104例成人间活体肝移植肝动脉重建

Reconstruction of hepatic artery in adult to adult riving donor fiver transplantation in 104 patients

目的探讨成人间活体肝移植的肝动脉重建技术的经验。方法自2002年1月至2007年8月，四川大学华西医院施行了104例成人间右半肝活体肝移植，包括98例不含中肝静脉（MHV）的右半供肝肝移植及6例双供肝肝移植（双亲属左半供肝1例，亲属右半肝加亲属左半肝3例，亲属右半肝加尸体左半肝2例），104例受者中男86例，女18例，年龄18～63岁（中位年龄38岁），在供受体间肝动脉的重建中，61例供体右肝动脉与受体肝右动脉吻合，15例与受体肝固有动脉吻合，此外与受体左肝动脉吻合7例，与受体肝总动脉吻合3例，与受体肠系膜上动脉发出的副右肝动脉吻合8例，供体右肝动脉与受体肝总动脉自体大隐静脉间置搭桥5例，受体腹主动脉与供体右肝动脉自体大隐静脉搭桥2例，用尸体冷冻保存髂血管行受体腹主动脉与供体右肝动脉搭桥3例，供体肝动脉直径1．5～2．5mm，分别采用8-0和9-0 Prolene无损伤血管缝线在手术显微放大镜下完成肝动脉重建。结果104例成人间右半肝活体肝移植，术后1、7d发生肝动脉血栓形成2例（1．9％），采用自体大隐静脉肾下腹主动脉至供体右肝动脉搭桥术，恢复供肝血流，痊愈出院。1例1个月后发生肝动脉血栓形成，随访期无临床症状未行处理。术后和随访期未发现肝动脉狭窄、肝动脉假性动脉瘤等并发症。全部病例获得随访，随访时间2～60个月，1、2和3年实际生存率分别为89．3％、76．0％和69．3％。结论根据供受体动脉解剖情况选择最适宜的重建位置和方式，采用显微外科技术是减少围手术期肝动脉并发症保证供肝存活的关键。

Objective To report the experience of hepatic artery reconstruction with adult-to-adult living donor liver transplantation （ALDLT） using right lobe liver grafts. Methods From January 2002 to August 2007, 104 patients underwent ALDLT using right lobe grafts. Hepatic arteries of donors and recipients were assessed carefully with spiral CT angiography and DSA before ALDLT. All patients underwent reconstruction of hepatic artery between right lobe liver grafts of donor and recipient which included the anastomosis between right hepatic artery of donors and recipients; the reconstruction of right hepatic artery between donor grafts and left hepatic artery of recipients; interposifional bypass using autogenous saphenous vein and cryopreserved iliac artery between right hepatic artery of donors and hepatic artery, common hepatic artery and abdominal aorta of recipients. The microsurgical technique was employed under the magnification of 3.5 times and operative microscope of 5-10 times. Results In these series, HAT occurred in 2 recipients at Days 1 and 7 post-ALDLT （ 1.9% ）. Both were revascularized with autogenous saphenous vein between right hepatic artery of donor and abdominal aorta of recipient. HAT occurred in 1 recipient at Days 90 post-ALDLT, but no symptom was presented. There was no severe complication and mortality related to hepatic artery reconstruction in recipients. No HAT, hepatic artery stenosis and aneurysm occurred during the follow-up period of 2-60 months. The 1, 2 and 3-year survival rates were 89.3%, 76. 0% and 69. 3% respectively. Conclusion Careful evaluation of hepatic artery condition and using microsurgical techniques are important for safer arterial reconstruction and a long-term patency of hepatic artery in living donor liver transplantation in adults using right lobe liver grafts.