肝移植围手术期门静脉血栓的处理

Management of portal vein thrombosis during the perioperative period of orthotopic liver transplantation

目的探讨肝移植围手术期门静脉血栓(PVT)的处理。方法回顾性分析中国医科大学附属第一医院1995年5月至2008年6月实施的194例肝移植病人临床资料,术前存在PVT24例,其中Ⅰ级12例,Ⅱ级9例,Ⅲ级2例,Ⅳ级1例。术中采取不同门静脉重建方式,结扎术前存在的门腔分流和粗大的侧支循环。术后根据凝血酶原时间(PT),应用普通肝素或低分子质量肝素预防性抗凝。术中、术后应用多普勒超声监测门静脉血供。结果术后PVT发生率2.58%(5/194)。1例PVT经外科门静脉取栓、重新吻合治愈,3例置管溶栓、支架植入治愈,另1例仅表现肝功能轻度异常,未特殊处理。与PVT相关病死率为0。其余病例随访6～104个月,未见PVT。结论理想的门静脉重建方式、结扎门腔存在的分流和术后有效的抗凝可以减少PVT的发生,多普勒超声监测能早期发现PVT,挽救移植物,避免再移植。

Objective To analyze the managements of portal vein thrombosis（PVT） during the perioperative period of orthotopie liver transplantation.Methods Between May 1995 to June 2008,194 orthotopic liver transplantation were performed in our institute,of which 24 presented portal vein thrombosis .12 were grade Ⅰ ,9 grade Ⅱ,2 grade Ⅲ and 1 grade Ⅳ . The management of PVT depended mainly on its extent.Ligation of the collateral circulation,especially spontaneous or surgical splenorenal shunt,was made as approaches to improve portal flow. Heparin or low-molecule-weight heparin as a prophylactic anticoagulation therapy was maintained during and after operation if prothrombin time is less than eighteensonds. Follow-up Doppler ultrasonography was used daily in the early postoperative period.Results After a follow-up of 6-104 months, overall incidence of portal vein thrombosis was 2.58% （5/194）.Surgical thrombectomy and revascularization was carried out in 1 case. Percutanous thrombolysis ,balloon angioplasty, or stent placement via portal vein were performed in 3 cases.No treatment was given in 1 patient without hepatic dysfunction. Mortality related to portal vein thrombosis was 0.Conclusion PVT might be avoid by performing a ideal technique for managing PYT as often as possible,by ligation of portosystemic shunt during surgery, and by postoperative anticoagulation.Close follow-up by Doppler uhrasonography may make a prompt diagnosis and reduce PVT-derived loss of grafts.