成人间活体肝移植肝动脉重建方法和并发症的处理

Hepatic arterial reconstruction and complications management in adult-to-adult living donor liver transplantation

目的探讨成人间活体肝移植的肝动脉重建和并发症处理的经验。方法自2002年1月至2006年7月，共施行50例成人间右半肝活体肝移植。在供受者间肝动脉的重建中，供者右肝动脉与受者右肝动脉吻合24例，与受者肝固有动脉吻合12例，与受者左肝动脉吻合3例，与受者肝总动脉吻合2例，与受者肠系膜上动脉发出的副右肝动脉吻合2例，与受者肝总动脉自体大隐静脉间置搭桥3例。受者腹主动脉与供者右肝动脉自体大隐静脉搭桥2例，用保存的尸体髂血管行受者腹主动脉与供者右肝动脉搭桥2例。供者肝动脉直径1．5～2．5mm，采用显微外科技术在3．5倍手术放大镜和5～10倍手术显微镜下完成肝动脉重建。结果50例成人间右半肝活体肝移植中，有2例（4％）分别于术后1d、7d发生肝动脉血栓形成，立即采用自体大隐静脉从肾下腹主动脉至供者右肝动脉搭桥术，恢复供肝血流，痊愈出院。1例术后1．5个月后发生肝动脉血栓形成，随访期无临床症状未行处理。术后和随访期未发现肝动脉狭窄、肝动脉假性动脉瘤等并发症。围手术期未有与肝动脉并发症有关的死亡病例。全部病例获得随访，随访时间2～52个月（中位随访时间9个月），1年实际生存率为92％。结论选择恰当的肝动脉重建方式和应用显微外科技术可显著降低肝动脉并发症，及时处理肝动脉并发症是保证供肝存活的关键。

Objective To explore the experience of hepatic arterial reconstruction and its management of complications in adult-to-adult living donor liver transplantation （A-A LDLT） using right lobe liver grafts. Methods From January 2002 to July 2006,50 of A-A LDLT using right lobe liver grafts were performed. All arterial anastomosis were performed to protect the donor hepatic arterial supply, in which donor right hepatic artery was sutured to recipient right hepatic artery in 24 patients, to recipient proper hepatic artery in 12 patients, to recipient left hepatic artery in 3 patients, to recipient common hepatic artery in 2 patients, to recipient aberrant right hepatic artery arising from superior mesenteric artery in 2 patients. Interpositional bypass using autogenous saphenous vein was performed between donor right hepatic artery and recipient common hepatic artery in 2 patients. Bypass was done between donor right hepatic artery and recipient abdominal aorta using autogenous saphenous vein in 2 patients and using stored cadaveric iliac vessels in 2 patients respectively. The diameter of donor right hepatic artery is between 1.5-2. 5 mm, microsurgical technique was used under the magnified lope of 3. 5 times and operative microscope of 5-10 times. Results In these series, hepatic artery thrombosis（HAT） occurred in 2 recipients on 1^ st and 7^th days following A-A LDLT （4%）, which were revascularized with autogenous saphenous vein between donor right hepatic artery and recipient abdominal aorta immidiately, HAT in 1 recipient occurred one and a half month following A-A LDLT, but no symptom was presented. No hepatic artery stenosis and aneurym occurred during follow-up period. No death related to hepatic artery complications occurred. All recipients were followed up from 2 to 52 months （ mean follow-up 9 months ）. 1-year survival rate was 92%. Conclusions Proper anastomotic vessel choose and use of microsurgical technique in hepatic arterial reconstruction would reduce significantly the incidence of hepatic artery complications and provide an excellent graft survival following AA LDLT.