接受了活体肝移植,其中男性26例,女性18例,年龄(12.1±9.0)个月,中位数为9个月(6～60个月);44名供者全部为患者直系亲属,年龄(32.7±8.0)岁,中位数为31岁(20～54岁).供、受者ABO血型相容,供肝均为供者肝脏的左外叶.对供、受者术前评估过程、手术方法、术后管理以及预后等临床资料进行总结.结果 术后对全部供者进行系统随访,随访时间(17.5±13.3)个月,无供者发生严重并发症和死亡,所有供者均恢复健康.44例受者中,死亡9例,死因分别为门静脉栓塞3例、肝动脉栓塞1例、胆道并发症2例、切口感染1例、腹腔出血1例及肺部感染1例,其余35例健康存活.术后1年和2年累积存活率分别为81.2%和76.1%,无一例受者接受再次肝移植.术后主要并发症有门静脉血栓、肝动脉血栓、胆汁漏及逆行性胆管炎、肺部感染、切口感染及急性排斥反应等.结论 活体肝移植是治疗儿童胆道闭锁的有效方法,预后良好.完善缜密的术前评估,熟练精细的手术操作以及精心的术后管理是改善受者预后的关键因素.

Abstract：

Objective To observe the outcomes of living donor liver transplantation (LDLT) for children with biliary atresia (BA) and to summarize the clinical experiences. Methods Forty-four BA patients (26 boys and 18 girls) underwent LDLT between October 2006 and December 2010. Mean (SD) and median (range) age at operation was (12.1 ± 9.0) months and 9 (6-60) months,respectively. The 44 donors were lineal relatives to the consorted recipients. Their mean (SD) and median (range) age at operation was (32. 7 ± 8. 0) months and 31 (20～54) years, respectively. All donor graft types were the left lateral segments with compatible ABO blood groups. Clinical data,including pre-operative evaluations, surgical technique, postoperative management and outcomes in all donors and recipients were retrospectively analyzed. Results All donors were followed up for (17. 5 ± 13. 3) months. No donor mortality was encountered, with a minimal morbidity and no long-term sequelae. Nine out of 44 recipients died. Three patients died of portal vein thrombosis (PVT), one of hepatic artery thrombosis (HAT), two of biliary complications, one of surgical site infections, one of abdominal bleeding and one of pulmonary infection. The overall 1-year and 2-year cumulative survival rate in recipients was 81. 2% and 76. 1 %, respectively. No re-transplantation was done. Postoperative complications included PVT, HAT, biliary leakage and refluxing cholangitis, pulmonary infections,surgical site infections and acute rejection. Conclusion LDLT has been the effective treatment for pediatric recipients with BA and provides favorable prognosis. To improve prognosis of recipients, the key points are pre-operative evaluations, surgical technique, and postoperative management     

儿童肝移植腹腔镜活体供肝切取术

因为尸体供肝来源的缺乏 ,在肝移植中活体供肝的应用越来越多。作者设计了一种安全可行的腹腔镜活体供肝切取技术 ,并进行了两例手术。两受肝者均为供者的儿子 ,均 1岁大小 ,患有胆道闭锁症 ,均在 2个月大小时做了肝门空肠吻合术 ,肝移植前伴有黄疸、腹水和肝功能衰竭。两供肝者为自愿献肝的一名 2 7岁妇女和一名 31岁男子。分别在全麻下进行了腹腔镜肝左外叶 (2、3段 )切除。取截石位 ,在中上腹置放 5个穿刺套管 ,在腹腔镜下对移植肝进行处理 ,步骤包括游离左半肝 ,分离左肝动脉、左门静脉和左肝胆管 ,分离肝左静脉。在肝圆韧带和镰状韧带…     

Adult-adult living donor liver transplantation

After the first report from Denver in 1998 of a successful liver transplant in an adult using the right lobe from a living donor, the procedure was rapidly adopted by many transplant centers as a potential solution to the critical shortage of donor livers. By the end of 2000, when the National Institutes of Health held a Consensus Conference on Adult-Adult Living Donor Transplantation (AALDT), a substantial body of literature had already developed and many of the associated technical and medical pitfalls had been defined. The exponential expansion of the procedure came to a dramatic halt in January 2002 when the death of a donor occurred at Mount Sinai Hospital—the busiest AALDT center in the United States. This led to a widespread reassessment of the risks inherent in right lobe donation. Yet, the problem that drove the development of this controversial technique—the dire shortage of organs for transplantation—still persists. After a 50% drop in the number of AALDT procedures performed in the United States in 2002 compared with 2001, centers are regrouping and approaching AALDT with renewed interest, albeit with heightened awareness of the attendant risks. On November 2, 2002, a state-of-the-art symposium on AALDT was held in Boston, MA, under the combined auspices of the American Hepatico-Pancreato-Biliary Association and the American Association for the Study of Liver Diseases. This article comprises the presentations at the symposium on three subjects of critical importance concerning AALDT. These include advances in surgical technique, candidate selection, and hepatic regeneration; each subject is acknowledged by an expert in the field. Presented at 2002 AHPBA/AASLD Surgical Forum, Boston, MA, November, 2002.     

Fatty liver caused by portal vein thrombosis after living donor liver transplantation: a case report

Portal vein thrombosis (PVT) is a rare complication that occurs after liver transplantation: however, it cannot be ignored as a cause of graft loss and death. We herein report a pediatric case of PVT that caused a fatty change in the graft after living donor liver transplantation. The portal vein was successfully reconstructed using the left great saphenous vein of the same donor. Moreover, the fatty liver recovered after the operation. Our case suggests that the finding of fatty liver is an important marker of PVT and immediate portal reconstruction is performed.     

活体肝移植后小肝综合征4例

目的:探讨活体肝移植后小肝综合征的病因及其诊治。方法:结合文献,回顾性分析4例小肝综合征的临床特点及治疗经验。结果:4例均有高胆红素血症,2例出现顽固性腹水,最终2例死亡,1例经保守治疗治愈,1例经急诊再次肝移植后治愈。结论:小肝综合征是活体肝移植术后严重并发症,诊治较困难;术前CT评估体积并不能绝对避免小肝综合征的发生;严重者需行再次肝移植。     

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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。     

Adult living donor liver transplantation using right posterior segment

Varying circumstances call for various types of donor hepatectomy. We report here on an unusual type of donor hepatectomy, right posterior segmentectomy. A 46-year-old sister of the recipient was the donor. Her preoperative CT showed that the right anterior portal vein originated from the umbilical portion of the left portal vein. Intraoperative cholangiography revealed that the right posterior hepatic duct joined the common hepatic duct in the extrahepatic area. Right posterior segmentectomy was performed without transfusion in the donor. The postoperative course proceeded favorably in both donor and recipient until postoperative day 41, when the recipient unexpectedly expired as a result of cerebral hemorrhage. The donor was discharged with good liver function. We can conclude that the right posterior segment of the donor can be used as a graft, when the volume of left liver is not enough for both donor and recipient, or the vascular structures favor right posterior segmentectomy.     

Direct measurement of hepatic blood flow during living donor liver transplantation in children

Background

The changes in liver blood flow associated with living donor liver transplantation (LDLT) in children have not yet been studied. The aim of the present study was to investigate changes in hepatic hemodynamics before and after pediatric partial liver transplantation.

Methods

In 7 pediatric recipients with congenital cholestasis and native liver Child-Pugh classes B and C, portal vein flow (PVF) and hepatic arterial flow (HAF) were measured using an ultrasonic transit time flow meter before removal of the native liver and after transplantation and compared with donor left PVF and donor left HAF.

Results

The mean portal contribution to total hepatic blood flow was markedly decreased in the recipient native liver compared with that in the donor (69% ± 15% vs 32% ± 15%; P = .0003) and after reperfusion changed to almost the same ratio as that in the donor liver (73% ± 18%; P < .0001).

Conclusion

The extreme imbalance between PVF and HAF that is common in implanted partial liver in adult LDLT recipients was not observed in pediatric LDLT. After transplantation of an appropriately sized liver graft, the portal contribution to total liver blood flow normalized to the value for normal liver.     

活体肝移植术后供体胆漏的诊治体会

目的  总结活体肝移植术后供体胆漏的诊治经验。 方法  回顾性分析95例活体肝移植供体的临床资料,了解术后胆漏并发症发生情况,重点分析胆漏并发症供体的临床表现、处理方法及治疗效果。 结果  95例肝移植供体术后发生胆漏9例,胆漏的发生率为9%。9例胆漏供体的供肝部位均为左外叶,均为肝断面迟发型胆漏,临床表现无典型胆汁性腹膜炎表现,血清胆红素升高。给予经皮穿刺引流或保留引流管处理后均治愈,无二次手术及死亡病例。 结论  活体肝移植供体术后应注意监测供体肝功能及肝动脉血流动力学变化,对并发胆漏的供体予以积极治疗,预后良好。     

右半肝活体肝移植验证标准肝体积公式

目的 分析216例活体肝移植患者的临床资料,探讨适合中国成人活体肝移植肝体积评估标准.方法 华西医院移植中心2001年7月至今共实施216例活体肝移植,选取符合标准的成人间活体右半肝(不含肝中静脉)179例肝移植供体,将供体的术中实测右半肝体积与CT测量右半肝体积以及各公式计算的标准右半肝体积进行比较,评估哪种公式更适合中国成人.结果 CT测量右半肝体积大于实际右半肝体积(P＜0.01).德国Heinemann、美国Yoshizumi、日本Urata、美国Vauthey、韩国Lee公式计算的右半肝体积结果显著大于实际肝脏体积(P＜0.01).香港Sheung Tat 公式计算的右半肝体积结果小于实际肝脏体积,差异有统计学意义(P＜0.05).华西Lünan-yan公式计算的右半肝体积结果与实际肝脏体积比较差异无统计学意义(P＞0.05).结论 华西Lünan-yan 标准肝体积公式适合中国成人活体肝移植标准肝体积评估.     

婴幼儿活体肝移植33例

目的 探讨活体肝移植治疗婴幼儿终末期肝病的疗效.方法 回顾性分析2006年10月至2009年9月上海交通大学医学院附属仁济医院33例实施活体肝移植的婴幼儿的临床资料.本组患儿中位年龄10.9个月,平均体质量8.2 kg,供肝均采用肝左外叶.术后采用他克莫司或环孢素A+激素二联方案或在此基础上再加用吗替麦考酚酯的三联方案行免疫抑制治疗.分析评价手术方法、围手术期处理和随访结果.结果 供者和受者手术时间、术中出血量、术中输血量分别为(384±108)min、(183±35)ml、0和(500±103)min、(296±163)ml、(292±159)ml,供肝冷缺血时间为(64±23)min,移植物质量为(249±52)g,移植物质量与受者体质量比为2.1%±0.4%.全部供者均顺利康复,无手术并发症.受者出现肝动脉栓塞3例,门静脉栓塞2例,各类胆道并发症9例,感染11例,急性排斥反应2例,围手术期死亡5例.本组患儿1年累积生存率为85%(28/33).结论 婴幼儿终末期肝病可通过活体肝移植取得理想的效果.外科技术的提高、围手术期管理经验的积累和规范的随访可提高手术成功率和长期生存率.

Abstract：

Objective To evaluate the efficacy of living donor liver transplantation in the treatment of infants with end-stage liver diseases. Methods The clinical data of 33 infants who received living donor liver transplantation at the Renji Hospital of Shanghai Jiaotong University from October 2006 to September 2009 were retrospectively analyzed. The median age of the infants was 10.9 months, and the mean body weight was 8.2 kg.All of the grafts were left lateral lobes. Tacrolimus (or cyclosporine A) + steroid or tacrolimus (or cyclosporine A)+ steroid + mycophenolate mofeti] were applied to the infants to suppress the immune reaction. Operative techniques, perioperative management and results of follow-up were analyzed. Results The mean operation time,blood loss and blood transfusion of the donors were (384±108)minutes, (183±35) ml and O, and the three indexes of the recipients were (500± 103) minutes, (296±163) ml and (292 ± 159) ml , respectively. The cold preservation time of the grafts was (64 ±23)minutes, the mean weight of the grafts was (249 ±52)g, and the mean graft to recipient weight ratio was 2.1% ± 0.4%. All donors recovered smoothly and no complication occurred. Of the recipients, three were complicated with hepatic artery thrombosis, two with portal vein thrombosis,nine with biliary complications, 11 with infection, two with acute rejection and five infants died perioperatively.The one-year cumulative survival rate of the infants was 85% (28/33). Conclusions Infants with end-stage liver diseases could be treated by living donor liver transplantation. The development of surgical techniques and perioperative managements improves the success rate of operation and the long-term survival rate.     

成人活体肝移植的早期经验

目的 总结成人活体肝移植的早期经验,提高活体肝移植效果.方法 回顾性分析解放军总医院肝移植中心2006年6月至2008年2月31例成人活体肝移植资料.结果 31例中慢性乙型肝炎肝硬化失代偿期8例,急性肝功能衰竭7例,肝细胞肝癌12例,肝脏紫癜病2例,肝门部胆管癌1例和Wilson 病1例.含肝中静脉(middle hepatic vein,MHV)的右半肝移植25例,不含MHV的右半肝移植3例,双供肝为含MHV的右半肝+左外叶和含MHV的右半肝+左半肝各1例,左半肝辅助性原位肝移植1例.33例供者中5例发生并发症6例次.9例受者发生并发症11例次,其中胆道并发症4例,血管并发症3例,感染性并发症3例,切口延迟愈合1例.2例肺部感染和1例全身多处曲霉菌感染者死亡.结论 活体肝移植已成为拓展供肝来源的有效途径,合理的供、受者评估,手术方式和术后处理是关键.