原位肝移植手术不同开放方式对循环及早期肝、肾功能的影响

Effects of different reperfusion approaches on hemodynamics and early postoperative hepatic and renal function in orthotopic liver transplantation

目的探讨原位肝移植术中不同开放方式对术中循环及术后早期肝、肾功能的影响。方法入选50例行肝移植术患者,其中逆灌组28例,顺灌组22例。逆灌组在下腔静脉吻合后即开放,然后吻合和开放门静脉。顺灌组在下腔静脉和门静脉吻合完毕后,先开放门静脉再开放下腔静脉。在麻醉诱导后(T1),无肝前期(T2),无肝期3min(T3),开放前1min(T4),新肝期1min(T5)、3min(T6)、5min(T7)、15min(T8)、30min(T9)、60min(T10)及术毕(T11),记录心率(HR)、收缩压(ABP)、平均动脉压(MAP)、中心静脉压(CVP)、下腔静脉压(ICVP)、体温(T)。在T4,T9,新肝期90、120min,T11,术后1、2、7d检测血肌酐(SCr)。在T11及术后1、3、5、7d检测丙氨酸转氨酶(ALT)和天冬氨酸转氨酶(AST)。结果两组间在各时间点的HR和T的差异均无统计学意义(P值均>0.05)。逆灌组在T5、T6时间点的ABP和MAP均显著高于顺灌组(P值均<0.05)。逆灌组T4时间点的CVP、ICVP均显著低于顺灌组(P值均<0.05)。逆灌组在术后1、2d的血清肌酐水平显著低于顺灌组(P值均<0.05)。逆灌组在T11的AST和ALT及术后1d的ALT水平均显著低于顺灌组(P值均<0.05)。结论逆行灌注可减轻门静脉开放后对循环的影响,有利于肝、肾功能的早期恢复。

Objective To investigate the influence of different reperfusion approaches on the hemodynamics,early postoperative liver and renal function in orthotopic liver transplantation（OLT）.Methods Fifty OLT patients were divided into retrograde reperfusion group（via vena cava,n=28） and antegrade reperfusion group（via portal vein,n=22）.Heart rate（HR）,arterial blood pressure（ABP）,mean arterial pressure（MAP）,central venous pressure（CVP）,inferior vena cava pressure（IVCP） and nasopharynx temperature were recorded at different time points including after anesthesia induction（T1）,anhepatic prophase（T2）,3 min in anhepatic phase（T3）,1 min before reperfusion（T4）,1 min in new hepatic phase（T5）,3 min in new hepatic phase（T6）,5 min in new hepatic phase（T7）,15 min in new hepatic phase（T8）,30 min in new hepatic phase（T9）,60 min in new hepatic phase（T10） and at the end of operation（T11）.Serum creatinine（SCr） was detected at T4,T9,T11,90 and 120 min in new hepatic phase,and 1,2,7 d postoperatively.Alanine aminotransferase（ALT） and aspartate aminotransferase（AST） were measured at T11,and 1,3,5,7 d postoperatively.Results The differences in HR and nasopharynx temperature had no statistical significance between the two groups at each time point（P0.05）.ABP and MAP in retrograde reperfusion group were significantly higher than those in antegrade reperfusion group at T5 and T6（P0.05）.CVP and ICVP in retrograde reperfusion group were significantly lower than those in antegrade reperfusion group at T4（P0.05）.SCr in retrograde reperfusion group was significantly lower than that in antegrade reperfusion group 1 d and 2 d after surgery（P0.05）.AST at T11 and ALT at T11 and 2 d after surgery in retrograde reperfusion group were significantly lower than those in antegrade reperfusion group（P0.05）.Conclusion Retrograde reperfusion can decrease hemodynamic changes induced by reperfusion via portal vein and improve early hepatic and renal function after surgery.