袖片技术在成人肝移植动脉重建中的应用

Application of patch technique in artery reconstruction during adult liver transplantation

背景：血管重建和端口吻合是临床肝移植的难点，将袖片技术应用于肝移植动脉重建，对扩大吻合口径、减少动脉血栓形成、促进移植物及受体长期存活具有重要意义。目的：分析袖片技术在全肝移植前供体间动脉重建和植入时供受体动脉重建的吻合部位，探讨动脉袖片技术的应用条件。设计、时间及地点：单中心抽样，回顾性病例分析，于2004—03／2006-07在解放军第二军医大学东方肝胆外科医院完成。对象：选取解放军第二军医大学东方肝胆外科医院单个医疗组同期收治的接受肝移植患者80例，供体均为脑死亡男性志愿捐献者，供受体ABO血型相合。方法：后台完成供体间动脉重建，尽量保留、重建全部供肝变异、受损伤动脉。植入时完成供受体重建，主要选用粗大且直径匹配的供受体动脉。选择动脉端或应用袖片技术进行动脉吻合，尽量通过单个吻合完成重建。通过修剪供体或受体动脉，获取吻合端的动脉分支或根部袖片。主要观察指标；统计植入前供肝动脉重建的远、近心端及植入时供受体重建的供、受体侧4个位置的吻合部位分布、袖片应用率、吻合口径。结果：植入前后台供肝动脉吻合11例（吻合口12个），其中10例来自肠系膜上动脉的迷走右肝动脉进行了后台重建；在吻合口远心端，迷走右肝动脉根部袖片吻合口直径明显大于其端口（t=5．423，P〈0．01）；在吻合口近心端，吻合部位以脾动脉端最常用（7／12），吻合口直径为（4．4±1．8）mm。植入时供受体肝动脉吻合80例，供体侧以肝总动脉分支袖片、腹腔动脉端和肝固有动脉分支袖片最常用，构成比分别为57．50％，16，25％，8．75％；吻合口径基本相似（P〉0.05）；受体侧以肝总动脉分支袖片和肝固有动脉分支袖片最多，构成比分别为60.00％，27.50％，前者吻合口径明显大于后者（P〈0.01）。植入前吻合的袖片应用率明显低于植入时吻合（χ^2=30．799，P〈0．01），植入前供肝动脉重建的远、近心端及植入时动脉重建的供、受体侧其袖片应用率分别为41．7％，0.70．0％和92．5％，仅植入前供体远心端与植入时供体侧组比较基本相似（P〉0．05），余部位两两比较差异有显著性意义（χ^2=13．292～51．004，P〈0．01）。结论：在供肝动脉植入前进行后台重建时，采用袖片技术的迷走右肝动脉可获得比动脉端更大的吻合口径。植入时供受体动脉重建的袖片应用率高于植入前供体动脉重建，且植入时动脉重建的受体侧均采用分支袖片的肝总动脉能够获得比肝固有动脉更大的吻合口径。

BACKGROUND： Vessel reconstruction and anastomosis are difficult in clinical liver transplantation. Patch technique in artery reconstruction of liver transplantation is important for expanding stoma diameter, reducing arterial thrombosis, promoting graft and recipient long-term survival. OBJECTIVE： To investigate the application features and clinic values of patch techniques in artery reconstruction in recipients before total liver transplantation and in donors during transplantation. DESIGN, TIME AND SETTING： Single-center sampling and retrospective analysis. The experiment was performed at Eastern Hepatobiliary Surgery Hospital, Second Military Medical University of Chinese PLA from March 2004 to July 2006. PARTICIPANTS： Eighty patients underwent liver transplantation in Eastern Hepatobiliary Surgery Hospital, Second Military Medical University of Chinese PLA were selected. Donors were volunteers of brain death males. The donors and recipients were ABO matched. METHODS： Artery reconstruction among donors was performed to retain and reconstruct total variant and injured arteries prior to implantation. Artery reconstruction among donors and recipients was performed during implantation. Thick and diameter-matched arteries were selected. Arterial anastomosis was conducted using patch technique. Donor or recipient arteries were trimmed to obtained arterial branches or root patches of anastomosis parts. MAIN OUTCOME MEASURES： The location of anastomosis, stoma diameter size and application of patch techniques were analyzed for four special sites respectively （proximal and distal part prior to and during implantation）. RESULTS： Twelve anastomoses in 11 cases were performed between donor arteries prior to implantation, 10 of which reconstructed due to aberrant right hepatic artery （AbRHA） arrived from superior mesenteric artery. On the donor arterial distal side in back-table reconstruction, the diameter of AbRHA with patch after anastomosis was larger than its end （t=5.423, P 〈 0.01）. On the proximal side, spleen artery end was the location used more often （7/12） with a stoma diameter of （4.4± 1.8） mm. In addition, 80 anastomoses were achieved during implantation. On the donor artery side during implantation, the common hepatic artery （CHA） branch patch, celiac artery end and proper hepatic artery （PHA） branch patch were often used, and possessed a location constituent ratio of 57.50%, 16.25% and 8.75% respectively. The diameter size did not differ statistically among them （P 〉 0.05）. On the recipient artery side during implantation, the branch patch of CHA and PHA were usually anastomosed with a constituent ratio of 60.00% and 27.50%, but the diameter size of CHA was significantly larger than PHA （P 〈 0.01）. The application rate of patch techniques differed statistically between anastomosis group prior to and during implantation （41.7%, 97.5%, P 〈 0.01）. The patch application rates in four locations were 41.7%, 0.0%, 70.0% and 92.5% respectively. There was no statistical difference in application rate between donor distal side in back-table reconstruction and donor side during implantation （P 〉 0.05）. The statistical differences were found between any other two groups （ χ^2=13.292-51.004, P 〈 0.01）. CONCLUSION： In back-table artery reconstruction prior to implantation, AbRHA adopting patch technique can get a larger stoma than its end. The application rate of patch techniques in artery reconstruction during liver implantation is higher than that in reconstruction prior to implantation, the recipient anastomosing side during implantation obtains the highest rate. With branch patch CHA can get a larger stoma than PHA with branch patch.