合并门静脉血栓患者肝移植术中血栓处理技巧

Intraoperative management of thrombosis in liver transplant patients complicated with portal vein thrombosis

目的探讨术前合并门静脉血栓(PVT)患者肝移植术中血栓处理方法及疗效。方法回顾性分析2018年2月至2018年10月在清华大学附属北京清华长庚医院接受肝移植的10例合并PVT患者临床资料。患者均签署知情同意书,符合医学伦理学规定。其中男7例,女3例;年龄37~66岁,中位年龄54岁。PVT分级标准采用Yerdel分级,Ⅰ级4例,Ⅱ级4例,Ⅲ级2例,无Ⅳ级患者。总结肝移植术中血栓处理方式和疗效。结果Ⅰ级血栓直接将血栓取出或高位离断门静脉主干,Ⅱ、Ⅲ级血栓根据血栓进展情况采用血栓剥除或取出全部血栓后行血管吻合,对于存在粗大分流血管者予以结扎离断。术后采用肝素静脉泵入和肝素皮下注射抗凝。术后超声定期监测门静脉血流,复查6个月,所有患者术后超声均证实门静脉血流正常通畅,无门静脉新发血栓形成、狭窄、血流不足等门静脉相关并发症发生。结论对于合并PVT肝移植患者,为了获得足够的移植物门静脉血流,术前须评估PVT的范围及阻塞程度,设计精确的手术方案。根据不同情况PVT予以相应处理,可保证术后门静脉供血通畅,减少并发症发生。

Objective To explore the managements for intraoperative thrombosis in liver transplant patients complicated with portal vein thrombosis(PVT)and its efficacy.Methods Clinical data of 10 patients complicated with PVT who underwent liver transplantation between February 2018 and October 2018 in Beijing Tsinghua Changgung Hospital Affiliated to Tsinghua University were retrospectively analyzed.The informed consents of all patients were obtained and the local ethical committee approval was received.Among them,7 patients were male and 3 female,aged 37-66 years old with a median age of 54 years old.PVT was classified based on Yerdel classification.Among them,4 cases were classified as gradeⅠ,4 grade Ⅱ and 2 grade Ⅲ.The managements for intraoperative thrombosis were summarized and clinical efficacy was evaluated.Results For patients with gradeⅠthrombosis,the thrombi were removed directly or treated by dissecting the portal vein trunk at the high end.According to the progression of thrombi,grade Ⅱ and Ⅲ thrombi were removed directly,or vascular anastomosis was performed after the removal.The large shunt vessels were ligated and dissected.After the operation,intravenous or subcutaneous injection of heparin was given for anticoagulation.The portal vein blood flow was monitored by ultrasound periodically after operation.During 6-month follow-up,postoperative ultrasound demonstrated normal portal vein blood flow in all patients.No portal vein-related complications,such as new PVT,stenosis and insufficient blood flow,occurred.Conclusions For patients complicated with PVT,assessment of range and severity of PVT should be performed before operation to obtain sufficient portal vein blood flow of the graft,and to design a precise surgical plan.PVT can be treated according to individual conditions to guarantee the well blood flow of portal vein and to reduce the postoperative complications.