活体右半肝移植的流出道重建21例

目的 探讨活体右半肝移植中的流出道重建技术,预防肝静脉淤血的发生.方法 回顾分析21例成人活体右半肝移植的临床资料.供者标准肝体积为1150.1～1629.8 cm3,供肝重量为585～920 g,与受者标准肝体积比为43%～67%,与受者重量比为0.82%～1.59%,供者残肝体积百分比为32%～55%,供肝大泡脂肪变性均＜10%.对于含肝中静脉的供肝,将肝中静脉和肝右静脉开口修整成尽可能大的三角形开口,供肝植入时,与受者肝右静脉扩大的三角形开口行端侧吻合.不含肝中静脉的供肝,如存在粗大的肝中静脉属支(直径超过5 mm),则用自体或异体血管搭桥(无粗大的肝中静脉属支者采用肝右静脉)与受者腔静脉直接吻合.供肝门静脉右支直接与受者门静脉主干吻合,供肝动脉与受者肝动脉行端端吻合,供肝右肝管与受者肝管行端端吻合.结果 21例供肝中,4例含肝中静脉,17例不含肝中静脉,其中有2例采用自体大隐静脉搭桥,5例采用冷冻的异体髂动脉搭桥,10例采用肝右静脉直接与受者腔静脉吻合.术后1个月,重建肝中静脉属支的7例受者流出道均通畅.含肝中静脉者、不含肝中静脉的血管搭桥者及不含肝中静脉且未使用血管搭桥者术后1年存活率分别为75%、85.7%和70%,三者间比较,差异均无统计学意义(P＞0.05).术后受者发生胆道并发症7例;发生小肝综合征1例,经脾动脉栓塞治疗后痊愈.术后供者未发生严重并发症,随访6～31个月,均恢复正常工作生活,无一例死亡.结论 含肝中静脉与不含肝中静脉的右半供肝植入后均可取得良好的临床效果.如果右半供肝不含肝中静脉,采用自体或异体血管重建肝中静脉属支是预防肝淤血和保证移植肝功能的有效方法.     

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。     

活体肝移植中肝中静脉的分配

本文描述了肝中静脉的解剖结构,以及在活体肝移植供、受体手术中肝中静脉分配的解剖学基础。     

肝中静脉在活体肝移植中的作用

本文通过对肝中静脉的解剖、在活体肝移植手术时供体和受体的肝中静脉的取舍、肝中静脉属支的重建与否的描述，以了解肝中静脉在活体肝移植的重要地位。     

背驮式肝移植中肝静脉流出道阻塞的预防

目的　探讨腔静脉成形术在背驮式肝移植中的应用价值及防止移植肝流出道阻塞中的作用。方法　 3位终末期肝病病人的供肝下腔静脉及受体肝后下腔静脉 (包括肝静脉 )均作了成形术 ,在单独股—腋静脉转流术下行改良背驮式肝移植。结果　 3例病人术中均非常平稳 ,手术时间、无肝期缩短 ,出血量减少 ,术后肝功能恢复快 ,康复顺利 ,无并发症发生。结论　腔静脉成形术可防止背驮式肝移植肝静脉流出道阻塞 ,术中对受体血流动力学干扰小 ,缩短无肝期 ,减少并发症发生     

肝中静脉在活体肝移植中的作用

本文通过对肝中静脉的解剖、在活体肝移植手术时供体和受体的肝中静脉的取舍、肝中静脉属支的重建与否的描述,以了解肝中静脉在活体肝移植的重要地位。     

成人间不含肝中静脉右半肝活体肝移植静脉流出道重建技术的改进

目的 探讨不含肝中静脉(middle hepatic vein,MHV)的成人间右半肝活体肝移植(living donor liver transplantation,LDLT)静脉流出道重建技术的改进方法.方法 通过长征医院器官移植研究所2007年6月至2008年1月完成的11例次成人间不含肝中静脉的右半肝活体肝移植病例的回顾性分析,对成人间不含肝中静脉的右半肝活体肝移植静脉流出道重建技术的改进进行总结.主要技术改进包括:采用供肝右肝静脉、受体腔静脉联合扩大成形吻合技术重建流出道;采用在4℃UW液中保存7 d以内的尸体同种异体静脉移植血管重建供肝Ⅴ、Ⅷ段肝静脉粗大属支以及右肝下静脉.结果 11例次成人间不含肝中静脉右半肝活体肝移植中10例次采用了右肝静脉、腔静脉联合扩大成形吻合技术;利用尸体同种异体静脉移植血管架桥重建肝Ⅴ、Ⅷ段肝静脉以及右肝下静脉流出道的例数占同期实施的成人间活体肝移植总例数的81.8%(9/11),其中架桥重建1支肝静脉7例,架桥重建2支肝静脉1例,架桥重建3支肝静脉1例,11例病人中,1例病人术后14 d死于肾功能衰竭和肺部感染,超声检查血流通畅,未发现架桥静脉血栓,余10例病人术后随访9～15个月,右肝静脉均通畅,未发现静脉血栓,架桥肝静脉累计通畅率为:1个月100%(11/11)、3个月72.7%(8/11)、6个月54.5%(6/11)和9个月36.5%(4/11),移植肝脏再生均衡,右肝端面Ⅴ或Ⅷ段无明显充血和肝萎缩坏死,肝功能正常.超声检查未发现血栓,血流通畅,移植肝脏再生均衡,右肝端面Ⅴ或Ⅷ段无明显充血和肝萎缩坏死,肝功能正常.结论 采用右肝静脉、腔静脉联合扩大成形吻合技术和在4℃UW液中保存7 d以内的尸体同种异体静脉移植血管重建肝Ⅴ、Ⅷ段肝静脉粗大属支以及右肝下静脉是一种简单、安全和有效的成人间不含肝中静脉右半肝活体肝移植肝静脉重建方法.     

成人间右半肝活体肝移植肝中静脉的处理

目的 总结成人间右半肝活体肝移植肝中静脉的处理经验。方法 回顾性分析两例成人间右半肝活体肝移植肝中静脉的处理方法，1例采取含肝中静脉的右半肝活体肝移植，肝中静脉移植供肝和剩余肝脏各保留一半，既有利于保证供体左肝内叶静脉回流，同时供肝右前叶静脉回流也不受到影响；另1例则采取不含肝中静脉的右半肝活体肝移植，术中重建供肝右前叶肝静脉回流通道，使供肝前叶淤血明显改善。结果 两例供体均存活，术后顺利出院，无并发症；受体1例存活，1例术后20d死于急性重度排斥反应。结论 成人间右半肝活体肝移植肝中静脉的处理十分关键，要注意保持供受体肝流出道的通畅，既要保证供体的绝对安全，又要尽量为受体提供足够的肝容量。     

活体右肝移植时的肝静脉重建29例分析

目的 探讨成人活体右肝移植时肝静脉重建的方法.方法 2004年8月至2005年3月加拿大多伦多总医院移植中心行成人活体右肝移植术29例.移植肝的右肝静脉与患者肝静脉行端端吻合,或与患者的下腔静脉进行端侧吻合重建.当移植肝有右下肝静脉且直径大于5 mm时则与患者下腔静脉进行端侧吻合重建.移植肝的中肝静脉V8和V5分支直径大于5 mm时则采用静脉搭桥方式重建静脉回流;术中、术后用超声多普勒检测肝脏血流情况.移植3个月后CT检查移植肝的再生情况.结果 17例移植肝的右肝静脉与患者肝静脉直接进行端端吻合;12例移植肝的右肝静脉与患者的下腔静脉进行端侧吻合.10例移植肝的右下肝静脉与患者的下腔静脉进行端侧吻合.15例移植肝的中肝静脉V8和V5段主要分支采用了静脉搭桥重建.B超检查显示移植肝血流状况良好,CT检查移植肝再生均衡,肝功能正常.结论 我们的静脉重建方法简单易行,应用于成人活体右肝移植获得了满意的效果.     

活体肝移植术前评估肝静脉引流域的临床价值

目的 探讨肝静脉属支的直径与引流域的相关性及活体肝移植术前评估肝静脉引流域的临床价值.方法 对68例供者术前行多层螺旋CT增强检查,并利用GE Advantage Windows 4.2工作站和IQQA(R)肝脏CT影像解读分析系统对图像进行重建与分析,标记肝静脉各属支,测定静脉直径与相应引流域,并对二者进行相关性分析.分别计算左、右半肝的功能肝体积,并依据术中血管重建情况计算有效肝体积及所对应的肝重量与体重比.结果 共测定了220支肝右静脉或肝中静脉的属支,其直径与引流域体积之间的相关系数为0.752(P＜0.01),二者呈一定的正相关性,但相同直径血管的引流域体积差异较大.将血管直径和引流域体积分别以5mm与50cm3进行分级和统计频数,二者差异有统计学意义(X2=61.97,P＜0.01).肝右静脉引流域体积为(510.80±168.33)cm3,右半肝功能肝体积为(577.26±156.72)cm3.肝左静脉引流域体积为(292.70±76.61)cm3,加上Ⅳ段属支的引流域体积为(551.26±111.82) cm3.25例不带肝中静脉的右半肝的有效肝体积为(405.52～1038.43)cm3,未保留肝中静脉的43例供者残肝的有效肝体积为(175.35～575.35)cm3.结论 相同直径血管的引流域差异较大,也并非直径越大,引流域就越大 ;活体肝移植术前评估供肝静脉引流域对于手术方案的制定具有重要的指导意义.     

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.     

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.     

�������ֲ��Ѫ�ܱ������ƴ���

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-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.     

Anatomical keys and pitfalls in living donor liver transplantation

The surgery of living donor liver transplantation is more technically challenging than cadaveric whole liver transplantation and liver resection for the treatment of various pathological conditions. It requires a thorough understanding of the intra- and extra-hepatic anatomical relationships between the portal vein, hepatic artery, biliary tract, and hepatic vein, and also their respective contributions to liver physiology. Although a precise understanding of general anatomical principles is the key to correctly performing living donor liver transplantation procedures, anatomic anomalies are often present, and the means of detecting them and the surgical methods of coping with them represent technical challenges. In this monograph, we describe the anatomical keys and pitfalls of living donor liver transplantation surgery based on our own experience with more than 1800 hepatectomies, and 150 living donor liver transplantations. We also elaborate on techniques of selective intermittent vascular occlusion and their teleological and practical background. Received: June 1, 2000 / Accepted: June 24, 2000     

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。     

Impact of post‐transplant flow cytometric panel‐reactive antibodies on late‐onset hepatic venous outflow obstruction following pediatric living donor liver transplantation

The development of late‐onset hepatic venous outflow obstruction (LOHVOO) following pediatric living donor liver transplantation (LDLT) can lead to uncontrollable fibrotic damage in liver grafts, even long‐term patency of the graft outflow is achieved with appropriate therapeutic modalities. The aim of this study was to verify our hypothesis that some immunological responses, particularly cellular and/or antibody‐mediated rejection (AMR), are associated with LOHVOO, which occurs following damage to liver sinusoidal endothelial cells in zone 3 of liver grafts. One hundred and eighty‐nine patients underwent LDLT between May 2001 and December 2010 at our institute. Nine patients (4.8%) were identified as having LOHVOO. The preoperative factors, operative factors, and mortality, morbidity, and survival rates were examined and compared between the groups with and without LOHVOO. No statistical differences were observed between the groups with regard to preoperative factors, technical factors, or postoperative complications. However, FlowPRA reactivity was found to be a statistically significant risk factor for LOHVOO (P = 0.006). The patients with both class I‐ and class II‐reactive antibodies also had a significant risk of developing LOHVOO (P = 0.03) and exhibited significantly higher retransplant rates. In conclusion, although further studies are needed to clarify this phenomenon, the pathophysiological mechanism underlying the development of LOHVOO after LDLT may be explained by immune‐mediated responses that facilitate damage in zone 3 of liver grafts.     

Intrahepatic venous collaterals formation following outflow block in adult-to-adult living donor liver transplantation

A right liver graft without the middle hepatic vein (MHV) trunk is now commonly used in adult-to-adult living donor liver transplantation (LDLT), but it is unclear whether hepatic venous collaterals would develop in clinical patient just after occlusion of hepatic veins. Between January 2005 and October 2006, 56 consecutive adult patients underwent LDLT using right lobe grafts without MHV in our center. Twenty-four patients (42.9%) had MHV tributaries reconstruction. Vascular flow in the graft and interposition vein graft patency was checked by Doppler ultrasonography (US) daily during hospital stay and monthly follow-up after discharge for 2 y. Among 24 cases with MHV reconstruction, interpositional graft block occurred in one case within 7 d after transplantation. A reversed flow in MHV tributaries and collaterals between MHV and right hepatic vein (RHV) was detected by Doppler US. Vessel graft blocks were found in 10 of 22 cases of MHV tributaries reconstruction between 4 to 9 mo after transplantation. Collaterals formation between MHV and RHV developed in 4 of 10 cases of vessel graft block, and their graft function did not deteriorate. In conclusion, nearly half of the patients needed reconstruction of MHV tributaries when a right lobe graft without MHV was used in LDLT. The authors thought that the reconstruction of MHV tributaries should be established when the congested area was dominant by the clamping test or when the diameter of the tributaries was >5 mm. It was found that there may not be any problems if reconstructed vessel graft obstruction was found 3 mo after transplantation, as intrahepatic venous collaterals between MHV and RHV could develop.     

活体肝移植术后早期肝动脉血栓形成的诊断与治疗

目的探讨活体肝移植术后早期肝动脉血栓形成的诊断与治疗。方法2006年9月至2009年8月天津市第一中心医院单一外科组共实施110例活体肝移植,移植术后7d内每日用彩色多普勒超声(彩超)监测肝动脉血流,怀疑肝动脉血栓形成行肝动脉造影或腹部CT检查,确诊者予介入治疗或手术治疗。结果该组3例术后5～6d发生肝动脉血栓,肝动脉血栓发生率2.7%(3/110)。其中1例再次手术行肝动脉取栓,术后血流正常;2例行介入治疗,放置支架,术后1例再次血栓形成,1例血流流速偏低,2例均发生胆道并发症,但肝功能正常。3例均存活。结论术后早期用彩超监测对肝动脉血栓的诊断至关重要,及时手术取栓或介入放置支架效果良好。     

成人右半肝活体肝移植切取肝中静脉对供者早期残肝功能和再生的影响

目的 探讨带与不带肝中静脉对活体右半肝移植供者早期残肝功能和再生的影响.方法 连续观察本中心2007年8月至2008年8月实施的活体右半肝移植供者66例,其中不带肝中静脉右半肝切取的供体36例(A组),带肝中静脉右半肝切取的供体30例(B组).所有供者均详细记录手术时间、术中失血以及术后住院期间胆红素、凝血功能(国际标准化比值,INR)、丙氨酸转氨酶、白蛋白变化情况.术后2周行CT检查测量残肝的体积.比较两组供者术后早期残肝功能和再生情况.结果 术后两周A组残肝体积为(959.3±195.2)ml,B组为(883.7±155.5)ml,两组之间无显著差异(P=0.16).A组残肝再生比例为78.2％±29.1％,B组为82.7％±40.4％,两组之间无显著差异(P=0.62).残肝体积与术前全肝体积的比值(RV)在两组之间也无显著差异(P=0.56).B组术后早期INR、胆红素及丙氨酸转氨酶均高于A组,但术后1周时两组比较无明显差异.结论 与不切除肝中静脉比较,成人右半肝活体肝移植切取肝中静脉对供者早期肝功能和残肝的再生无明显影响,行含肝中静脉的扩大右半肝切除对于供者来说是安全可行的.