再次肝移植手术技巧:附24例报告

Operative technique of liver retransplantation:a report of 22 cases

目的探讨再次肝移植的手术技巧。方法总结近4年多来2 4例行再次肝移植术患者的临床资料。全部采用改良背驮式原位肝移植术。6例采用体外静脉转流,1 8例未转流。肝上下腔静脉吻合应用附加腔静脉成形-改良背驮式。门静脉重建均为端端吻合。肝动脉的重建:7例为肝动脉、腹主动脉搭桥术,余均为肝动脉端端吻合术。胆道的重建:6例为胆管、胆管端端吻合术,余均为胆管、空肠吻合术(Roux-en-Y或W arren术式)。对所有患者进行随访。结果住院期间病死率为4 1.6%(1 0/2 4)。死亡原因:脓毒症7例;手术出血性休克2例;脑血管意外1例。痊愈率为58.4%(1 4/2 4)。痊愈患者并发症发生率为2 1.4%(3/1 4),包括胆道并发症2例,伤口裂开1例。结论再次肝移植与初次肝移植手术时间及出血量无显著差异。针对患者进行个体化处理是手术成功的关键。手术难点在于下腔静脉的显露与游离。肝动脉搭桥及胆肠吻合机率高于初次肝移植。

Objective To explore the operative technique of liver retransplantation. Methods The clinical data of 24 patients who underwent liver retransplantation in the recent 4 years in our center were reviewed. In all of the patients a modified piggy- back liver transplantation was adopted. Extracorporeal venous bypass was used in 6 cases, and no bypass was used in 18 cases. We anastomosed the suprahepatic inferior vena cava to the annexed vena cava in a modified piggy-back figuration. The portal vein was reconstructed by end- to-end anastomosis. In 17 cases the hepaticy artery was anastomosed end-to-end, and in the other 7 cases was anastomosed to abdominal aorta by interposition graft. In 6 cases the biliary tract was reconstructed by end-to-end anastomosis, and in the others by choledochojejunostomy. All of the patients were routinely followed up after operation. Results Postoperative mortality of liver retransplantation was 41. 6 % （ 10/24 ）. The cause of death was sepsis in 7 patients , intraoperative bleeding in 2 , and cerebral hemorrhage in 1 . The other patients（ 14/24,58.4% ） successfully recovered after liver retransplantation. The complication rate in this group was 21.4 % % （ 3 / 14 ） , including biliary tract complications in 2 patients, and wound dehiscence in 1. Conclusions There was no significant difference in operative time and blood loss between liver retransplantation and primary transplantation. The key for success is to adopt individuation in selection of methods for liver retransplantation. The difficulty of liver retransplantation is exposure and mobilization of inferior vena cava. The probability of interposition graft from hepatic artery to abdominal aorta and choledochojejunostomy is higer than that of primary liver transplantation.