84例二次肝移植受者手术死亡风险因素分析

The risk factor for death related to surgery of recipients subject to liver re-transplantation： A report of 84 cases

目的分析二次肝移植受者手术死亡风险因素。方法回顾分析84例二次肝移植的临床资料。二次移植采用经典非转流术式78例，背驮式6例。供、受者门静脉端端吻合83例，门静脉一腔静脉半转位1例；肝动脉端端吻合78例，供肝动脉与受者的脾动脉吻合4例，与腹主动脉搭桥2例；胆管一空肠Roux-en-Y吻合10例，胆道端端吻合并留置T管72例，置管外引流2例。分析指标包括受者的性别、年龄、术前终末期肝病模型评分、二次移植距初次移植时间和二次移植原因，供肝因素包括热缺血时间、冷保存时间，手术因素包括手术耗时、无肝期时间、术中失血量、术中输注红细胞量、胆道重建方式和胆漏发生率。结果84例中，72例术后恢复顺利，12例死亡。在所设定的分析指标中，经逐步回归模型检验，术中输注红细胞数量的相对危险度为1．000，95％可信区间为1．000～1．000，P=0．009；胆漏的相对危险度为3．935，95％可信区间为1．107～13．990，P=0．034。结论术中输注红细胞数量和胆漏是二次肝移植受者手术死亡的风险因素，由经验丰富的移植医生来完成二次移植手术，尽量减少术中出血，选择合适的胆道重建方式，避免胆漏，可以降低二次移植受者的手术死亡风险。

Objective To analyze the risk factor for death related to surgery of recipients who underwent liver re-transplantation. Method We reviewed clinical data of 84 cases subject to liver re- transplantation, retrospectively. Seventy-eight cases received classical method without by pass, and rest 6 cases piggyback. Portal vein end-to-end anastomosis of 83 cases was done, and 1 case received portal vein-vena cava half-transposition. Hepatic artery end-to-end anastomosis in 78 cases was performed, splenic artery anastomosis in 4 cases, and aorta bypass in 2 case. Bile duct reconstruction of 10 cases was performed by jejunum Roux-en-Y anastomosis, and 72 cases by end-to-end with T tube, and 2 cases by catheter drainage. The factors including gender, age, MELD score, time to first transplant, warm and cold ischemia time, operative time, anhepatic phase, intraoperative blood loss, intraoperative transfusion of red blood cells, and incidence of bile leakage were analyzed. Result Seven cases recovered smoothly, and 12 cases died. The amount of RBC infusion during operation （HR = 1. 000, 95% CI 1. 000-1. 000, P = 0. 009） and bile leak （HR = 3. 935, 95% CI 1. 107-13. 990, P = 0. 034） were the risk factors for death related to surgery of recipients who underwent liver re transplantation. Conclusion Experienced transplant surgeon, reducing bleeding during operation as possible, selecting appropriate fashion for bile duct anastomosis and avoiding bile leak can decrease the risk factors for death related to surgery.