肝脏单独与肝肾整块快速获取方法的比较

Rapid liver procurement versus liver-kidney en bloc procurement

目的:目前器官移植尸体供体来源仍占相当的比例,多器官来源于同一供体的需求增多,快速整块获取的技术发展迅速。比较肝脏单独与肝肾整块快速获取的技术特点与脏器损伤情况的差异。方法:①回顾分析2004-03/2006-07解放军第二军医大学东方肝胆外科医院单个手术组获取并应用于移植的74例供肝资料。②使用快速肝脏获取方法,不进行热解剖,开腹先进行腹主动脉联合门静脉原位冷灌注。肝脏单独切取方法:肾静脉上缘离断腔静脉,胰颈下方离断肠系膜上血管;腹主动脉前解剖法剥离肠系膜上动脉至根部,与肾动脉之间离断腹主动脉,游离胰腺体尾、腹主动脉后方,取下肝脏。肝肾整块获取方法:肝周韧带游离后,游离结肠、输尿管、肾及脾脏,离断肠系膜上血管,横断腹主动脉、腔静脉,游离血管、肝胰脾肾后方,整块切取肝肾。离体腹主动脉后解剖法显露分离肝肾动脉,离断下腔静脉,完全分离肝肾。③记录两种方法的肝脏热缺血、肝脏获取、冷缺血时间,统计肝肾主要部位的获取损伤率并进行比较。结果:①完成肝脏单独获取28例,肝肾整块获取46例,两组中分别有1例同时获取心脏。未发生因器官获取原因导致的器官损失,获取肝脏全部用于移植,无原发性器官无功能发生,无肝动脉血栓形成。②单独获取患者肝脏获取时间短于肝肾整块获取患者(P<0.01)。③肝肾整块获取患者的腹腔动脉和肠系膜上动脉的Carrel袖片损伤率低于肝脏单独获取患者(P<0.05)。结论:快速肝脏单独和快速肝肾整块获取方法的主要技术差别在于分离肝肾血管的先后顺序及解剖显露肝肾动脉的方法;快速肝脏单独获取在手术耗时上少于快速肝肾整块获取,但更容易出现腹腔动脉和肠系膜上动脉Carrel袖片的损伤。

AIM：At present, there are still many organ grafts from corpse donors. The increasing demands of multiple organs from one donor accelerate the development of rapid en bloc technique for organ procurement. This study compared technique characterization and organ injuries of rapid liver procurement versus en bloc liver-kidney procurement. METHODS： ①Between March 2004 and July 2006, the data of 74 liver donors by single operation team were retrospectively analyzed. ②Warm dissection was performed after cold perfusion of abdominalis aorta combined with portal vein in situ. Rapid liver procurement： the inferior vena cava （IVC） above renal veins and superior mesenteric vessels below the neck of pancreas were transected; the superior mesenteric artery （SMA） to its root anterior to aorta were dissected, then the aorta between the SMA and renal arteries was transected, the pancreas and aorta posterior from the spinal column was liberated to remove the liver. In the procedure of liver-kidney en bloc procurement, after ligaments were divided, the colon, ureters, kidneys and spleen were transected and the superior mesenteric vessels, the aorta, IVC above inferior mesenteric artery and these organs upward in prespinal space were transected to remove the liver-kidney. Then the aorta above renal arteries was ex vivo transected, and the liver was separated from kidneys after transecting the IVC. ③Liver warm ischemia, procurement, and cold ischemia time by two methods was recorded. Iatrogenic organ injuries were also recorded. RESULTS： Twenty-eight liver grafts were obtained with liver only procurement method, and 46 liver-kidneys were harvested with liver-kidney en bloc method. One heart graft was procured simultaneously respectively in each method group. No graft was discarded due to iatrogenic injuries, and no liver graft developed primary nonfunction or hepatic artery thrombosis. ②The liver only procurement time was significantly shorter than liver-kidney en bloc group （P 〈 0.01）. ③The injury rates on celiac artery （CA）/SMA Carrel patch, common/aberrant hepatic artery, renal artery and renal vein in liver-kidney en bloc group were significantly lower than in liver only group （P 〈 0.05）. CONCLUSION： The main differences of techniques between rapid procurement of liver only and liver-kidney en bloc are the order of vessel separation between liver and kidney, and the method of dissecting SMA and renal arteries （anterior or posterior to aorta）. Using rapid liver only procurement techniques, the procurement time is less but CA/SMA Carrel patch injuries rate is higher than using rapid liver-kidney procurement techniques.