补救性肝移植19例手术体会

Operative techniques of salvage liver transplantation:a report of 19 cases

目的探讨采用补救性肝移植(salvage liver transplantation,SLT)治疗原发性肝细胞癌(肝癌)切除术后肝内复发或肝功能衰竭的疗效及手术体会。方法肝癌切除术后肝内复发16例,肝癌切除术后肝功能衰竭3例,其中合并肾功能异常2例,均接受SLT。术前充分评估病情。手术方式采用附加腔静脉整形的改良背驮式原位肝移植,其中肾功能异常的2例采用股静脉-颈内静脉转流术。肝动脉的重建采用供肝腹腔干动脉与受者肝固有动脉行端端吻合17例,采用供肝腹腔干动脉通过供者髂动脉间置搭桥与受者腹主动脉行端侧吻合2例。胆道的重建全部采用胆道端端吻合。术程始终遵循精细的无瘤操作,术后常规抗排斥和抗感染治疗,并对患者进行了长期随访。结果围手术期19例SLT患者无死亡。术后1、3、5年累积生存率分别为100%、84%、84%;1、3、5年无瘤生存率分别为100%、89%、89%。结论采用SLT治疗肝癌切除术后肝内复发或肝功能衰竭患者的疗效较好。采用腔静脉整形的改良背驮式肝移植术式、充分的术前评估以及遵循精细的无瘤操作是手术成功的关键。

Objective To explore the clinical efficacy and operative techniques of salvage liver transplantation（SLT）for hepatocellular carcinoma recurrence or liver failure after hepatocellular carcinoma resection.Methods Nineteen patients underwent SLT,including 16 cases with hepatocellular carcinoma palindromia and 3 cases with liver failure（2 cases combined with abnormal renal function）after hepatocellular carcinoma resection.All the patients received modified piggyback liver transplantation with venacavaplasty after preoperative evaluation,and extracorporeal venous bypass was used in 2 cases with abnormal renal function.For arterial reconstruction,end-to-end anastomosis from celiac truck of donors to arteriae hepatica propria of recipients was performed in 17 recipients,while end-to-side anastomosis from celiac truck of donors to abdominal aorta of recipients was performed in the other 2 patients.Biliary duct was reconstructed by end-to-end anastomosis without T-tube in all patients.No tumor manipulation was strictly carried out during the whole operative procedures.Anti-rejection and anti-infection treatment were routinely given in all patients after operation.Long-term follow-up of these 19 cases was recorded.Results The perioperative mortality rate of 19 cases after SLT was 0.The 1-,3-,5-year accumulative survival rates of SLT were respectively 100%,84% and 84%.And the 1-,3-,5-year disease-free survival rates of SLT were respectively 100%,89% and 89%.Conclusions SLT strategy is still effective in treating hepatocellular carcinoma palindromia or liver failure after live resection.Modified piggyback liver transplantation with venacavaplasty,adequate preoperative evaluation and precise no tumor manipulations during operation procedures are the keys for successful SLT.