术前脾切除对肝移植术后预后的影响

Effect of preoperative splenectomy on the prognosis after liver transplantation

目的：探讨术前脾切除对肝移植术后预后的影响。方法：采用回顾性队列研究方法。收集2004年1月至2014年1月中山大学附属第三医院收治的95例肝移植受者的临床资料。95例受者中，35例肝移植术前行脾切除联合贲门周围血管离断术，设为研究组；60例保留脾脏，直接行肝移植，设为对照组。肝移植受者均采用改良背驮式肝移植，由同一团队医师施行。观察指标：（1）术中及术后情况。（2）随访和生存情况。采用门诊和电话方式进行随访，术后3个月内每周1次，6个月内每个月1次，1年后每 3个月1次。随访内容包括复查血常规、免疫抑制剂的血药浓度、肝肾功能。超声造影或腹部CT检查监测远期并发症情况和受者生存情况。随访时间截至2016年1月。正态分布的计量资料采用±s表示，组间比较采用t检验，计数资料比较采用χ^2检验。结果：（1）两组受者术中及术后情况：两组受者均顺利施行肝移植。研究组受者手术时间、术中出血量和术中输血量分别为（483±136）min、（5 683±2 950）mL、（4 887±3 682）mL，对照组受者分别为（392±103）min、（3 522±1 885）mL、（3 455±2 630）mL，两组受者上述指标比较，差异均有统计学意义（t=3.683，4.358，2.202，P〈0.05）。研究组受者肝移植术中，6例存在门静脉血栓（1级4例、2级1例、3级 1例），对照组受者术中未发现门静脉血栓，两组比较，差异有统计学意义（χ^2=1.979，P〈0.05）。5例1、2级门静脉血栓受者均行血栓切除术，再行门静脉端端吻合，1级门静脉血栓受者中有1例再发血栓，术后给予溶栓后治愈。1例3级门静脉血栓受者术中通过行人工血管搭桥重建门静脉，术后再发血栓，予以处理。两组受者肝移植术中均未发现门静脉狭窄。研究组和对照组受者术后1、3、7 d血小板（PLT）分别为（75±60）×10^9/L和（57±32）×10^9/L、（71±45）×10^9/L和（52±46）×10^9/L、（111±73）×10^9/L和（87±53）×10^9/L，两组比较，差异均有统计学意义（t=1.909，1.957，1.848，P〈0.05），术后14、30 d PLT分别为（230±152）×10^9/L和（193±125）×10^9/L、（310±140）×10^9/L和（286±62）×10^9/L，两组比较，差异均无统计学意义（t=1.284，1.199，P〉0.05）。研究组受者术后感染、术后急性排斥反应、术后新发门静脉血栓（1～2级、3～4级）、术后门静脉狭窄分别为23、0、2、0、2例，对照组分别为35、1、2、0、1例，两组受者上述指标比较，差异均无统计学意义（χ^2=1.171，0.590，0.547，1.184，P〉0.05）。术后感染及急性排斥反应受者均经对症治疗好转。研究组2例术后新发门静脉血栓受者均给予抗凝、溶栓治疗，其中1例受者接受介入取栓治疗。对照组2例术后新发门静脉血栓受者均经抗凝、溶栓治疗后治愈。3例术后门静脉狭窄受者给予经皮肝穿刺门静脉造影置管球囊扩张，其中研究组 1例受者接受支架植入术后恢复良好。（2）随访和生存情况：95例受者均获得术后随访，随访时间为3～ 24个月，平均随访时间为18个月。随访期间，研究组和对照组受者发生慢性排斥反应率分别为5.7%（2/35）和5.0%（3/60），两组比较，差异无统计学意义（χ^2=0.023，P〉0.05）。研究组受者1、2年累计生存率分别为91.4%（32/35）和82.9%（29/35），对照组分别为93.3%（56/60）和76.7%（46/60），两组受者生存情况比较，差异无统计学意义（χ^2=0.780，P〉0.05）。结论：肝移植术前行脾切除易形成门静脉血栓，增加肝移植手术时间和难度，但不增加肝移植术后并发症风险，不影响术后生存。

Objective：To investigate the influence of preoperative splenectomy on the prognosis after liver transplantation. Methods：The retrospective cohort study was conducted. The clinical data of 95 patients who underwent liver transplantation in the Third Affiliated Hospital of Sun Yatsen University between January 2004 and January 2014 were collected. Thirtyfive patients undergoing preoperative splenectomy and pericardial devascularization and 60 undergoing spleenpreserving liver transplantation were allocated into the study group and control group, respectively. All patients received modified piggyback liver transplantation by the same team. Observation indicators： （1） intra and postoperative situations; （2） followup and survival. The followup using telephone interview and outpatient examination was performed once every a week within 3 months postoperatively, once every one month within 6 months postoperatively and once every 3 months after 1 year postoperatively up to January 2016, including routine blood test, plasmadrug concentration of immunosuppressive agent and function of liver and kidney. Ultrasound and abdominal CT were used to monitor the longterm complication and survival. The measurement data with normal distribution were represented as ±s, and comparison between groups was done by the t test. Comparison of count data was done by the chisquare test. Results：（1） Intra and postoperative situations： all patients underwent successful liver transplantation. The operation time, volumes of intraoperative blood loss and blood transfusion were （483 ± 136） minutes, （5 683±2 950）mL, （4 887±3 682）mL in the study group and （392±103）minutes, （3 522±1 885）mL, （3 455±2 630）mL in the control group, respectively, with statistically significant differences between groups （t=3.683, 4.358, 2.202, P〈0.05）. Six patients in the study group had intraoperative portal vein thrombosis （PVT）, including 4 in level 1, 1 in level 2 and 1 in level 3, and no patients in the control group, showing a statistically significant difference between groups （χ^2=1.979, P〈0.05）. Five patients with PVT in level 1 or 2 underwent thrombectomy and then endtoend anastomosis of PV. One patient with PVT in level 1 had PVT recurrence and was cured by postoperative thrombolytic therapy. One patient with PVT in level 3 received PV reconstruction using artificial blood vessels, and had PVT recurrence and then was cured. There was no PV stenosis between groups. The levels of platelet at 1, 3 and 7 days postoperatively were （75±60）×10^9/L, （71± 45）×10^9/L, （111±73）×10^9/L in the study group and （57±32）×10^9/L, （52±46）×10^9/L, （87±53）×10^9/L in the control group, respectively, with statistically significant difference between groups （t=1.909, 1.957, 1.848, P〈0.05）. The levels of platelet at 14 and 30 days postoperatively were respectively （230± 152）×10^9/L, （310±140）×10^9/L in the study group and （193±125）×10^9/L, （286±62）×10^9/L in the control group, with no statistically significant difference between groups （t=1.284, 1.199, P〉0.05）. The cases with postoperative infection, acute rejection, newonset PVT in level 1-2 and 3-4 and PV stenosis were respectively 23, 0, 2, 0, 2 in the study group and 35, 1, 2, 0, 1 in the control group, with no statistically significant difference between groups （χ^2=1.171, 0.590, 0.547, 1.184, P〉0.05）. Patients with postoperative infection and acute rejection were improved by symptomatic treatment. Two patients in the study group with PVT underwent anticoagulant and thrombolytic therapy, including 1 receiving interventional thrombectomy therapy. Two patients in the control group with newonset PVT were cured by anticoagulant and thrombolytic therapy. Three patients with PV stenosis underwent percutaneous transhepatic portography （PTA） for balloon dilation, including 1 in the study group with good improvement after stent implantation. （2） Followup and survival： 95 patients were followed up for 3-24 months, with an average time of 18 months. During the followup, the rate of chronic rejection in study and control groups was 5.7%（2/35） and 5.0%（3/60）, showing no statistically significant difference between groups （χ^2=0.023, P〉0.05）. The 1 and 2year accumulative survival rates were respectively 91.4%（32/35）, 82.9%（29/35） in the study group and 93.3%（56/60）, 76.7%（46/60） in the control group, with no statistically significant difference between groups （χ^2=0.780, P〉0.05）. Conclusion：The splenectomy before liver transplantation is easy to form PVT, increase time and difficulty of transplantation surgery, however, it doesn′t increase complication risk after transplantation and affect postoperative survival.