肝中静脉完全劈分的成人间劈离式肝移植临床研究

Clinical research of adult to adult split liver transplantation with middle hepatic vein fully split

目的探讨肝中静脉完全劈分在成人间劈离式肝移植中的临床应用及效果。方法回顾性分析2010年9月在天津市第一中心医院实施的1例供肝行肝中静脉完全劈分,进行劈离式肝移植的两例受者的临床资料。供肝为尸体供肝,无脂肪肝,全肝重960 g。两例受者均为女性,年龄分别为41、61岁,体重分别为55、35 kg。原发病分别为肝细胞肝癌(肝癌)、原发性胆汁性肝硬化。患者均签署知情同意书,符合医学伦理学规定。手术将供肝沿Cantlie线向肝中静脉主干劈分肝实质,沿肝中静脉主干纵行锐性劈开肝中静脉,将引流左、右半肝的肝中静脉属支保留至相应的供肝侧,以髂静脉分别重建左、右半肝的残留肝中静脉。两例受者分别行右半肝经典非转流的肝移植和左半肝背驮术式肝移植。结果两例受者的供肝冷缺血时间分别为790、740 min,移植物重量分别为606、354 g,移植物重量与受体体重比(GRWR)分别为1.12%、1.01%。两例受者重建肝中静脉通畅,术后肝功能均顺利恢复,未出现小肝综合征。术后3周行多层螺旋计算机体层摄影术(MSCT)三维重建检查显示,移植肝体积较术前明显增加,重建肝中静脉通畅。随访2年,受者1因肝癌复发于术后1年死亡,受者2健康存活。结论肝中静脉完全劈分的成人间劈离式肝移植可同时保留两侧供肝的流出道完整,最大限度地保护供肝功能性肝体积,避免小肝综合征,可供临床选择。

Objective To investigate the clinical application and efficacy of adult to adult split liver transplantation （SLT） with the middle hepatic vein fully split. Methods The clinical data of 2 patients received SLT with the middle hepatic vein of cadaver liver fully split in the Tianjin First Central Hospital on September 2010 were analyzed retrospectively. The total weight of liver graft was 960 g without any evidence of hepatic adipose infiltration. The 2 recipients were both female with the age of 41, 61 years old and their weight were 55 kg and 35 kg respectively. The protopathy were hepatocellular carcinoma （HCC） and primary biliary cirrhosis. The informed consents of the participants were obtained and the ethical committee approval was received. The donor liver was split following the Cantlie line to the main middle hepatic vein. The main middle hepatic vein was acutely split lengthways. Middle hepatic vein divides the liver into night and left lobes. The iliac vein of the same donor was used to rebuild as the middle hepatic veins of the left and right remnant liver. The 2 recipients received classic orthotopic liver transplantation of right lobe without venovenous bypass and piggy-back liver transplantation of left lobe respectively. Results The cold ischemia time of liver grafts were 790 rain and 740 min. The weight were 606 g and 354 g. The graft to recipient weight ratios （GRWR） were 1.12% and 1.01% respectively. The reconstructed middle hepatic vein in each hemi-liver graft showed no hemiliver venous outflow obstruction after the operation. The liver function of both recipients recovered well and no small-for-size syndrome was observed. The graft volume gained evidently 3 weeks after the operation compared with the preoperative graft and no outflow obstruction of the reconstructed middle hepatic veins was detected by multislice spiral computed tomography （MSCT）. The recipients were followed up for 2 years. One recipient died of tumor recurrence one year after the operation, and the other still survived up till now. Conclusions Adult to adult SLT with the middle hepatic vein fully split can ensure complete venous outflow for both split liver grafts with maximal functional liver volume of grafts and decrease the morbidity of small-for-size syndrome.