成人间活体右半肝肝移植24例报告

目的 探讨成人间活体右半肝肝移植的可行性及安全性。方法 自2002年1月至2005年12月,施行了24例成人间右半肝活体肝移植,术中采用了一系列改良的手术技术,包括右肝静脉的重建,右下肝静脉的重建,肝中静脉分支的搭桥,肝动脉塔桥及胆道吻合等改进措施。效果良好。结果 全组供体无严重并发症及死亡。前阶段2例受体中,1例发生肝静脉吻合口狭窄,另1例发生小肝综合征,最终导致死亡。后阶段22例,受体发生并发症7例,包括急性排斥反应2例,肝动脉栓塞,肠肠吻合口出血,胆漏,左膈下脓肿及肺部感染各1例,其中1例再移植因术后肺部感染,多器官功能衰竭死亡。22例中除右肝静脉与肝后下腔静脉直接吻合外,其中9例加行右肝下静脉重建,另10例采用自体大隐静脉搭桥行肝中静脉分支与IVC重建,保证了右肝的流出道通畅。移植物与受体重量比为0.72％～1.17％,19例〈1.0％,其中4例〈0．8％,无小肝综合征发生。结论 采用了改进的手术技术,特别是肝静脉流出道的充分重建可有效的避免小肝综合征,从而使活体右半肝移植成为相当安全的手术。     

Hepatic venous outflow reconstruction in adult right lobe living donor liver transplantation without middle hepatic vein

Background It is difficult and challenging to reconstruct hepatic venous outflow in adult right lobe living donor liver transplantation (LDLT) without the middle hepatic vein (MHV). Excessive perfusion of the portal vein and venous outflow obstruction will lead to acute congestion of the graft, ultimately resulting in primary nonfunction. Although various reconstruction patterns have been explored in many countries, there is currently no clear consensus. In this study we describe a technique to prevent “chocking” of the graft at the outflow anastomosis with the inferior vena cava (IVC) in LDLT using right lobe graft without the MHV. Methods A retrospective analysis was conducted on clinical data from 55 recipients undergoing LDLT using right lobe grafts without the MHV or reconstruction of hepatic venous outflow. The donor’s right hepatic vein (RHV) was anastomosed with a triangular opening of the recipient IVC; the inferior right hepatic vein (IRHV), if large enough, was anastomosed directly to the IVC. The great saphenous vein (GSV) was used for reconstruction of significant MHV tributaries.Results No deaths occurred in any of the donors. Of the 55 recipients, complications occurred in 6, including hepatic vein stricture (1 case), small-for-size syndrome (1), hepatic artery thrombosis (1), intestinal bleeding (1), bile leakage (1), left subphrenic abscess and pulmonary infection (1). A total of three patients died, one from small-for-size syndrome and two from multiple system organ failure. Conclusions The multiple-opening vertical anastomosis was reconstructed with hepatic vein outflow. This technique alleviates surgical risk of living donors, ensures excellent venous drainage, and prevents vascular thromboses and primary nonfunction.     

活体右半肝移植静脉流出道重建技术的改进

目的 探讨在不包含肝中静脉(middle hepatic vein,MHV)的成人间活体右半肝移植(living donor liver transplantation,LDLT)流出道的重建模式.方法 对我院肝移植中心47例不含MHV成人间活体右半肝移植,其受体流出道重建的临床资料进行回顾性分析.移植肝右肝静脉(RHV)与受体下腔静脉的吻合口成形为"三角形";右肝下静脉(IRHV)与下腔静脉直接吻合,MHV粗大属支即肝Ⅴ段(V5)、Ⅷ段(V8)静脉用大隐静脉搭桥后,分别开口与下腔静脉垂直式吻合.结果 本组供体术后无严重并发症和死亡.受体47例发生并发症9例,其中肝静脉狭窄1例,小肝综合征1例,肝动脉栓塞1例,肠肠吻合口出血1例,胆漏2例,隔下脓肿1例,肺部感染2例.死亡3例,死因为小肝综合征1例,多器官功能衰竭 2例.47有31例重建V5、V8和(或)右肝下静脉,其流出道重建率65.96%(31/47),其中重建1支静脉为36.17%(17/47),重建2只静脉为21.28%(10/47),重建3只静脉为8.51%(4/47).所有病例术后随访2～48月,CT和超声检查1例肝静脉狭窄,4例在7～25d发现血栓,但侧枝循环已建立.结论 采用"多口垂直式吻合" 的方式重建流出道,可保证移植肝的有效静脉回流,预防小肝综合征,减少供体的手术风险.     

小肝移植物与小肝综合征

小肝移植物和小肝综合征是限制成人活体肝移植进一步应用的重要因素。小肝移植物是指移植物与受者质量比小于0.8%或移植物体积与受者标准肝体积比小于40%。小肝综合征是指移植物不能满足受者的功能需要,引起肝功能障碍,包括凝血病、腹水、长期胆汁淤积和脑病,甚至伴有肺功能衰竭和肾功能衰竭,如果不行再次肝移植常会导致受者死亡。小肝综合征的发生与多种因素有关,如移植物大小、潜在病变、再生能力、流入道、流出道情况,受者病情轻重等。门静脉过度灌注、静脉病变、肝动脉缓冲效应在小肝综合征早期和晚期的临床和组织病理学表现中起重要作用。小肝综合征的防治措施,主要集中在两个方面:选择更大的移植物和进行门静脉压力和血流的调控。门静脉压力和血流的调控,可能是成功采用更小移植物进行成人活体肝移植的关键所在。     

成人间活体肝移植研究

目的探讨提高成人间活体肝移植存活率的手术方法。方法2005年3月至6月,我院施行了13例成人间右半肝活体肝移植,术中采用了改良的手术技术包括右肝静脉的重建,肝中静脉分支的搭桥,肝动脉搭桥及改进的胆道重建技术。结果全组供体无严重并发症及死亡;受体发生并发症4例．其中包括肝动脉栓塞、胆漏、右膈下脓肿及肺部感染各1例。1例再移植因术后肺部感染,并发多器官功能衰竭（MOF）死亡。13例行右肝静脉与下腔静脉（IVC）直接吻合,其中5例加行右肝下静脉重建．另5例采用自体大隐静脉搭桥行肝中静脉分支与IVC重建,保证了右肝的流出道通畅。移植物与受体重量比（GRWR）为0．72％～1．24％,其中9例〈1．0％,2例〈0．8％,无小肝综合症发生。结论采用改进的手术技术,特别是肝静脉流出道的充分重建可有效的避免小肝综合症,从而使活体右半肝移植成为比较安全的手术。     

Hemi-Portocaval Shunt---A Simple Salvage Maneuver for Small-for-size Graft during Living Donor Liver Transplantation: A Case Report

Since the fast expansion of living donor liver transplantation (LDLT) over last few decades, small-for-size syndrome (SFSS) has  emerged as a tough problem. Herein the first case of LDLT combined hemi-portocaval shunt in the mainland of China was reported. Portal venous overperfusion was well modulated and the recipient recovered uneventfully. LDLT combined hemi-portocaval shunt was a feasible procedure for preventing SFSS in LDLT.

     

活体右半肝移植肝中静脉取舍选择与供受者的安全性

目的 根据术前CT评估供体残余肝脏比例(RLV%)和评估移植物重量与受者体重比(GRWR),参考肝中静脉解剖情况等因素制定术前肝中静脉(MHV)切取分配方案,研究这种分配方案对活体肝移植供、受体安全的影响,并为今后临床工作提供参考.方法 同一外科小组连续73例活体右半肝肝移植病例按术前肝中静脉分配方案,切取肝中静脉28例,不切取肝中静脉45例.对供受者性别、年龄、体重、手术时间及失血量等基本资料,移植物重量、无肝期、供肝冷保存时间、围术期供受者存活率、小肝综合征发生率以及供受者术后肝功能恢复情况等移植物相关资料进行比较.结果 两组供者术中均未输注血制品,术后均无死亡及小肝综合征发生病例.1例受体术后6 d出现移植肝急性肝坏死转尸体肝移植后痊愈,1例发生小肝综合征保守治疗后痊愈,受者围手术期死亡1例(术后30 d),死亡原因为全身播散性感染并发呼吸功能衰竭旭肝功能已恢复正常.切取MHV组与不切取MHV组之间受者年龄、供体体重小于受体病例所占比例、实际GRWR、移植物重量、移植物冷保存时间、受体术后ALT最高值问差异有统计学意义.结论 这种以术前CT评估供者残肝比例和评估GRWR为分类标准,重点参考MHV解剖因素的MHV取舍方案对供、受者均是安全的.     

活体肝移植的胆道重建

目的探讨活体肝移植（LDLT）中胆道重建技术及并发症处理原则,减少胆道并发症的发生．方法回顾性分析活体肝移植18例,其中右半肝11例,左半肝10例,双供体（右半肝＋左半肝）3例,胆道重建采用显微外科技术．17例行胆管-胆管端端吻合,1例行肝管空肠吻合．结果术后3例受体发生了胆道并发症．2例为成人右半肝移植,1例于术后2d发现胆漏,经保守治疗无效,再次开腹改行肝管空肠吻合后治愈;1例术后3月发现胆管轻度狭窄,行保守治疗治愈．1例为双供体置入T管者,术后第3天发现胆漏,行保守治疗后治愈．结论在活体肝移植中采用显微外科技术,适当整形胆管行胆管-胆管端端吻合,有助于降低术后胆道并发症的发生．     

多模式部分肝移植关键技术及其临床应用

针对目前全世界肝脏移植的瓶颈问题——供肝匮乏,课题组提出了一种新的肝移植方式——部分肝移植,取得了一系列原创性成果。与国内外同类研究比较,主要有以下发现和创新点:①确立了对移植物的选择标准和右半肝移植物静脉回流的重建方式;②比较了带或不带肝中静脉的右半肝移植物的活体肝移植的术后结果,确定了带肝中静脉的右半肝移植物的安全性和必要性;③首次在国内开展劈离式肝移植治疗终末期肝病患者,并保持国内单中心最大病例数;④首次在国内开展不同血型两供一受活体肝移植并获成功,该手术方式为受体提供了更大重量的肝脏,最大限度地保证了供体的安全;⑤在国际上率先报道了中国肝移植人群免疫抑制剂霉酚酸药代动力学变化规律,首次建立了霉酚酸完全暴露的简化计算公式,并首次比较了活体肝移植和全肝移植霉酚酸药代动力学的差异。该研究成果获2010年国家科技进步二等奖。     

Current status of adult-to-adult living donor liver transplantation: surgical techniques and innovations

In response to critical organ shortage, transplant surgeons have utilized living donors in an attempt to decrease the mortality rate associated with waiting on the liver transplant list. Although the surgical techniques were first utilized clinically 15 years ago, the application of living donor liver transplantation （LDLT） has been somewhat limited by the steep learning curve associated with developing a program. Clinical success with LDLT in children was realized early, but the application of the techniques to adult patients has only occurred more recently. This procedure is now widely applied to adult recipients, with many technical improvements.     

大鼠小体积肝移植肝动脉重建的意义探讨

目的:探讨肝动脉重建在大鼠小体积肝移植中的意义?方法:采用改良二袖套法建立大鼠40%小体积肝移植模型,实验分动脉重建组和动脉未重建组,观察1周生存率,并于术后1?2?4?7天检测肝功能?移植肝组织学变化和免疫组化法检测肝细胞的增殖细胞核抗原(PCNA)?结果:动脉重建组1周生存率为66.7%,动脉未重建组1周生存率为50.0% (P > 0.05)?丙氨酸氨基转移酶(ALT)和总胆红素(TB)术后第1天即开始明显增高,第2天达高峰,以后逐渐降低,动脉未重建组和动脉重建组各时间点相比较,TB第2?7天高于动脉重建组,ALT第2?4天高于动脉重建组,差异有显著性(P < 0.05)?动脉重建组术后中央静脉及肝窦扩张程度相对较轻,可见较多二倍体和多倍体肝细胞?PCNA表达于术后第2天最高,动脉重建组术后第1天的移植肝细胞PCNA阳性表达率高于动脉未重建组,而术后第7天移植肝细胞PCNA阳性表达率低于动脉未重建组,差异有显著性(P < 0.05)?结论:肝动脉重建可明显改善大鼠小体积移植肝的功能,促进移植肝的再生,有效地保护移植肝的组织学结构,减轻术后移植肝的组织学改变,动脉化模型术后早期增殖较静脉化模型活跃?     

Small-for-size graft in liver transplantation

Controversies on small-for-size (SFS) graft in liver transplantation have evolved in parallel with the history of living donor liver transplantation for adults. It is true that the liver regenerates rapidly within a limited threshold. But 'normal' liver weight itself is variable and the influences of variable liver graft and extrahepatic factors are not negligible in pathological condition. Clinical features of 'SFS syndrome' are neither specific nor inevitable in low-weight liver and many other factors than actual graft weight contribute to their occurrence. Among them, early elevation of portal venous pressure highly probably plays a key role. In the clinical trials of surgical modification and local pharmacological manipulation targeting portal hemodynamics and tissue congestion, it may be the time to discard an excessive fear for SFS grafts and to minimize unnecessary withdrawal from the opportunity of transplantation.     

成人活体肝移植肝中静脉搭桥后桥血管的超声显像

目的 探讨彩色多普勒超声在成人活体肝移植(living donor liver transplantation,LDLT)肝中静脉搭桥后受体的桥血管显像中的应用.方法 2005年12月至2006年7月我院25例患者接受右半供肝活体肝移植,术中用大隐静脉重建肝脏Ⅴ(V5)、Ⅷ(V8)段的肝中静脉粗大属支,静脉搭桥模式和例数为:单一V5(8例),两条V5(2例),V5和V8(9例),V8(6例),25例患者重建桥血管共36根.术后使用彩色多普勒超声对桥血管进行动态观察,随访7d至8月.结果 彩色多普勒超声能显示成人活体肝移植肝中静脉搭桥后的桥血管;24例患者桥血管34支超声显示通畅,血管管径4.6～7 mm,流速8.4～39.5 cm/s.1例(2支)术后7d重建的静脉未探及血流,术后25d桥血管与右肝静脉形成侧枝循环.结论 彩色多普勒超声可以准确显示肝中静脉搭桥后的桥血管,了解血管的通畅情况,测量其流速,为临床治疗提供详细、准确的信息.     

Early experiences on living donor liver transplantation in China: multicenter report

Background Because of the lack of brain death laws in China, the proportion of cadaveric organ donation is low. Many patients with end-stage liver disease die waiting for a suitable donor. Living donor liver transplantation （LDLT） would reduce the current discrepancy between the number of patients on the transplant waiting list and the number of available organ donors. We describe the early experience of LDLT in the mainland of China based on data from five liver transplant centers. Methods Between January 2001 and October 2003, 45 patients with end-stage liver disease received LDLT at five centers in China. The indication and timing, surgical techniques and complications, nonsurgical issues including rejection, infection, and advantages of LDLT in the series were reviewed. Actuarial patient and graft survival rates were calculated by using the Kaplan-Meier product-limit estimate. Statistical analysis was completed by using SPSS 10.0. Results All LDLT recipients were cirrhotic patients, except for one man with fulminant hepatic failure. Among the 45 cases of LDLT, 35 （77.8%） were performed in one center （the First Affiliated Hospital of Nanjing Medical University）. The overall 1 and 3 year survival rate of the recipients was 93.1% and 92.0%, respectively. Of the 45 LDLT donors, there were 3 cases of biliary leakage, 2 subphrenic collections, 1 fat liquefaction around the incision and 1 biliary peritonitis after T tube removal. All donors recovered completely. Conclusions LDLT provides an excellent approach to addressing the problem of donor shortage in China even though the operation is complicated, uncompromising and difficult with respect to the safety of the donors and receptors. Despite early technical hurdles having been overcome, perfection of technique is still necessarily. At present, LDLT is a good choice for the patients with irreversible liver disease.     

成人间活体右半肝移植供体手术技巧探讨

目的 探讨活体肝移植(living donor liver transplantation,LDLT)的供肝切取技术.方法 对2002年1月至2006年6月期间,我中心进行的47例活体肝移植中不含肝中静脉的右半肝供体切取技术进行回顾性分析.术前CT对供肝管道系统、体积充分评估;术中使用血液回收器回收出血.用超声刀(CUSA)、电刀、滴水双极电凝切取供肝,术中不阻断入肝血流;注意保留＞5 mm的右肝下静脉、肝Ⅴ段(V5)、肝Ⅷ段(V8)静脉以备重建.结果 供体术后无严重并发症和死亡.右半肝切取的中位手术时间为425 min(380～620 min),术中失血250～735 mL,平均345 mL,术中收集自体血并回输0～500 mL,平均263 mL,仅4例输异体血(自2005年供体切取已常规不输血).并发症包括切口脂肪液化2例,乳糜漏1例,门静脉血栓1例,腹腔内出血1例.47例供体中,有31例出现粗大的V5静脉和(或)V8静脉、右肝下静脉,并进行了流出道重建.全部供体术后随访至今,供体生活和工作正常.结论 在切取供肝过程中,CUSA、双极电凝和电刀联合使用,仔细及精良的供肝切取技术值得推广;通过流出道的充分重建,不包含肝中静脉右半供肝可以降低供体的风险,是较为安全的手术方式.     

Transdiaphragnatic exposure for direct atrioatrial anastomosis in liver transplantation

Background Liver transplantation in Budd-Chiari syndrome remains controversial; however, some improved techniques lead to better results. We report medium-term follow-up results of liver transplantation with atrioatrial anastomosis for Budd-Chiari syndrome and explore the indications of liver transplantation with atrioatrial anastomosis for patients with end stage liver disease.Methods Nine patients (six Budd-Chiari syndromes, one end stage hepatolithiasis, one hepatocellular carcinoma and one incurable alveolar echinococcosis) underwent liver transplantation with atrioatrial anastomosis in West China Hospital of Sichuan University from 1999 to 2006. Eight liver transplants used cadaveric orthotopic livers and one a living donor liver. The operative technique was transdiaphragmatic exposure for direct atrioatrial anastomosis and replacement of inferior vena cava by cryopreserved vena cava graft with the help of venovenous bypass.Results All liver transplantations were successful. Two patients contracted pulmonary infection and acute rejection took place in another case. With proper treatment, all patients recovered well and had good quality of life. To date, they have been followed up for more than 24 months. The only death followed recurrence of hepatic carcinoma three years after liver transplantation.Conclusions Transdiaphragmatic exposure for direct atrioatrial anastomosis and the cryopreserved vena cava graftreplacement of inferior vena cava are possible for patients with end stage liver disease thus extending the indications of liver transplantation.     

肝中静脉分支重建对活体肝移植中最小供肝质量与受体体质量比的影响

  目的  分析不伴肝中静脉分支(MHVT)重建的活体肝移植(LDLT)患者所需最小供肝质量与受体体质量比(GRWR)。  方法  回顾性分析四川大学华西医院2001年1月至2017年11月完成303例LDLT患者临床资料。应用倾向性评分匹配法(PSM)分析伴或不伴MHVT重建LDLT患者所需最小GRWR。  结果  通过PSM匹配后,MHVT重建和非重建组在术后并发症,小肝综合征,住院时间,肝功能和凝血功能差异无统计学意义,两组间的1年,3年和5年生存率差异有统计学意义,MHVT重建组患者的短期和长期生存率优于未重建组。  结论  对非MHVT重建患者,GRWR应大于0.86%;对MHVT重建患者,GRWR在0.5%~0.6%之间是可接受的。     

104例成人间活体肝移植肝动脉重建

目的 探讨成人间活体肝移植的肝动脉重建技术的经验.方法 自2002年1月至2007年8月,四川大学华西医院施行了104例成人间右半肝活体肝移植,包括98例不含中肝静脉(MHV)的右半供肝肝移植及6例双供肝肝移植(双亲属左半供肝1例,亲属右半肝加亲属左半肝3例,亲属右半肝加尸体左半肝2例),104例受者中男86例,女18例,年龄18～63岁(中位年龄38岁),在供受体间肝动脉的重建中,61例供体右肝动脉与受体肝右动脉吻合,15例与受体肝固有动脉吻合,此外与受体左肝动脉吻合7例,与受体肝总动脉吻合3例,与受体肠系膜上动脉发出的副右肝动脉吻合8例,供体右肝动脉与受体肝总动脉自体大隐静脉间置搭桥5例,受体腹主动脉与供体右肝动脉自体大隐静脉搭桥2例,用尸体冷冻保存髂血管行受体腹主动脉与供体右肝动脉搭桥3例,供体肝动脉直径1.5～2.5 mm,分别采用8-0和9-0 Prolene无损伤血管缝线在手术显微放大镜下完成肝动脉重建.结果 104例成人间右半肝活体肝移植,术后1、7 d发生肝动脉血栓形成2例(1.9%),采用自体大隐静脉肾下腹主动脉至供体右肝动脉搭桥术,恢复供肝血流,痊愈出院.1例1个月后发生肝动脉血栓形成,随访期无临床症状未行处理.术后和随访期末发现肝动脉狭窄、肝动脉假性动脉瘤等并发症.全部病例获得随访,随访时间2～60个月,1、2和3年实际生存率分别为89.3%、76.0%和69.3%.结论 根据供受体动脉解剖情况选择最适宜的重建位置和方式,采用显微外科技术是减少围手术期肝动脉并发症保证供肝存活的关键.     

肝移植术中异体髂动脉架桥重建肝动脉的临床效果观察

目的了解肝移植术中特殊情况下异体髂动脉架桥重建肝动脉的临床效果。方法回顾2004年至2010年首都医科大学附属北京佑安医院肝移植中心进行的427例肝移植临床资料,分析异体髂动脉架桥重建肝动脉的情况。结果 427例患者中,有12例患者共进行了13次成功的异体髂动脉架桥重建肝动脉,其中与腹主动脉架桥11例次,与脾动脉架桥1例次,与左侧髂总动脉架桥1例次;因二次肝移植而行架桥者4例次,因受体肝动脉不能利用而动脉架桥9例次(其中1例为活体右半肝移植);架桥耗时90～120 min;移植物平均存活时间为(511.8±573.9)d(2～1 577 d,中位时间270 d),受体平均存活时间为(554.5±606.1)d(2～1 577 d,中位时间317 d);随访期间无肝动脉相关合并症发生。结论异体髂动脉架桥对于各种原因所致的肝动脉异常而不能按常规方法吻合的受体,是一种安全有效的肝动脉重建方式。但术前病情或合并症常可能影响这部分患者的术后生存。     

成人活体肝移植胆道并发症的防治

目的 探讨成人活体肝移植胆道并发症的防治策略.方法 回顾性分析2002年1月至2007年8月间108例成人活体肝移植胆道并发症的发生与处理,其中102例为不含肝中静脉(MHV)右半肝移植,6例双供肝移植(双亲属左半肝1例,亲属右半肝加左半肝3例,亲属右半肝加尸体左半肝2例).结果 受体并发症共24例(22.2%),其中胆漏4例,肝断而胆漏1例,胆管吻合口狭窄3例;供体并发症共7例(6.3%),其中残留肝断面胆漏2例.胆道并发症者除1例死亡外,其余均经及时处置,恢复良好.结论 改进术前、术中检查与评估方法 ,选择适当的胆道重建方式,结合显微手术技术精细操作,及时发现与处置,可明显地降低成人活体肝移植胆道并发症的发病率与病死率.