活体肝移植治疗终末期肝病患者12例

Living-donor liver transplantation for patients with end-stage liver diseases: 12 cases report

目的总结亲属间活体肝移植治疗终末期肝病患者的手术技巧及体会。方法本组回顾性研究对象为2005年9月至2012年9月在新疆医科大学第一附属医院行活体肝移植的12例供体及12例受体。供体中男7例，女5例，年龄19～51岁，中位年龄28岁；受体中男7例，女5例，年龄13～51岁，中位年龄39岁。供体与受体为合法的亲属关系，均签署知情同意书，符合医学伦理学规定。1例小儿受体接受不含肝中静脉的左半肝移植，其余11例成人均接受不含肝中静脉的右半肝移植。2例肝泡型包虫病（HAE）患者术后长期服用阿苯达唑15—20mg／（kg·d）。观察移植物及供、受体术中血管、胆管重建情况，记录无肝期、输血量、手术时间、住院时间和并发症发生情况。供、受体出院后接受门诊随访，记录供、受体并发症、存活和死亡情况。结果12例活体肝移植供、受体手术均获成功。1例小儿受体移植物质量为400g，移植物与受体标准肝体积比（GV／SLV）为0．52，s4段肝动脉发自肝右动脉，胆囊动脉发自肝左动脉，S4段肝与胆囊动脉端端吻合后将供体肝左动脉与受体肝左动脉端端吻合。其余1l例受体移植物质量中位数为550（450～720）g，GV／SLV为0．45（0．35—0．60）。s5段肝静脉属支用异体髂静脉架桥重建，s8段肝静脉属支直接与肝后下腔静脉吻合。供体术中输注红细胞悬液为1（0-4）U，手术时间为318（280～334）min，术后住院时间为9（7—12）d；受体无肝期为72（45～180）min，术中输注红细胞悬液为12（2～35）U，手术时间为690（580～1080）min，术后住院时间为17（14～28）d。供、受体术后均恢复顺利，无发生并发症。12例供体随访时间为3—87个月，均存活。12例受体随访时间为3．63个月，存活8例，死亡4例。1例死于慢性排斥反应；1例死于严重的肺部感染；1例死于肝细胞颅脑出血；1例死于肝癌复发。2例HAE患者肝内及肝外均未见新生病灶。结论活体肝移植的成功有赖于对供、受体血管及胆道的全面、精准的评估和精细的手术操作。HAE术后长期服用阿苯达唑是预防HAE复发的关键措施。

Objective To summarize the clinical experience of living donor liver transplantation （LDLT） of relatives for the end-stage liver disease （ESLD）. Methods Clinical data of 12 donors （7 males and 5 females; 19 to 51 years of age; 28 years of mean age） and 12 recipients （7 males and 5 females; 13 to 51 years of age; 39 years of mean age） who underwent LDLT in the First Affiliated Hospital, Xinjiang Medical University from September 2005 to September 2012 were retrospectively analyzed. The real kinship between the donors and recipients was carefully identified and proved. The informed consents of all participating subjects were obtained and all procedures were performed in accordance with the medical ethics. One child received transplantation of left lobe without middle hepatic vein. And the other 11 adults received transplantation of right lobe without middle hepatic vein. Two patients with hepatic alveolar echinococcosis （HAE） were given long-term treatment of albendazole 15-20 mg/（kg-d）. The reconstruction of vessels and bile duct of the grafts, donors and recepients were observed. The anhepatic phase, the blood transfusion volume, operative time, hospital stay and complications were recorded. The donors and recepients were followed up after discharge from the hospital. The complications, survival rate and mortality were observed. Results All operations were successfully performed. The graft weight of the child recipient was 400 g with the graft volume/standard liver volume （GV/SLV） was 0.52. The artery of S4 segment originated from the right hepatic artery. The cystic artery originated from the left hepatic artery. The anastomosis of the S4 segment and gall bladder artery were performed and then the left and right hepatic arteries of the donor and recepients were anastomosed. The graft weight of the other 11 adult cases was 550 （450-720） g and the GV/SLV was 0.45 （0.35-0.60）. The hepatic veins of S5 segment were bridged and reconstructed with allograft iliac veins. The hepatic veins of $8 segment was anastomosed with the inferior vena cava. For the donors, the intraoperative administration of red cell suspension was 1 （0-4） U, the operative time was 318 （280-334） min, the postoperative hospital stay was 9 （7-12） d;The anhepatic phase of the receptor was 72 （45-180） nfin,the intraoperative administration of red cell suspension was 12（2-35） U,the operative time was 690（580-1 080） min,the postoperative hospital stay was 17（14-28） d. All the donors and recipients recovered well and no complications were observed. The follow-up time of the 12 donors was 3-87 months and all survived. The follow-up time of the 12 recipients was 3-63 months with 8 survivals and 4 deaths. One case died of chronic rejection, one of severe lung infection, one of cerebral hemorrhage and the other one of HCC recurrence. No new intrahepatic and extrahepatic lesions were observed in the 2 patients with HAE. Conclusions Comprehensive and accurate assessment of the donor and recipient＇s vessels and bile duct and perfect surgical skills are the keys to the success of living donor liver transplantation. The long-term use of Albendazole after transplantation for HAE patients is the key measure to prevent recurrence of HAE.