右叶活体肝移植的肝静脉应用解剖研究

目的 研究右叶活体肝移植的肝静脉应用解剖.方法 解剖观测133例成人肝静脉的分支数、最大径、长度、肝外长度、汇合;肝中静脉相对于肝中裂的偏移程度等指标.结果 A型:粗大的肝右静脉和小的右副肝静脉,占59.4%,B型:中等大小的肝右静脉和中等大小的右副肝静脉,占27.8%,C型:小的肝右静脉和粗大的右副肝静脉,占12.8%.肝左静脉与肝右肝静脉共干,占60.3%,共干长度(1.12±0.61)cm,大小(1.29±0.40)cm.96.15%肝中静脉相对于肝中裂的向右偏移,偏移程度(14.11±12.65)°.结论 该组肝静脉的结果 提示中国人的肝静脉分型中各型所占的比例与国外文献报道明显不同;中国人可能更适合右叶活体肝移植.     

A thoracoabdominal approach in revision of the hepatic hilum after left lobe living donor liver transplantation

We present an approach to safely expose the hepatic hilum for revision procedures after left lobe living donor liver transplantation. A 14-year-old adolescent girl who had undergone left lobe living donor liver transplantation experienced repeated episodes of cholangitis. Because treatment with interventional techniques failed, surgical revision was indicated. The right thoracoabdominal approach was selected to minimize dissection. Intraoperative findings showed adhesive kinking of the Roux-Y limb just distal to the bilioenteric anastomosis, and a side-to-side jejunojejunostomy was performed. The thoracoabdominal approach leads to easy and excellent reoperative exposure of the hilar site of a left lobe liver graft.     

活体亲属部分供肝的切取技术

目的 探讨活体部分肝移植（LDLT）手术中，供者手术的安全性。方法 自1995年1月至今，对14例终末期肝病患者施行了LDLT手术。14例LDLT供者中，2例行扩大左外叶切除。10例行扩大左半肝切除（含肝中静脉），2例行右半肝切除（不含肝中静脉）。结果 仅1例供者术后拔除T管后出现胆漏，经引流后好转。对所有供者随访1个月-5年，均无不适，肝功能正常。结论 对于富有经验的医生来说，LDLT的供者手术是安全的。     

MRCP在活体肝移植术前供者胆管解剖结构评估中应用价值的荟萃分析

目的 评价磁共振胰胆管成像(MRCP)在评估活体肝移植术前供者胆管解剖结构中的应用价值.方法 检索Cochrane图书馆、MEDLINE、EMBASE、中国生物医学文献数据库等文摘数据库收录的中英文文献摘要,辅以Springer、OVID、Sciencedirect等全文数据库,按照Coehrane协作网推荐的诊断试验纳入标准筛选文献,采用循证医学软件包检验纳入文献的异质性,并选择相应的效应量合并模型,对纳入的研究进行加权合并,计算敏感性、特异性、阳性预测值、阴性预测值、诊断比值比,绘制汇总受试者工作特征曲线(SROC),计算曲线下面积,最后进行敏感性分析.结果 符合纳入标准的文献有17篇,共有34项研究,异质性检验发现各研究间存在异质性,进行荟萃回归分析发现异质性来源为MRCP成像方法,按照不同的MRCP成像方法进行亚组分析,各亚组内异质性检验未发现异质性.按照固定效应模型获得厚层MRCP、三维MRCP、厚层MRCP与三维MRCP结合、增强MRCP等亚组的汇总敏感性分别为0.89、0.92、0.95和1.00,特异性分别为0.78、0.80、0.82和0.76,阳性预测值分别为4.1、4.5、5.2和4.1,阴性预测值分别为0.14、0.10、0.06和 0),诊断比值比分别为29、45、85和1228,SROC曲线下面积分别为0.83、0.92、0.96和0.99.结论 厚层MRCP和三维MRCP相结合在评估活体肝移植供者术前胆管解剖结构中具有很高的敏感性和特异性,完全可以满足术前对胆管结构评估的要求.     

活体肝移植中肝动脉的处理

目的 探讨活体肝移植中动脉重建技术及肝动脉变异的处理,减少肝动脉并发症.方法 行活体肝移植11例,其中右半肝5例、左半肝2例、左外叶1例、供体(右半肝+左半肝)3例,供受体术前均行肝动脉造影明确肝动脉的解剖及变异,肝动脉均采用显微外科技术重建.结果 肝动脉变异2例,1例右半肝供体副肝右动脉来源于肠系膜上动脉,1例左半肝供体副肝左动脉来源于胃左动脉.4例行双动脉重建,肝动脉吻合时间25～76 min,无肝动脉血栓形成、狭窄等并发症.受体并发症3例.结论 术前明确肝动脉的解剖及变异,选择合适的吻合部位,应用精细的显微外科技术重建肝动脉,能有效降低活体肝移植中动脉并发症的发生.     

Surgical anatomy of the hepatic hilum with special reference to the caudate lobe

The portal triad around the hepatic hilum, including the caudate lobe, was investigated using 106 adult cadavers. The portal vein showed regular branching at the hepatic hilum. The round ligament was attached mainly to the pars umbilicalis of the left branch of the portal vein (81.3%), especially to its lower portion (64.6%). Typical extrahepatic branching of the hepatic artery was noted in 67% of the cadavers. Intrahepatic branching of the middle and left hepatic arteries showed some variations in 9.4% and 12.5% of the cadavers, respectively. The cystic artery originated from the right hepatic artery in 84.4% of the cadavers, and a dual cystic artery was observed in 30.2%. An aberrant hepatic duct, previously reported as an accessory hepatic duct, was observed in 9.0% of the cadavers; each entered the common hepatic duct on the right side. With reference to the course of bile duct and hepatic artery, the middle hepatic artery traversed the left main hepatic duct anteriorly in 13.5% of the cadavers, and ran partly in front of the duct in 52.0%. Furthermore, the right hepatic artery or its branches traversed the right main hepatic duct anteriorly in 9.4% of the cadavers and ran partly in front of the duct in 38.5%. The caudate lobe is supplied by both the right and left branches of the portal triad, mainly by the left. The caudate process is mainly supplied by the posterior branches of the portal triad, being continuous with the posterior segment of the liver.

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Resumen Se realizó una investigación de la triada portal alrededor del hilio hepático, incluyendo el lóbulo caudado, en 106 cadáveres adultos. La vena porta mostró ramificaciones regulares al nivel del hilio hepático. El ligamiento redondo apareció unido principalmente al pars umbilicalis de la rama izquierda de la vena porta (81.3%), especialmente sobre su portión inferior (64.6%). La ramificación extrahepática, típica de la arteria hepática, fué observada en el 67%. La ramificación intrahepática de las arterias hepáticas media e izquierda mostró algunas variaciones en 9.4% y 12.5% respectivamente. La arteria cistica se originó en la arteria hepática derecha en 84.4% de los casos y se observó una arteria cística doble en 30%.Un canal hepático aberrante, previamente reportado como un canal hepático accesorio, fué observado en 9.0%; cada cual entraba al canal hepático comÚn sobre el lado derecho. En cuanto al curso del conducto biliar y la arteria hepática, la arteria hepática media cruzaba el canal hepático izquierdo por su aspecto anterior en 13.5% y corría parcialmente enfrente del canal en 52%. La arteria hepática derecha o sus ramas cruzaban el canal hepático derecho por su aspecto anterior en 9.4% y corría parcialmente enfrente del canal en 38.5%. El lóbulo caudado es irrigado por las dos ramas, derecha e izquierda, de la triada portai, especialmente por la izquierda. El proceso caudado es irrigado principalmente por las ramas posteriores de la triada portai, siendo anatómicamente continuo con el segmento posterior del hígado.

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Résumé L'anatomie du hile du foie et du lobe caudé a été étudiée sur 106 cadavres. La division de la veine porte au niveau du hile est toujours régulière. Le ligament rond se rattache principalement à la pars umbilicalis de la branche gauche de la veine porte (81.3%) et plus particulièrement à sa partie inférieure (64.6%). La division extra-hépatique classique de l'artère hépatique a été observée dans 67% des cas. La division intra-hépatique des artères hépatiques moyenne et gauche a été constatée respectivement dans 9.4% et 12.5% des cas. L'artère cystique prend son origine dans 84.4% des cas au niveau de la branche droite de l'artère hépatique et dans 30.2% des cas l'artère cystique est double.Un canal bilaire aberrant, considéré auparavant comme un canal biliaire associé, a été observé dans 9% des cas, le canal aboutissant toujours au bord droit du canal hépatique. En ce qui concerne le trajet du canal biliaire et de l'artère hépatique, l'artère hépatique moyenne croise en avant le canal hépatique gauche dans 13.5% des cas, et court partiellement en avant de lui dans 52% des cas. L'artère hépatique droite ou ses branches croisent en avant le canal hépatique droit dans 9.4% des cas et courént partiellement en avant de lui dans 38.5% des cas. Le lobe caudé dépend à la fois des branches droites et des branches gauches de la triade portale mais principalement de ces dernières. Ce sont les branches postérieures de ces éléments qui le concernent ainsi que le segment postérieur du foie.

     

成人间活体肝移植肝中静脉的取与舍

1993年,日本的Makuuchi等[1]成功完成了世界上第一例成人间活体肝移植(A-A LDLT);1996年香港的Fan等成功完成了世界上第一例成人间使用扩大右半肝的活体肝移植[2].活体肝移植有诸多优点:活体供肝来源相对较多,可尽早手术从而潜在地挽救了生命;尽管体积可能偏小,但移植物的质量事先就可得以保证;有着与尸肝移植同样令人满意的长期生存率.     

Surgical management of biliary complications following living donor liver transplantation

Khalaf H, Alawi K, Alsuhaibani H, Hegab B, Kamel Y, Azzam A, Albahili H, Alsofayan M, Al Sebayel M. Surgical management of biliary complications following living donor liver transplantation.
Clin Transplant 2011: 25: 504–510. © 2010 John Wiley & Sons A/S. Abstract: Background: Biliary complications (BC) account for much of the morbidities seen after living donor liver transplantation (LDLT). Surgical reconstruction might be necessary after the failure of endoscopic or percutaneous procedures. Methods: Between November 2002 and December 2009, a total of 76 LDLTs were performed. Six patients were excluded from statistical analysis because of early graft or patient loss. Results: Of 70, 26 (37.1%) developed BC; 12 (46.2%) were successfully managed by non‐surgical procedures, three (11.5%) died from BC‐related sepsis, one (3.8%) died from BC‐unrelated causes, and 10 (38.5%) underwent surgical reconstruction. Of those 10, four patients had single duct reconstruction, five patients had double ducts reconstruction, and reconstruction was abandoned in one patient because of hepatic artery thrombosis. After a median follow‐up period of 4.5 yr (0.1–6), seven (70%) remained well with no recurrent biliary problems, and three (30%) had recurrent BCs that were managed either conservatively or by retransplantation. Patients who underwent surgical reconstruction had significantly fewer hospital admissions, less need for invasive procedures, and shorter cumulative hospital stay (p < 0.05). Conclusions: In our experience, BCs after LDLT were frequently resistant to non‐surgical procedures. Surgical reconstruction is associated with fewer hospital admissions and less need for invasive procedures leading to reduced resources utilization.     

Microsurgical reconstruction of hepatic artery during living donor liver transplantation

Living donor liver transplantation (LDLT) has become a well-recognized treatment modality for patients with end-stage liver disease. Arterial reconstruction during LDLT is perhaps the most important aspect of the grafting procedure. Although microsurgical hepatic artery reconstruction has become the essential technique in LDLT, it poses significant challenges even to experienced microsurgeons. In this report, the experiences of 155 microsurgical reconstructions of the hepatic artery in 150 LDLTs were reviewed, and the problems that were encountered and the solutions are discussed. From June 1999-March 2004 150 LDLTs were performed on 148 recipients at Ege University Organ Transplantation and Research Center. Hepatic arterial thrombosis was encountered in 3 patients. Microsurgical technique has overcome the difficulties in LDLT. This has increased liver transplantations in the presence of limited cadaver grafts and has decreased the patient mortality in the waiting list.     

Emergency adult to adult living donor liver transplantation for fulminant hepatic failure

BACKGROUND: The high mortality rate associated with fulminant hepatic failure combined with the limited availability of cadaveric organs requires consideration of alternatives to conventional cadaveric transplantation. Use of the donor right lobe in adult-to-adult living donor transplantation holds promise in a variety of circumstances, including high-acuity situations. METHODS: A 28-year-old male with fulminant hepatic failure secondary to hepatitis B was referred to our institution. He rapidly progressed to grade IV encephalopathy, and laboratory values were indicative of a poor prognosis without transplantation. He was listed for transplantation as UNOS status I. Three siblings were simultaneously evaluated for living liver donation. Following established protocols, we completed donor evaluation in less than 24 hr, and donor right lobectomy and living donor transplantation were performed within 36 hr of the recipient's admission to our center. RESULTS: The donor surgery was uncomplicated, and the patient was discharged on postoperative day 4. The recipient experienced full recovery and was discharged home on postoperative day 14. Of note, the first offer for a cadaveric liver came more than 60 hr after living donor transplantation. CONCLUSIONS: Thorough donor workup can be completed in less than 24 hr without inappropriate abbreviation of the evaluation. Simultaneous workup of willing individuals prevents unnecessary delay. Living donor transplantation should be considered for patients with fulminant hepatic failure who are appropriate transplant candidates.     

肝胆管外科入路的应用解剖

目的探讨在不同肝门解剖结构条件下，肝内及肝门胆管的暴露途径。方法选用成人肝脏标本３０例，沿肝十二指肠韧带向肝门及肝内解剖，观察肝内外胆管的行径特点及其毗邻关系。结果肝管汇合的常见方式有３型，本组左右肝管正常汇合型１８例、二级肝管直接汇合型和右侧胆管变异支异常汇合型分别为６例。肝管行出肝门的水平有较大差异。肝门区管道结构的相互毗邻关系及Ｇｌｉｓｏｎ束在肝内的行径相对恒定。结论在正常的肝门解剖结构条件下，通过解剖肝门的方法可以暴露肝总管及左右肝管，在解剖变异或需要暴露更高位胆管时，可以借助肝正中裂切开法或肝方叶切开法达到暴露目的。     

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。     

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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

The number of adult living-donor liver transplantations is rapidly increasing world wide. Donor selection, technical innovation, and postoperative management are important for donor safety. The adequacy of graft size is the major limitation and the most critical issue in adult living-donor liver transplantation. The outcome of this surgery is significantly influenced by the pretransplant patient condition and the original patient disease. Further study is needed to clarify the indications for and timing of living-donor transplantation for adult recipients.     

Monosegmental living donor liver transplantation

BACKGROUND: Living donor liver transplant (LDLT) program has been started from 1990 in Japan, and is still major form of liver transplantation because of the scarcity of cadaveric donor organs. In small infants, implantation of left lateral segment grafts can be a problem because of a large-for-size graft. Until November 2002, we performed 867 transplants for 828 patients (561 children and 306 adults), and 14 cases received monosegment grafts from living donors. METHODS: Fifteen patients, median age 211 days, median weights 5.95 kg, received monosegmental LDLT. The indication for using this technique was infants with an estimated graft-to-recipient weight ratio of over 4.0%. RESULTS: Graft and patient survival is 85.7%. There were no differences in donor operation time and blood loss between monosegmentectomy and left lateral segmentectomy. Segment III grafts were indicated in 13 cases. Two vascular complications were observed (one hepatic artery thrombosis and one portal vein thrombosis). CONCLUSIONS: Monosegental living donor liver transplantation is a feasible option with satisfactory graft survival in small babies with liver failure.     

肝门部海绵状血管瘤18例的外科治疗体会

目的 总结肝门海绵状血管瘤的手术经验。方法 采用改良式全肝血流阻断下包膜外剥离法切除肝门部海绵状血管瘤１８例。其中行下腔静脉和肝右静脉损伤修复,行肝中静脉损伤修复各１例。结果 全组１８例术中平均每位患者输血６６２．５ｍｌ,均痊愈出院,其中下腔静脉及肝静脉损伤修复患者术后两周彩色Ｂ超显示下腔静脉和肝静脉血流通畅。结论 改良式全肝血流阻断下包膜外剥离法是切除肝门部海绵状血管瘤的安全方法。