原位肝移植肝动脉重建临床分析

目的 总结分析原位肝移植肝动脉重建经验,提高肝移植疗效和受体存活率.方法 总结1995年5月至2006年12月实施的183例肝移植临床资料,常规动脉重建163例,供者腹腔动脉干Carrell's袖片或肝总动脉-脾动脉汇合部与受者肝左-右动脉汇合部吻合25例,胃十二指肠-肝固有动脉汇合部吻合134例,腹腔动脉干吻合4例.采用髂动脉.腹主动脉搭桥20例.术后根据凝血酶原时间(PT),应用普通肝素或低分子肝素抗凝.术中、术后应用多普勒超声监测肝动脉血供.结果 183例肝移植患者中有6例发生肝动脉并发症,发生率为3.28%(6/183),其中肝动脉血栓形成(hepatic artery thrombosis,HAT)5例,肝动脉狭窄(hepatic artery stenosis,HAS)1例.常规通路动脉重建组动脉并发症发生率1.84%(3/163),髂动脉-腹主动脉搭桥组为15.0%(3/20),两者比较差异有统计学意义(X2=9.73,P＜0.01).6例并发症患者中有1例HAT于术后19 d死于多器官功能衰竭,另5例通过介入治疗治愈,死亡率16.7%.结论 正确地选择肝动脉重建吻合的部位和术后有效的抗凝治疗减少HAT和HAS的发生,多普勒超声的早期发现和放射介入的及时治疗可以挽救移植物,避免再移植.

Hepatic artery reconstruction in orthotopic liver transplantation

Objective To summarize experience for hepatic artery reconstruction in orthotopic liver transplantation(OLT).Method A retrospective analysis was made for 183 cases of orthotopic liver transplantation performed in our institute from May 1995 to december 2006.All the arterial reconstructions were performed with 6-0 polypropylene sutures in an interrupted fashion under a 3.5 magnification surgical loupe.Donor hepatic arteries were anastomosed at the origin of the celiac artery with a Carrel's patch or at the level of splenic artery confluence.Extra-anatomic arterial reconstruction was based on recipient aorta using donor iliac artery graft.OLT with routine anatomic arterial construction served as control.Heparin or low-molecule-weight heparin as a prophylactic anticoagulation therapy was maintained during and after operation if prothrombin time is less than eighteen seconds.Follow-up Doppler ultrasonography was used daily in the early postoperative period.Results Overall incidence of hepatic artery complications was 3.28%.Hepatic artery thrombosis(HAT)was observed in 5 cases.Hepatic artery stenosis(HAS)occurred in 1 patient.Routine anatomic arterial construction was performed in 89.07%(163)of cases,and HAT developed in 3(1.84%)cases.Extra-anatomic arterial reconstruction was carried out in 10.93%(20)of the patients;the presence of HAT was identified in 3(15.0%)cases(X2=9.73,P＜0.01).Thrombolysis,balloon angioplasty,and vascular stenting via hepatic artery were performed.One patient suffering from identified hepatic artery thrombosis died of liver failure 19 days post-op.The other 5 patients were cured successfully with patent blood flow by interventional therapy.Mortality related to hepatic artery complication was 16.7%.Conclusion HAT and HAS may be minimized by using gastroduodenal branch-patch anastomosis and postoperative anticoagulation.Close follow-up by Doppler ultrasonography helps to make a prompt diagnosis and reduce HAT-and HAS related graft loss.