原位肝移植术后静脉流出道梗阻的原因和处理

The cause and management of postoperative venous outflow obstruction after orthotopic liver transplantation

目的探讨原位肝移植术后静脉流出道梗阻的原因和处理方法。方法对2000年1月至2006年12月收治的776例同种原位肝移植患者的临床资料进行回顾性分析。总结原位肝移植术后静脉流出道梗阻的诊治经验。结果776例肝移植患者中共发生术后静脉流出道梗阻10例，发生率为1．29％。其中肝上下腔静脉吻合口狭窄6例，肝后段下腔静脉狭窄2例，肝静脉流出道梗阻2例。10例均进行了下腔静脉造影而明确诊断，8例患者在下腔静脉造影的同时施行了气囊扩张或放置血管内支架术，2例介入治疗效果不佳而中转再次肝移植术；该组因术后静脉流出道梗阻而死亡3例，与静脉流出道梗阻相关的病死率为30％（3／10）。结论原位肝移植术后静脉流出道梗阻的发生与腔静脉的吻合技术，腔静脉吻合方式以及供肝体积与受者肝床不匹配有关；术后尽早发现流出道梗阻的存在，并及时做出正确的治疗选择如介入治疗或再次肝移植等是改善该并发症预后的关键。

Objective To investigate the causes and treatment of postoperative venous outflow obstruction after orthotopic liver transplantation （OLT）. Methods Clinical data of 776 patients after OLT were analyzed retrospectively between January 2000 and December 2006. The accumulated experiences in diagnosis and treatment of postoperative outflow obstruction after OLT were reviewed. Results Venous outflow obstruction occurred in 10 patients （ 1.29% ） after OLT, among those 6 had superahepatic inferior vena cava（IVC） stenosis,2 had IVC stenosis of the posthepatic segment,and 2 had outflow obstruction of hepatic vein. The diagnosis was confirmed by inferior vena cavography in all the patients. Of the 10 patients, 8 received percutaneous transluminal angioplasty （PTA） or metallic stent replacement, and 2 underwent liver retransplantation （re-LT） when interventional therapy failed. Three patients died from outflow obstruction, so the outflow obstruction related mortality was 30% in the patients. Conclusions Complications of outflow obstruction after OLT were associated with surgical technique like vascular anastomosis, various types of cavocaval anastomosis and graft size mismatch between donor and recipient. Making an early diagnosis and giving timely treatment including interventional therapy or re-LT is the key to improve the prognosis of outflow obstruction.