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.

Technological Refinement to Reconstruction of Liver Outflow Vein in Living Donor Right Liver Lobe Graft

OBJECTIVE: To explore the reconstructed pattern of hepatic outflow vein in right lobe without middle hepatic vein (MHV) of adult living donor liver transplantation (LDLT). METHODS: The retrospective analysis was made on the clinical data of 47 recipients who underwent the operation in LDLT including the outflow vein reconstructed in right liver lobe without MHV. The right hepatic veins (RHV) in transplanted donor liver were anastomosed to a triangular opening in the recipient's inferior vena cava (IVC); the inferior right hepatic veins (IRHV) of significant size that had been preserved were anastomosed directly to the IVC. The great saphenous vein (GSV) as interposition connector was used to reconstruct the significant tributaries (V5,V8) of MHV, the other end of interposition was anastomosed with IVC. RESULTS: No death occurred in all the donors. Of 47 recipients, complications occurred in 9 recipients including the hepatic vein stricture (1 case), small-for-size liver syndrome (1 case), hepatic artery thrombosis (1 case), intestinal bleeding (1 case), bile leakage (2 cases), left subphrenic abscess (1 case) and pulmonary infection (2 cases). Three cases died of the small-for-size liver syndrome (1 case) and multiple system organ failure (2 cases). The total rate of outflow veins reconstructed for V5, V8 and IRHV was 65. 96% (31/47), the rate of one-vein reconstruction, two-vein reconstruction or three-vein reconstruction was 36.17%, 21. 28% or 8.51% respectively. The successive postoperative investigation for vein grafts were performed by Color Doppler Ultrasound. Four cases experienced GSV graft obstruction or obliteration among the 31 cases in 7-25 days after operation, but extensive collateral circulation has established. CONCLUSION: We used the "multiple-opening vertical anastomosis" to reconstruction of hepatic outflow vein. This technique alleviates the surgical risk on living donors, ensures the excellent venous drainage and prevents from the syndrome in small-for-size livers.