肝小肠联合移植的术式探讨及术后处理一例

Combined liver and intestinal transplantation： surgical procedures and treatment after operation （one case report）

目的 总结1例保持门静脉连续性的小肠双造口方式肝小肠联合移植病例的手术操作和术后处理的经验。方法受者为短肠综合征合并肝功能不良的男性患者，供者为尸体供者。联合切取器官，确保供者肠系膜上静脉和门静脉的连续性。移植肝静脉采用背驼式吻合，受者自体门静脉和供肝门静脉端侧吻合，胆道端端吻合，供者肝动脉和肠系膜上动脉吻合于受者腹主动脉；移植小肠约2ITI，两端双造口于腹壁，未作肠道吻合。采用人源化抗CD52单克隆抗体诱导治疗，维持期单用他克莫司。行内镜下黏膜活检监测排斥反应。结果术后1个月内，患者发生腹腔感染和疑似排斥反应各1次，分别经过手术和甲泼尼龙冲击治疗后痊愈。随访6个月，受者移植肝和小肠功能恢复良好，但仍有腹泻，需补充静脉营养，体重尚未完全恢复。结论保持门静脉连续性的小肠双造口方式肝小肠联合移植可以简化手术操作，发生外科并发症的风险小，有利于肝脏和小肠功能恢复及术后排斥反应的监测，但是消化液未能进入移植小肠，也影响了受者的恢复。

Objective To discuss the surgical procedures and treatment after combined liver and intestinal transplantation with portal venous drainage and enterostomy of two ends in one case. Methods A male patient with liver dysfunction and short bowel syndrome underwent the combined liver and intestinal transplantation. With the techniques of ＂en bloc＂, the liver and intestinal grafts were harvested from cadaveric donor. The intestinal graft, 200 cm long, was implanted with portal venous drainage and aortic inflow, and enterostomy of both ends was performed instead of intestinal anastomosis. The liver graft was placed in a piggyback fashion with end to end anastomosis of the bile ducts without T tube. Immunosuppression protocol was administrated with campath-lH and taerolimus. Endoscopic biopsy of intestinal graft was performed regularly, and clinical observation was done to monitor the acute rejection. Results In the first month after operation, abdominal infection was controlled by intraperitoneal drainage with open surgery. One suspect acute rejection was treated with methylprednisolone. Until sixth month, the functions of liver and intestine were progressively restored. However, the patient lost weight and could not be free from intravenous nutrition because of diarrhea： Conclusion Combined liver and intestinal transplantation with portal venous drainage and enterostomy of two ends is a simple surgical procedure with lower risk of surgical complications. This method is propitious to monitoring rejection and function improvement of the grafts. Diarrhea and loss of digestive iuice are the main reasons of low body weight and malnutrition.