合并Ⅳ级门静脉血栓的肝移植六例报告

Management of grade Ⅳ portal vein thrombosis in liver transplantation （report of 6 cases）

目的探讨合并Ⅳ级门静脉血栓（PVT）者肝移植时门静脉重建的方法。方法合并Ⅳ级PVT的乙型肝炎后肝硬化（失代偿期）患者6例，4例并发上消化道出血，1例并发肾功能不全，1例并发肾功能不全和肝性脑病。术前4例曾接受脾切除＋门奇断流术，1例曾接受脾切除＋门奇断流术＋脾肾分流术＋经颈静脉肝内门腔内支架分流术，1例曾接受脾切除术。术前均明确诊断为Ⅳ级PVT。6例均行经典非转流原位肝移植术。4例采取门静脉一内脏曲张静脉吻合重建门静脉，其中2例将门静脉与扩张的胃冠状静脉吻合，2例将门静脉与胆总管旁曲张静脉吻合。另2例采取门静脉动脉化重建门静脉，1例将结肠中动脉与供肝门静脉吻合，供肝肝动脉与受者的肝动脉吻合，另1例将供肝门静脉与受者的肝总动脉吻合，供肝肝动脉与受者的胃十二指肠动脉远端吻合。结果采取内脏曲张静脉吻合重建门静脉者，术中检测门静脉血流量为（1258±345）ml／min，1例术后2个月死于腹腔感染，其余3例分别随访14、16和17个月，门静脉血流均保持通畅，无狭窄及血栓形成，肝功能正常，食管胃底静脉曲张有所减轻。采取门静脉动脉化重建者，术中检测门静脉血流量为（2275±247）ml／min，1例术后反复出现上消化道出血，术后47d死于腹腔感染；另1例目前已随访33个月，肝肾功能良好，食道胃底静脉曲张程度加重。采取门静脉动脉化重建者各时间点的AST和ALT均优于采取内脏曲张静脉吻合重建者。结论合并Ⅳ级PVT者肝移植时采用供肝门静脉-内脏曲张静脉吻合重建门静脉临床效果满意；门静脉动脉化重建门静脉通道有利于移植肝功能的早期恢复，但只能作为合并PVT者肝移植时的一种有效的补救措施。

Objective To investigate the methods for reconstructing portal vein in liver transplantation patients with grade Ⅳ portal vein thrombosis. Methods Clinical data of 6 patients with grade Ⅳ portal vein thrombosis who underwent liver transplantations were analyzed retrospectively. Different portal vein reconstructing approaches were applied： 4 patients underwent portal vein anastomosis with internal organ varicosis vein （group A）, and 2 patients underwent portal vein arterialization （group B）. Portal venous flow was monitored by intraoperative ultrasound and postoperative liver function was tested periodically during follow-up. Results In group A, one patient died of celiac infection 2 months post-transplantation. The remaining three patients were followed up for 14-17 months, and their portal veins remained smooth without thrombosis and with mitigated esophageal varicosity. In group B, one patient, with recurrent upper gastrointestinal bleeding, died of celiac infection 47 days after liver transplantation. The patient was followed up for 33 months with satisfactory liver and kidney functions although stomach esophagus varicosity was aggravated. Portal vein blood flow in groups A and B was 1258 ＋ 345 and 2275 ＋ 247 ml/min respectively after anastomosis by intraoperative color Dopplar ultrasound monitoring. Aspertate aminotransferase （AST） in group B was significantly lower on the fourth day after liver transplantation, and alanine aminotransferase （ALT） in group B was significantly lower on the 3rd, 4th, 5th and 6th day after liver transplantation than in group A （all P（0. 05）. Serum total bilirubin （TBIL） had no statistically significant difference during the 10 days post-operation （P）0. 05）. Conclusion Patients with grade Ⅳ portal vein thrombosis may achieve a satisfactory clinical effect by reconstructing portal vein through anastomosis of donor portal vein with internal organ？ varicosis vein. PVA may be associated with early recovery of graft function and may be an effective remedial measure for patients with grade Ⅳ portal vein thrombosis who undergo liver transplantation.