三次肝移植的临床疗效

Clinical efficacy of tertiary liver transplantation

目的 探讨三次肝移植的临床疗效.方法 回顾性分析2002年4月至2012年12月武警总医院收治的4例肝胆疾病患者的临床资料.供肝植入均采用经典原位肝移植.术后均采用他克莫司＋吗替麦考酚酯＋激素3联免疫抑制方案.通过移植随访中心随访至2014年5月,了解患者预后并进行用药指导.计量资料采用t检验.结果 4例患者中,3例良性肝脏疾病患者多次行肝移植原因主要为胆道并发症,其次为慢性排斥反应;1例肝癌患者多次肝移植原因主要为肝癌复发.4例患者第1、2次肝移植中位间隔时间为16.0个月,短于第2、3次肝移植的22.5个月.第2次肝移植手术时间为（11.4±1.0）h,第3次肝移植手术时间为（14.1±2.2）h,第2、3次肝移植手术时间比较,差异有统计学意义（t=3.644,P＜0.05）.第2、3次肝移植中位出血量分别为1 300 mL和1 800 mL,中位输血量分别为1 400mL和3 100 mL.4例患者肝移植术后早期肝功能均恢复顺利.4例患者中,有2例3例次[其中1次为术后早期（＜30 d）出现肺部铜绿假单胞菌感染]发生移植后感染,后经过积极抗感染治疗后痊愈.4例患者中,1例于第1次肝移植术后80个月死于肝衰竭;1例于第1次肝移植术后107个月死于肝癌复发合并肺、骨及腹膜后淋巴结等多处转移;另2例于第1次肝移植术后分别生存104个月和26个月.结论 三次肝移植是治疗移植肝胆道并发症及慢性排斥反应的有效方法;如有条件,三次肝移植对肝癌复发患者也能明显延长其生存时间.

Objective To investigate the efficacy of tertiary liver transplantation. Methods The clinical data of 4 patients with hepatobiliary disease who were admitted to the General Hospital of Chinese People＇s Armed Police Forces from April 2002 to December 2012 were retrospectively analyzed. All the patients received orthotopic liver transplantation, and received tacrolimus ＋ mycophenolate mofetil （MMF） ＋ hormone after operation. All the patients were followed up till May 2014, and their prognosis was learned. The measurement data were analyzed using the t test. Results Three patients with benign hepatic disease received tertiary liver transplantation due to biliary complications and chronic rejection, and 1 patient with hepatic cancer received tertiary liver transplantation because of hepatic cancer recurrence. The average interval between the primary and secondary liver transplantation was 16.0 months, which was shorter than 22.5 months of the interval between the secondary and tertiary liver transplantation. The mean operation time in the secondary liver transplantation was （ 11.4 ± 1.0） hours, which was significantly shorter than （ 14. 1 ± 2.2） hours in the tertiary liver transplantation （t = 3. 644, P 〈 0.05 ）. The median volumes of blood loss in the secondary and tertiary liver transplantation were 1 300 mL and 1 g00 mL, and the median volumes of blood transfusion were 1 400 mL and 3 100 mL. The hepatic function of the 4 patients recovered smoothly at the early time after liver transplantation. Two patients （3 cases ） were complicated with infection postoperatively （1 patient was infected by pseudomonas aeruginosa within 30 days after liver transplantation, and was cured by active antimicrobial treatment）, and they were cured after anti-infectional treatment. One patient died of hepatic failure at the 80th month after the primary liver transplantation, 1 died of hepatic cancer recurrence complicated by pulmonary, bone and retroperitoneal lymph node metastasis at the 107th month after the primary liver transplantation, and the other 2 patients survived for 104 months and 26 months after the primary liver transplantation, respectively. Conclusion Tertiary liver transplantation is effective for thetreatment of biliary complications and chronic rejection after liver transplantation, and it can extend the life span of patients with hepatic cancer recurrence if there are insufficient donor resources.