肝移植术中复杂门静脉机化血栓的处理

Management of portal vein organized thrombosis during liver transplantation

目的探讨存在复杂门静脉机化血栓者肝移植术中门静脉的处理要点。方法为17例机化血栓超过门静脉内径50%的患者施行肝移植,术中9例在切除血栓段门静脉或取栓后,将受者的门静脉与供肝门静脉行端端吻合;5例将供肝门静脉与受者的曲张冠状静脉行端侧吻合;1例切除闭塞段门静脉,利用供者的髂静脉于供肝门静脉与受者肠系膜上静脉间搭桥;1例供肝门静脉与受者的胆总管前曲张静脉行端侧吻合;1例采用供者的髂静脉在供肝门静脉和受者的脾门旁曲张静脉间搭桥,行端侧吻合。结果17例患者,死亡2例,1例死于感染,1例死于肝动脉出血,但此2例患者的门静脉血流一直通畅。存活的15例随访2～12个月,其中1例术后因门静脉血流量不足,而行二次肝移植,在缝扎分流的侧支后,门静脉血流恢复正常,其他患者的门静脉血流均通畅。结论存在复杂门静脉机化血栓时首选栓塞段门静脉切除或取栓后门静脉重建,不能取栓或取栓后血流量不足时,可改行供肝门静脉与受者曲张内脏静脉的端侧吻合,也可取得较好效果。

Objective To analyze the key point of management of complicated portal vein organized thrombosis （PVOT） during liver transplantation （LT）. Methods LT was performed on 17 patients with the extent of PVOT 〉50 % inner diameter of portal vein （PV）. Among them, 9 cases were subjected to end-to-end anastomosis between graft PV and recipient PV after thromboendovenectomy or removing thrombosis, 5 to end-to-side anastomosis between graft PV and recipient varicose coronary vein, 1 case to end-to-end anastomosis between graft PV and recipient superior mesenteric vein by interpositioning graft iliac vein after thromboendovenectomy, 1 case to end-to-side anastomosis between graft PV and recipient varicose vein before common bile duct, and 1 case to end-to-side anastomosis between graft PV and recipient varicose vein near spleen hilus by interpositioning graft iliac vein. Resulls Among 17 patients, 1 case died of infection and 1 case died of hepatic artery bleeding, but their PV were unobstructed. Fifteen cases were followed up for 2-12 months. Re-transplantation was performed on 1 case 14 days after the first LT because of the insufficient PV flow, and the PV flow recovered to normal after ligating the shunt veins. The PV flow of the other patients were unobstructed. Conclusion Thromboendovenectomy or removing thrombosis is the first choice in the management of PVOT during LT. Anastomosis between graft PV and recipient splanchnic varicose vein can also make a good effect, when PV flow is insufficient after thromboendovenectomy or removing thrombosis.