背驮式肝移植术中、术后肝静脉回流梗阻的原因分析

Relationship between hepatic venous outflow obstruction and patterns of hepatic vein drainage into inferior vena cava in piggyback liver transplantation

【摘要】目的探讨肝静脉回流下腔静脉解剖分型与背驮式肝移植术中、术后肝静脉流出道梗阻发病率的相关性。方法收集2000年5月至2015年8月间202例背驮式肝移植受者的临床资料，术前对每一例患者肝静脉回流下腔静脉的类型进行3D重建，并测量重建流出道与下腔静脉的横切面角度么COB，术中测量受者肝静脉的长度和直径。肝静脉回流下腔静脉Ⅰ型为肝左中静脉合干，肝右静脉单独回流下腔静脉型；Ⅱ型为肝右中静脉合干，肝左静脉单独回流下腔静脉型；Ⅲ型为三支肝静脉合干回流下腔静脉型。流出道重建均采用受者肝静脉合干血管成形后与供者腔静脉端一端吻合。根据发病时间分为术中即期肝静脉流出道梗阻，术后急性期肝静脉流出道梗阻，术后慢性期肝静脉流出道梗阻。结果本组202例背驮式肝移植受者肝静脉回流腔静脉的分型中，有136例为Ⅰ型；52例为Ⅱ型；14例为Ⅲ型。Ⅰ型：肝左中共干静脉成形后流出道与腔静脉成角么COB为（164±10．14）°；Ⅱ型：肝右中共干静脉成形后流出道与腔静脉的成角角度么COB为（44±12．2）°；Ⅲ型：三支共干静脉成形后与腔静脉成角么COB为（96±13．1）°，三型间角度差异有统计学意义（P〈0．05）。每一型受者三支肝静脉间直径和长度均无统计学差异。I型患者中有32例肝静脉流出道梗阻，其中28例为术中即期肝静脉流出道梗阻，4例为术后急性期肝静脉流出道梗阻。Ⅱ型有2例患者为术中即期肝静脉流出道梗阻，3例患者为术后急性期肝静脉流出道梗阻。Ⅲ型中只有1例诊断为术后慢性肝静脉流出道梗阻。Ⅰ型患者中肝静脉流出道梗阻总发病率为23．5％，Ⅱ型患者中为9．6％，Ⅲ型患者中为7．1％，（x^2=6．109，P〈0．05）。三型之间出现不同类型肝静脉流出道梗阻的阳性率卡方检验（x^2=44．532，P〈0．01，差异有统计学意义，相关性系数Cramer’s V=0．765：结论肝静脉回流分型与背驮式肝移植术中、术后肝静脉流出道梗阻发病率有较高相关性。I型较为常见，术中易出现即期肝静脉流出道梗阻；Ⅱ型可有少部分患者出现肝静脉流出道梗阻；Ⅲ型较理想，肝静脉流出道梗阻发生率较低。

Objective To investigate the relationship between hepatic venous outflow obstruction （HVOO） and patterns of the hepatic vein （HV） drainage into inferior vena cava （IVC） in piggyback liver transplantation （PBLT）. Methods A retrospective analysis on 202 cases of PBLT （from May 2000 to Aug. 2015） was conducted. The recipients＇ patterns of HV drainage into IVC and the angle ∠COB between the reconstructed outflow and IVC in the cross section were recorded by preoperative 3D reconstruction. And the lengths and diameters of recipients＇ HVs were measured during operations. The relationship between the incidence of HVOO and patterns of HV drainage into IVC was analyzed. Results There were 3 patterns of HV drainage into IVC： type I （n = 136）, trunk of left and middle HVs; type II （n = 52）, trunk of right and middle HVs; type III （n = 14）： trunk of three HVs. There was no statistically significant difference within the HVs of each type, when the lengths and diameters were compared respectively. However, the angle ∠COB of type I [（ 164 ± 10. 14）°] was significantly bigger than type II E（44 ± 12. 2）°] and type III E（96 ± 13.1） °] （P〈 0. 05）. Accordingly, the highest incidence of HVOO （23. 5%） was found in type I, followed by type II （9.6%）, and type III had the lowest incidence （7. 1%） （P〈0. 05）. The correlation coefficient Cramer＇s V = 0. 765. Conclusion This study demonstrated that there was preferable relativity between the HVOO incidence and the patterns of HV drainage into IVC. Type I is more likely to have HVOO. Type III is the most ideal one for PBLT.