成人肝移植术后早期再次手术

Early-stage reoperation after liver transplantation in adults

目的回顾性观察肝移植术后早期再次剖腹探查及对预后的影响,分析其原因及特征,并籍此找出可能避免再次手术的措施。方法总结密歇根大学医院自2006年8月1日至2007年2月28日间所行成人肝移植手术患者资料,将再手术患者组与未再手术患者组资料进行对照和统计学分析。结果52例患者行肝移植手术共54次。随访3至9个月,其中共14次(12例患者)术后再次剖腹探查,所有再手术均在移植术后20 d内。6例系手术技术相关的术后腹腔出血,2例为非手术技术相关腹腔出血,2例术后肝动脉栓塞,1例术后移植物无功能再次肝移植,1例肝动脉取栓后再栓塞行再次肝移植,1例术后肠粘连保守治疗无效,1例阴性探查。行剖腹探查者1例患者死亡。结论移植术后手术技术相关的腹腔出血是再次手术探查的主要指征,MELD评分较高的患者建议移植术后常规置放引流;原发性移植物无功能和肝动脉栓塞是早期再次肝移植的主要指征;肝动脉栓塞的诊断和处理需要快速果断,再次手术取栓、融栓与吻合口的校正可能是解决问题的根本办法;移植术后的真菌感染后果是致死性的,提高警惕性和早期预防是关键。

Objective To observe retrospectively the effect of early-stage reoperation after liver transplantation, analyze its causes and characteristics and to look for a better strategy to prevent reoperations. Methods The materials of adult liver transplantations performed between August 1, 2006 and February 28, 2007 in the transplant center of the University of Michigan Health System were collected. The data between the reoperative group and the non-reoperative group statistically were compared. Results Fifty-eight liver transplantations were performed in 52 patients, including 4 pediatric cases which will be excluded in this research. They were followed-up for three to nine months. Twelve patients experienced 14 reoperations, which all happened within 20 days following liver transplantation. Six patients were reoperated due to intraabdominal bleeding, two with intraabdominal bleeding were unrelated to technique. Two cases experienced hepatic artery thrombosis and underwent reoperation. Two reexplantations are indicated by primary nonfunction following first liver transplantation, and rethrombosis after hepatic artery thrombectomy and thrombolysis respectively. One patient was undergone lysis of adhesion for small bowel obstruction after invalid conservative therapy. One experienced a negative reexploration. Conclusion Technique related to intraabdominal bleeding is the main indication to reoperate following liver transplantation. Regular drainage is recommended in transplanted patients with higher MELD score. Primary nonfunction and hepatic artery thrombosis are the main indications for re-transplantation in the early period following liver transplantation. The key point to treat hepatic artery thrombosis is early diagnosis and reoperation with thrombectomy and thrombolysis and revision of anastomosis. Fungal infection after liver transplantation is complicated with high mortality, requiring more vigilance and early antifugal prophylaxis.