肝移植治疗肝硬化门静脉高压症的临床疗效

Clinical efficacy of liver transplantation for liver cirrhosis and portal hypertension

目的 探讨肝移植治疗肝硬化门静脉高压症的临床疗效.方法 回顾性分析2000年1月至2012年1月北京大学人民医院收治的181例肝硬化门静脉高压症患者的临床资料.肝移植手术适应证为反复发作上消化道大出血,经内、外科和介入治疗无效,或合并肝功能失代偿的门静脉高压症患者.根据患者情况选择行经典原位肝移植或背驼式肝移植.术中于移植肝植入前后分别经胃网膜右血管置入套管针,连接测压管测压.观察手术前后门静脉压力变化情况,术后并发症的发生情况.术后通过肝移植随访中心定期随访,并根据具体指标调整用药,随访时间截至2012年12月,监测患者食管静脉曲张再出血及生存情况.Kaplan-Meier法计算生存率,计量资料采用（x）±s表示,均值比较采用t检验.结果 181例患者中,65例行经典原位肝移植,116例行背驮式肝移植.手术时间为（485±97） min,术中出血量为（4 380±1 993） mL,无肝期时间为（56±24） min.157例患者留置T管,24例患者未留置T管.102例患者术中经胃网膜右静脉测量了肝移植前后的门静脉压力,术前门静脉压力为（32±11）cmH2O（1 cmH2O =0.098 kPa）,术后门静脉压力为（21±6）cmH20,手术前后门静脉压力比较,差异有统计学意义（t=2.412,P＜0.05）.肝移植术后严重感染23例、急性肾衰竭20例、严重腹腔内出血6例、血管相关并发症5例和移植物原发无功能2例.181例患者均获得随访,随访时间为6 ～131个月.138例患者术后1年复查内镜或行上消化道造影检查,112例曲张静脉完全消失,其余26例较术前明显减轻,总改善率为85.71％（138/161）.术后1年内4例患者出现了上消化道再出血,再出血率为3.70％（4/108）,其中3例经止血药物或内镜治疗后得到缓解,1例死于再次出血导致的肝衰竭.随访患者术后1个月、1年及5年生存率分别为86.8％、84.9％、77.4％.23例死亡患者中,15例死于MODS,5例死于血管相关并发症（肝动脉血栓形成2例、门静脉血栓形成2例、腔静脉吻合口狭窄1例）,2例死于原发性移植肝无功能,1例死于呼吸系统并发症.结论 肝移植是肝硬化门静脉高压症的有效治疗方式,降低门静脉压力效果好,再出血率低.

Objective To investigate the clinical efficacy of liver transplantation for liver cirrhosis and portal hypertension.Methods The clinical data of 181 patients with liver cirrhosis and portal hypertension who were admitted to the People＇s Hospital of Peking University from January 2000 to January 2012 were retrospectively analyzed.The efficacy of liver transplantation for liver cirrhosis and portal hypertension was investigated.The indications of liver transplantation included repeated upper gastrointestinal hemorrhage,failure of medication,surgical treatment and interventional therapy,and portal hypertension combined with hepatic functional decompensation.Orthotropic liver transplantation or piggyback liver transplantation was selected according to the condition of the patients.The pressures of the portal vein were detected before and after the transplantation of the liver graft by the manometer tube.The incidence of postoperative complications was detected.Patients were followed up regularly till December 2012.The varices and rebleeding of the esophageal veins and the survival of the patients were monitored.The survival rates was calculated using the Kaplan-Meier method,and the measurement data were analyzed using the t test.Results Of the 181 patients,65 received orthotropic liver transplantation,and 116 received piggyback liver transplantation.The operation time,volume of blood loss and anhepatic phase were （485 ± 97） minutes,（4 380 ± 1 993） mL and （56 ± 24） minutes,respectively.T tube was placed in 157 patients.The portal vein pressure was detected in 102 patients.The portal vein pressures before and after liver transplantation were （32 ± 11） cmH2O （1 cmH2O =0.098 kPa） and （21 ± 6） cmH2O,respectively.There was significant difference in the portal vein pressure before and after liver transplantation （t =2.412,P 〈 0.05）.Severe infection was detected in 23 patients,acute renal failure in 20 patients,severe abdominal bleeding in 6 patients,vascular complications in 5 patients and primary graft non-function in 2 patients after liver transplantation.A total of 181 patients were followed up for 6-131 months.One hundred and thirty-eight patients received endoscopy or upper gastrointestinal imaging at 1 year after liver transplantation.The varices were disappeared in 112 patients and alleviated in 26 patients,with the overall alleviation rate of 85.71% （138/161）.Four patients were complicated with upper gastrointestinal rebleeding within 1 year after liver transplantation,and the rebleeding rate was 3.70% （4/108）.The condition of 3 patients was alleviated by haemostatics and endoscopic treatment,and 1 patient died of liver failure caused by rebleeding.The 1-month,1-,5-year survival rates were 86.8%,84.9% and 77.4%,respectively.Twenty-three patients died.Fifteen patients died of multi-organ dysfunction syndrome,5 died of vascular complications （2 died of hepatic artery thrombosis,2 died of portal vein thrombosis and 1 died of anastomotic stricture of vena cava）,2 died of primary graft non-function,and 1 died of respiratory complications.Conclusion Liver transplantation is an efficient method for the treatment of liver cirrhosis and portal hypertension with the advantages of low rebleeding rate and ideal efficacy of reducing portal vein pressure.