经典原位肝移植手术之经验

所谓经典原位肝移植（也叫传统原位肝移植）是指切除受体的病肝及肝后下腔静脉,利用供体的肝上、肝下下腔静脉来重建和恢复肝脏的流出道与腔静脉的连续性。早年的肝移植方法大都采用此种术式并有别于后来的背驮式肝移植,故称之为传统的或经典的术式。我院自１９９３年开展首例肝移植以来,现已实施８０余例,其中包括６例肝肾联合移植,一例小儿活体肝移植和一例成人－成人间扩大右半肝移植,余均为经典式原位肝移植。其中良性终末期肝病一年生存率为７５％,最长存活已近３年。现就手术方面的经验与体会谈几点看法。供体手术在目前我国脑…     

原位肝脏移植中的血管整形

目的　探讨原位肝移植术中常见的血管整形方法与临床效果。方法　根据肝脏移植的不同术式及供、受体血管之间的差异, 对供或／ 和受体的肝上下腔静脉、门静脉、肝动脉进行必要的整形。结果　共施行肝上下腔静脉整形１３９ 例次,门静脉整形２ 例, 术后均未发生相关并发症, 肝动脉整形９ 例,术后１ 例发生肝动脉栓塞,需再次肝移植。结论　血管整形为肝移植手术技术中的重要环节,术前对供、受体各血管的准确评估,精细的血管整形技术是保证肝移植手术成功的关键     

腔静脉成型术在背驮式肝移植术中的应用

目的推荐和总结在实施背驮式肝移植术中采用腔静脉成型术，以期减少术后肝脏流出道梗阻并发症的发生。方法总结2002年1月至2003年4月所实施的23例背驮式肝移植病人，术中实施受体肝静脉成型后，在腔静脉前壁做等腰三角形成型，与供体肝后腔静脉后壁的等腰三角形成型后对口吻合，以减少肝脏流出道梗阻的经验。结果22例病人术中过程顺利，术后恢复良好，无一例发生肝脏流出道梗阻。1例由于术中切肝时误将受体肝后腔静脉横断而改行原位肝移植，术后恢复良好，未发生流出道梗阻。结论在背驮式肝移植术中采用腔静脉成型技术，可以明显降低肝脏流出道梗阻并发症的发生。同时具有简化切肝过程，降低吻合难度，强化移植肝的稳定性，无肝期短的优点。当供受体之间大小存在明显差异时，或实施儿童的减体积性肝移植时该技术具有明显优势。强调用此法切肝时切忌误伤受体肝后腔静脉。     

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.     

附加腔静脉成形的背驮式原位肝植术

目的 探讨腔静脉成形术在背驮式原位肝移植中的应用价值及在防止移植肝流出道阻塞并发症中的作用。方法 ３例终末期肝病病人选为肝移植受者。供肝的下腔静脉及受体的肝后下腔静脉（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术。结果 ３例病人术中均较平稳,手术时间和无肝期缩短,出血量减少,术后肝功能恢复快,恢复顺利,无并发症发生。结论 腔静脉成形术可防止背工肝移植肝静脉流出道阻塞,术中     

小儿肝移植的探讨

目的本研究探讨肝移植治疗小儿终末期肝病的方法和疗效。方法我院分别于2001年11月至2002年12月对7例患儿(先天性胆道闭锁5例，先天性肝纤维化1例和肝脏血管内皮肉瘤1例)进行肝移植术，患儿年龄6个月至12岁。其中亲体部分肝移植术两例，供体分别为患儿的母亲和父亲。手术分别切取供体的右半肝和左外侧叶。受体行保留下腔静脉的全肝切除术，然后将供肝进行原位移植。减体积肝移植3例，取左半肝和左外侧叶为移植物。割离式肝移植2例，分别取左外后叶和右后叶为移植物。结果7例患儿分别移植肝重260～565g，亲体肝移植的两例供体随访14～15个月，均无并发症健康生活。接受移植的7例患儿中6例术后已经分别健康存活15～1个月，1例于术后第5天死于心功能衰竭。结论肝移植是治疗小儿终末期肝病的有效方法，术前准确的血管影像学检查，严格的围手术期管理特别是精确的手术技术是小儿肝移植成功的关键。     

附加腔静脉成形的背驮式原位肝移植术

目的　探讨腔静脉成形术在背驮式原位肝移植中的应用价值及在防止移植肝流出道阻塞并发症中的作用。方法　 3例终末期肝病病人选为肝移植受者。供肝的下腔静脉及受体的肝后下腔静脉 (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术。结果　 3例病人术中均较平稳 ,手术时间和无肝期缩短 ,出血量减少 ,术后肝功能恢复快 ,恢复顺利 ,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 ,术中对受体的血流动力学干扰小 ,并可缩短无肝期和减少腔静脉梗阻并发症的发生。     

背驮式肝移植技术改良（附41例次临床病例分析）

目的：探讨背驮式肝移植在终末期肝病中应用的利弊。方法：自1995年9月至2000年7月,对39例患施行了41次背驮式肝移植。对供肝静脉回流通道重建技术进行了逐步改变,由供肝下腔静与受体成型的肝静脉重建,到供、受下腔静脉的端－侧吻合及侧－侧吻合,并进行了供体下腔静脉与受体下腔静脉－右心房的桥式吻合和原旁位供肝肝上下腔静脉－右心房重建悬吊。结果：手术技术的改良既避免了肝静脉回流不同程度受阻的弊端,同时缩短了无肝期和下半躯体淤血时间。结论：背驮式肝移植技术改良减少了术后并发症,缩短了手术时间,并拓宽了手术适应证。     

改良的小鼠原位肝移植实验模型

目的 介绍一种稳定、可靠、存活率高的小鼠原位肝移植实验模型。方法 选择同系雄性C57BIV6小鼠，供、受体各22只（其中16只作长期存活观察）。供肝经肝门静脉灌注4℃威斯康星大学保存液。血管重建时，肝上腔静脉端端吻合，肝门静脉和肝下腔静脉采用袖套法吻合。不作动脉重建。术后观察肝移植物组织学改变和肝脏再生反应。结果 小鼠肝脏移植手术成功率为100％。受体存活率为100％（超过30d）。无肝期保持在23min内。术后组织学检查移植肝组织结构良好，肝脏再生反应不明显。结论 改良方法建立的小鼠肝移植实验模型稳定性强，存活率高，精细的显微外科技术是成功的关键。     

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     

背驮式肝移植的技术改进(附一例报告)

目的 探讨更完善的背驮式肝移植术式。方法 保留受者的腔静脉、肝静脉全部结扎,在受者的下腔静脉上开一侧孔,将供肝腔静脉近端与受者的下腔静脉侧孔行端侧吻合,远端缝扎。术中测定受者各时相的血流动力学参数。结果 无肝期为５０例,整个手术历时８小时,术中失血２５００ｍｌ。术中血流动力学平稳。术后肝功能指标大部分恢复正常,胆汁引流量约２００ｍｌ／ｄ。术后第５８天因肾功能衰竭死亡。结论 本术式适合于良性终末期肝     

门静脉-下腔静脉吻合术预防活体肝移植术后小肝综合征3例报道

目的探讨门静脉-下腔静脉吻合术用于预防活体肝移植术后小肝综合征(small-for-size liver syndrome,SFSS)的效果。方法 3例活体肝移植均采用不含肝中静脉的右半肝作为移植物。术中发现实测移植物(肝)重量/受体的体质量(体重)的比值(graft to recipient weight ratio,GRWR)为0.58%、0.77%及0.71%,均<0.8%,符合小移植物的诊断。处理:首先吻合肝静脉流出道,其次吻合门静脉,将受体门静脉右支与移植肝门静脉右支端端吻合,将受体门静脉左支与下腔静脉行端侧吻合达到门腔分流的作用,之后按顺序吻合动脉和胆道。术中均未行脾静脉结扎或脾切除等处理。术后定期随访。结果 3例患者术后均未发生SFSS并顺利出院,出院时间分别为术后25d、34d及56d。移植肝功能逐步好转,术后1d门静脉流速理想。移植肝增长良好。门静脉-下腔静脉短路通畅时间:除1例通畅持续仅104d,其余2例持续通畅。结论 LDLT术中进行门静脉-下腔静脉吻合术可以及时有效预防小移植物背景下的SFSS,受体门静脉左支与下腔静脉行端侧吻合的分流技术安全可靠。     

Replacement of the vena cava with aortic graft for living donor liver transplantation in budd-Chiari syndrome associated with hydatid cyst surgery: a case report

A 12-year-old girl, operated because of a hydatid cyst of the liver, with Budd-Chiari syndrome was evaluated for postoperative development of ascites and paraumbilical varicose veins. A vena caval stent was placed for the relief of inferior vena caval obstruction. The patient was admitted because of progressive deterioration in ascites and liver functions. Imaging techniques showed degeneration adjacent to the right hepatic vein in liver segments 7 to 8, a partially calcified 5-cm hydatid cyst, and a thrombosis in the inferior vena cava was that addressed with a 10-cm metal stent. A living donor segments 2 to 3 liver transplantation was obtained from the patient's mother. After completion of the donor operation without complications, the vena caval stent was removed following the recipient hepatectomy. Suprarenal flow continued after resection of the fibrotic vena cava and placement of a cadaveric cryopreserved aortic graft for the vena cava, anastomosed between the suprarenal and subdiaphragmatic segments of the vena cava. An end-to-side anastomosis was performed between the left hepatic vein of the donor liver and the aortic graft. There was no complication and the patient was discharged on postoperative day 19. Follow-up Doppler ultrasonography showed the aortic vena caval graft to be open, along with the hepatic/portal vein and hepatic artery. This case demonstrated that operations for liver hydatid cyst surgeries can iatrogenically induce Budd-Chiari syndrome; a cryopreserved aortic graft can be an alternative to ensure the continuity of the vena cava in living donor liver transplantation.     

Living donor liver transplantation in the absence of inferior vena cava: a case report

Because of difficulties in the supply of cadaveric organs, of living donor liver transplantations are performed in increasing numbers. Congenital hepatic fibrosis associated with fibrosis and atrophy of the inferior vena cava were present in a potential recipient of living donor liver transplantation. This case report documented living donor liver transplantation as a treatment modality for a patient with absence of the inferior vena cava due to chronic liver failure.     

A new method of segmental orthotopic liver transplantation in children

Orthotopic liver transplantation requires matching of the donor and recipient for size. The rarity of suitable pediatric and infant donors in many countries has resulted in the acceptance of the principle of a reduced-sized adult liver graft for children. A new method of segmental orthotopic liver transplant is described. This method involves resecting the recipient liver off the inferior vena cava, which is left in situ, and the donor hepatic vein is anastomosed end to side to the inferior vena cava. The technique allows orthotopic liver transplantation with widely mismatched sizes from adults to infants.     

Short hepatic vein reconstruction in biliary atresia patients with absent inferior vena cava

Liver transplantation in patients with biliary atresia and polysplenia syndrome requires some technical adjustments. During eight yr, 75 biliary atresia patients underwent living donor liver transplantation. Of these, two patients were complicated by absent inferior vena cava with azygos continuation. Both patients received hemi-liver grafts with short hepatic veins. Outflow was reconstructed using a cryopreserved vena cava. In both patients, the short hepatic vein was anastomosed to the vein graft end-to-end and the end of the vein graft was anastomosed with the common orifices of recipient's hepatic veins. Both of the patients survived the operation with satisfactory graft function. A hemi-liver graft with short hepatic veins can be used for patients with biliary atresia with inferior vena cava agenesia using the current technique.     

原位肝移植术后下腔静脉狭窄的原因及防治

目的 探讨肝移植术后下腔静脉狭窄的原因和防治方法。方法 本组共施行原位肝移植术8例,通过彩超及下腔静脉造影检查证实术后发生下腔静脉狭窄2例。结果 在2例下腔静脉狭窄中,1例经球囊扩张及支架置入术而治愈;另1例病人拒绝手术自动出院。结论 肝移植术后下腔静脉狭窄的重要因素是吻合技术不当,肝脏体积过大,血肿形成,腹水生成,癌肿复发。球囊扩张、支架置入是有效的治疗手段。     

Pathology of the inferior vena cava and liver transplantation

Pathology of the inferior vena cava is not frequently encountered in the context of liver transplantation. Such a pathology was observed in 7.9% of our recipients, in the pre- intra- and post-operative period. Pre-existing anomalies of the IVC consisted the absence of the retrohepatic vena cava in 7 children with biliary atresia; technical adjustments were quite simple. During the operative period, dissection of the supra-hepatic vena cava was made very difficult in 2 patients with hepatic alveolar echinococcosis complicated by secondary biliary cirrhosis it was necessary to make a trans-diaphragmatic approach to the inferior vena cava. Post-operative inferior vena cava thrombosis occurred in four recipients, in three cases, it was caused by the inadequate size of the graft and major anastomotic discrepancy between the inferior vena cava of donor and recipient and in one case IVC thrombosis occurred in a context of allergy to heparin. Six of the 13 recipients with pathology of inferior vena cava died directly of indirectly because of these problems. Analysis of the causes of this pathology and their possible correction will perhaps allow better results in these patients who undergo liver transplantation.     

20%小体积的大鼠肝脏移植模型

目的 应用显微外科技术建立20%小体积移植物的大鼠原位肝脏移植模型.方法 原位移植建立20%小体积大鼠肝脏移植模型.雄性Lewis大鼠40只,供体20只,受体20只.供肝经门静脉用4℃ UW液灌注.肝上下腔静脉用端端吻合连续缝合的方法.肝下下腔静脉和门静脉分别用套管方法固定.套叠缝合法重建肝动脉.胆管重建采用内支架管端端连接的方法.观察移植物的存活率.免疫组化检测肝细胞摄取溴脱氧尿核苷的情况.结果 共施行肝脏移植手术20例,移植手术成功率为100%.20%小体积肝脏移植物的存活率为93.8%(＞14 d).组织学检查移植后的肝脏组织结构良好.移植术后72 h溴脱氧尿核苷染色阳性的肝细胞计数明显增多.结论 20%小体积大鼠肝脏移植物可启动完成移植后的肝脏再生.显微外科技术是移植模型成功的关键.该模型稳定性强,适合于部分肝脏移植领域的基础研究.     

Artificial vascular graft for inferior vena cava reconstruction in living donor liver transplantation: a case report

Artificial grafts are not recommended because of the high incidence of thrombogenic effects. However, in some situations, such as emergency or when no vascular bank is available, an artificial graft must be used. We present a case in which a polytetrafluoroethyline graft was used as a conduit to reconstruct the retrohepatic vena cava severed during living donor liver transplantation (LDLT). A 48-year-old woman had end-stage primary biliary cirrhosis for 5 years received a right lobe liver graft from her son. The retrohepatic vena cava was divided and ligated in several sequences. The upper end of the severed retrohepatic vena cava retracted into the liver parenchyma. The lower end of the severed vena cava was distended, with multiple stitches. A 16-mm artificial graft was used as a conduit to replace the inferin vena cava for outflow reconstruction. The patient tolerated the complicated procedure well. No anticoagulant was used throughout the entire course. The patient has been well with excellent liver function after follow-up for more than 5 years. Magnetic resonance imaging and Doppler ultrasonographic studies showed good patency of the cava with no evidence of thrombosis. We suggest use of an artificial graft in living donor liver transplantation, in particular in urgent situations when autologous or allogeneic vessels are not available.