成人间活体肝移植的手术技术改进(附13例报告)

Modifications of surgical technique in adult-to-adult living donor liver transplantation

目的探讨成人间活体肝移植的手术技术改进。方法2005年3—6月,施行了13例成人间右半肝活体肝移植,其中1例接受了2个左半肝,另1例接受了1个活体右半肝,1个尸体左半肝,术中采用了改良的手术技术,包括右肝静脉的重建,肝中静脉分支的搭桥,肝动脉搭桥及胆道吻合的改进。结果全组供体无严重并发症及死亡,受体发生并发症4例,包括肝动脉栓塞,胆漏,右膈下脓肿及肺部感染各1例,1例再移植因术后肺部感染,导致多器官衰竭(MOF)死亡。13例中除右肝静脉与下腔静脉(IVC)直接吻合,5例加行右肝下静脉重建,另5例采用自体大隐静脉搭桥行肝中静脉分支与IVC重建,保证了右肝的流出道通畅。移植物与受体重量比(GRWR)为0·72%至1·24%,其中9例<1·0%,2例<0·8%,无小肝综合征发生。结论采用了改进的手术技术,特别是肝静脉流出道的充分重建可有效避免小肝综合征,从而使活体右半肝移植成为相当安全的手术。

Objective To report the authors＇ experience with adult-to-adult living donor liver transplantation using right lobe liver grafts performed by a modified technique. Methods From March to June 2005, 13 patients underwent living donor liver transplantation using right lobe grafts. Among these, one patient received two left lobes from his two elder sisters, one received a right lobe from his mother and a left lobe from a cadaveric donor. All patient underwent a modification designed to improve the reconstruction of right hepatic vein, the reconstruction the tributaries of the middle hepatic vein by interpositioning a vein grafts, and the anastomosis of the hepatic arteries and bile ducts. Results There were no severe complications and deaths found in donors. Four complications occurred in recipients including hepatic artery thrombosis （ n = 1 ）, bile leakage （ n = 1 ） left subphrenic abscess （ n = 1 ） and palmonary infection （ n = 1 ）. The patient with palmonary infection died of multiple organ failure （MOF）. All patients underwent direct anastomosis of right hepatic vein and inferior vena cava （ IVC ） , 5 cases plus the reconstructions of right inferior hepatic vein, and the other 5 cases plus the reconstruction of the tributaries of the middle hepatic vein by interpositing a vein graft to provide sufficient venous outflow. The graft and recipient weight ratio （GRWR） were between 0.72% and 1.24%, among these, 9 cases 〈 1.0% and 2 cases 〈0. 8%, and there was no ＂small-for-size syndrome＂ occurred. Conclusions With modifications of surgical technique, especially the reconstruction of hepatic vein to provide sufficient venous outflow, living donor liver transplantation in adults using right lobe liver grafts can become a relatively safe procedure and prevent the ＂ small-for-size syndrome＂.