成人间活体右半肝移植术中变异门静脉右支切取与重建技术

Excision and reconstruction of anomalous portal venous branching in adult-to-adult right lobe living donor liver transplantation

目的探讨成人间活体右半肝移植术中变异门静脉支（APVB）切取与重建的技巧。方法2002年1月至2007年4月，共实施70例成人间活体右半肝移植。术前肝脏血管三维CT成像显示供肝动脉及静脉走向，70例右半供肝中有9例门静脉分支变异，其中7例为Ⅱ型变异，2例为Ⅲ型变异。除1例供者行狭窄桥状连接单口切取APVB外，其余8例均采用供者优先的原则即距门静脉主干2-3mm处双口切断APVB。Ⅱ型变异中有2例双口切取其右前、右后支成形为一个开口后与受者门静脉主干吻合，4例右前、右后支分别与受者门静脉左、右支吻合，1例行右前、右后支间狭窄桥状组织连接单口切取后与受者门静脉主干单口吻合。Ⅲ型变异中有1例双口切取其右前、右后支分别与受者门静脉支双口吻合，1例双口切取后行新型的U形血管移植物间置与受者门静脉主干单口吻合。结果9例受者均无门静脉狭窄或血栓、肝动脉狭窄或血栓以及肝静脉流出道狭窄等血管并发症发生。1例供者术后3d并发门静脉血栓，手术取栓及门静脉壁修补成形后痊愈。新型的U形血管移植物间置重建术后通畅，无并发症发生。结论成人间活体右半肝移植术中采用供者优先的原则双口切取APVB、双口吻合重建以及新型的U形血管间置等门静脉重建技术是安全可行的，未增加手术难度，且临床效果良好。

Objective To disuss the techniques for excision and reconstruction of anomalous portal venous branches （APVB） in adult-to-adult right lobe living donor liver transplantation （A-A RL LDLT）. Methods From February 2002 to April 2007,70 cases of A-A RL LDLT were performed. Preoperative three-dimensional computed tomography of the donor revealed the configurations of hepatic artery, portal vein and hepatic vein. Nine donors had anomalous portal venous branching （APVB）. The APVB were type Ⅱ （trifurcation） in 7 cases and type Ⅲ in two. Except the excision of APVB with a common opening by a narrow bridge of main portal vein tissue in one type Ⅱdonor, all the right APVB were transected on the principal of donor priority： right APVB being excised approximately 2-3 mm from the confluence while leaving the donor＇s portal vein intact. In type ⅡAPVB, the donor portal venous branches were transected with separate two openings and reconstructed as double anastomoses in 4 cases, with separate two openings joined as a common orifice at the back table and reconstructed as single anastomoses in 2 cases, and with one common opening with narrow-bridge of tissue and reconstructed as single anastomoses in 1 case. In type Ⅲ APVB,the APVB were transected with separate two openings and were reconstructed by double anastomoses in 1 case and by a new technique named U-shaped vein graft interposition in the another one. Results There were no vascular complications such as portal vein stricture or thrombosis, hepatic artery stricture or thrombosis and hepatic vein outflow stricture in all 9 recipients transplanted with grafts with APVB. Only the type ⅡAPVB donor undergoing a excision of APVB with a common opening by a narrow bridge of main portal vein tissue developed portal vein thrombosis on the third postoperative day and underwent thrombectomy followed by repair with vein patchplasty. The velocity of blood flow in the U-graft was normal.Conclusions It is feasible and safe of APVB excision on the principal of donor priority and reconstruction including double anastomoses and the novel U-graft interposition in A-A RL LDLT, and has a good outcome without increasing the management difficulty.