原位肝移植的常用手术方式及应用体会

Comparison among three surgical techniques for orthotopic liver transplantation

目的探讨经典原位肝移植术、改良背驮式肝移植术、原位肝移植腔静脉成形术在临床应用中的利弊。方法对2001年10月至2004年5月实施的155例病人的159次肝移植术式进行回顾性分析,其中经典原位肝移植术94例,改良背驮式肝移植术48例(包括改良背驮+术中门-腔静脉端侧吻合转流8例),原位肝移植腔静脉成形术17例;术中行血管架桥5例,其中因门静脉闭锁及栓塞行供肝门静脉与受体肠系膜上静脉间架桥2例,因动脉变异分支细小不能利用行供肝腹腔干与受体腹主动脉间架桥3例。159例次肝移植手术均未应用体外静脉转流技术。结果原位肝移植腔静脉成形术的手术时间、无肝期最短,术中失血输血量最少,其术中对循环和肾功能的影响与经典术式相仿。经典原位肝移植术与背驮式肝移植术相比流出道不畅发生率较低,总手术时间较短(平均少30 min),但无肝期较长(平均长8 min),术中及术后肾上腺出血发生率较高,对肾功能影响较大,三组术后ICU留置天数差异亦无显著性意义(P=0.542)。结论不同的肝脏移植术式各有其优缺点,术者的经验以及对术式的熟悉程度会影响手术方式的选择,从原则上讲,手术方式的选择应根据具体病情及术中情况而决定。

Objective To compare the clinical efficacy of the 3 surgical techniques of traditional orthotopic, modified piggyback and cavaplasty liver transplantation. Methods The clinical data of 159 patients receiving liver transplantation in our hospital from October 2001 to June 2004 were retrospectively analyzed. The traditional orthotopic liver transplantation was applied in 94 patients, modified piggyback liver transplantation in 48 （including 8 simultaneously undergoing temporary end-to-side portocaval shunt） and cavaplasty liver transplantation in 17. Interpositional vessel grafts were applied in 5 patients during the operation. Of the 5 patients, 2 underwent the interpositional vessel graft between portal vein trunk and superior mesenteric vein due to portal vein thrombosis and 3 had that between donor celiac artery and recipient abdominal aorta because the hepatic artery was too thin. The femoro-axillary veno-venous bypass was not used in all the 159 patients. Results As compared with other 2 surgical techniques, cavaplasty liver transplantation brought the shortest surgical time and anhepatic period, as well as the least amount of blood loss and transfusion （P〈0.05）. The influence on the circulation and renal function was similar between the traditional orthotopic liver transplantation and cavaplasty liver transplantation. Compared with modified piggyback liver transplantation, the technique of traditional orthotopic liver transplantation had lower incidence of obstruction of outflow tract, shorter surgical time but longer anhepatic period, higher incidence of adrenal hemorrhage and greater damage to renal function. There was no significant difference in ICU stay among the 3 groups. Conclusions The 3 surgical techniques for liver transplantation have their respective advantages and disadvantages. The selection of the surgical techniques depends on several factors such as the recipient＇s anatomic features, state of illness and the familiarity of the operators with these surgical techniques.