肝肺联合移植术1例临床分析

Analysis of combined liver and lung transplantation in one case

目的 分析1例特发性肺纤维化合并酒精性肝硬化失代偿期行肝肺联合移植术患者的临床资料,探讨其临床治疗效果。方法 患者于体外膜肺氧合辅助下先行左肺移植术,后行肝移植术。肺移植吻合顺序为左主支气管、左肺动脉、左侧左房袖;肝移植吻合顺序为肝上下腔静脉、肝下下腔静脉、门静脉、肝动脉、胆总管-胆总管端端吻合。肺动脉开放前予以巴利昔单抗、甲泼尼龙琥珀酸钠诱导免疫;术后鼻饲他克莫司、吗替麦考酚酯,静脉注射甲泼尼龙琥珀酸钠。结果 患者术后64 h撤离体外膜肺氧合;术后第4天撤离呼吸机并下床活动;术后第10天出现不明原因的顽固性低氧血症,行气管切开、呼吸机辅助呼吸及肺动脉球囊扩张,低氧血症仍存在,拟行右肺移植术;术后第21天肺泡灌洗液培养出大肠埃希氏菌、嗜麦芽窄食单胞菌、烟曲霉;术后第32天因感染性休克、心脏骤停死亡。结论 终末期肝脏、肺部疾病患者可行肝肺联合移植术;严格选择供体、进一步优化手术流程、尽可能双肺移植是该病例带来的经验教训;应用体外肺灌注技术改善供体质量、延长器官保存时间,是未来发展的方向。

Objective To analyze the clinical data of combined liver and lung transplantation in one patient with idiopathic interstitial pulmonary fibrosis complicated with decompensated alcoholic cirrhosis, and to investigate the clinical outcome. Methods This patient was performed left lung transplantation under the assistance of extracorporeal membrane oxygenation, followed by liver transplantation. The anastomosis of lung transplantation was performed in the following procedures: left bronchus, left pulmonary artery and left atrium. The anastomosis of liver transplantation was performed in the following procedures: superior hepatic vena cava, inferior hepatic vena cava, portal vein, hepatic artery, and common bile duct. Induced immunity with basiliximab and methylprednisolone was given before the opening of pulmonary artery. The patient received nasal delivery of tacrolimus and mycophenolate mofetil, and intravenous injection of methylprednisolone after operation.Results Extracorporeal membrane oxygenation was removed 64hafter operation.The ventilator was weaned by day 4after operation,and the patient did out-of-bed activity.The patient was performed tracheotomy,ventilator assisted respiration and balloon pulmonary angioplasty due to intractable hypoxemia of unknown cause by day 10after operation,and right lung transplantation was scheduled because of hypoxemia.Escherichia Coli,Stenotrophomonas maltophilia,and Aspergillus fumigatus were detected in the alveolar irrigation fluid by day 21after operation.He died of septic shock and cardiac arrest by day 32after operation.Conclusions Combined liver and lung transplantation can be performed in patients with end-stage liver and lung diseases.To select donor strictly,further optimize the surgical procedure and try to perform double lung transplantation are the experiences and lessons of this patient.Ex vivo lung perfusion can improve donor quality and prolong organ preservation time,and it is the focus of future development.