多种血管材料重建肝静脉在离体肝脏切除联合自体肝脏移植治疗晚期肝包虫病中的应用

Application of hepatic vein reconstruction with various vascular materials in treatment of end-stage hepatic alveolar echinococcosis by ex-vivo liver resection and autologous liver transplantation

目的总结多种血管材料重建肝静脉在离体肝脏切除联合自体肝脏移植(ex-vivo liver resection and autologous liver transplantation,ELRA)治疗晚期肝泡型棘球蚴病(hepatic alveolar echinococcosis,HAE)中的手术要点及疗效。方法回顾性分析四川省人民医院收治的1例行ELRA联合复杂肝静脉重建的晚期HAE患者的临床病理资料。结果患者为一60岁男性,因巨大HAE入院,患者体质量60 kg,标准肝脏体积为1024.5 mL。影像学检查提示包虫病灶侵犯第一、二肝门、肝中静脉、肝左静脉及肝后下腔静脉,CT三维重建提示残余肝脏体积为1270.6 mL。患者入院后予以支持治疗并严格评估后行ELRA,术中发现多支肝静脉及肝后下腔静脉广泛受侵,在“在体优先”原则下,在体劈裂肝脏结合离体切除包块,选取同种异体静脉、自体肠系膜下静脉及肝圆韧带将肝静脉修补重建为一广口流出道,将修补重建的肝静脉与下腔静脉人工血管行端侧吻合,残余肝脏行自体肝脏移植术。手术时间16 h,术中出血约2000 mL。术后予以他克莫司口服,24 h后予以低分子肝素抗凝。患者于术后第6天转回普通病房,复查增强CT提示重建的肝脏流出道通畅、无狭窄及血栓形成,术后18 d顺利出院。术后病理学诊断:肝泡型棘球蚴病。结论从本病例结果看,多种血管材料联合重建静脉流出道是ELRA治疗晚期HAE重建肝静脉的可选术式,严格的术前评估、成熟的血管吻合技术以及术后抗凝是维持术后重建血管通畅的重要措施。

Objective To summarize the key operative points and efficacy of ex-vivo ex-vivo liver resection and autologous liver transplantation(ELRA)using various vascular materials for hepatic vein reconstruction in the treatment of end-stage hepatic alveolar echinococcosis(HAE).Method The clinicopathologic data of a patient with end-stage HAE who underwent ELRA combined with complex hepatic vein reconstruction were retrospectively analyzed.Results The patient was a 60-year-old male who was admitted to the Sichuan Provincial People’s Hospital due to giant alveolar hydatid in the liver,with a body weight of 60 kg and a standard liver volume of 1024.5 mL.The imaging showed that the hydatid invaded the first and second hepatic portals,middle hepatic vein,left hepatic vein,and retrohepatic inferior vena cava.The three-dimensional reconstruction of CT showed that the residual liver volume was 1270.6 mL.The patient received supportive treatment after admission and underwent ELRA following strict evaluation.Intraoperatively,it was found that the multiple hepatic veins and retrohepatic inferior vena cava were widely invaded.The liver was split in vivo and the mass was excised ex vivo by“in vivo first”principle.The hepatic vein was repaired and reconstructed into a wide mouth outflow tract using allogeneic veins,autologous inferior mesenteric vein,and hepatic round ligaments,then performed the autotransplantation by wide mouth outflow-artificial inferior vena cava anastomosis(end to side).The operative time was 16 h,and the intraoperative blood loss was approximately 2000 mL.FK506 was orally administered after operation,and low-molecular-weight heparin sodium was administered 24 h later for anticoagulation.The patient was returned to the general ward on the 6th day after the operation,and the enhanced CT scan showed that the hepatic outflow tract was unobstructed,without stenosis and thrombosis,and the patient was discharged on day 18 after the operation.The patient was pathologically diagnosed with alveolar echinococcosis.Conclusions From the results of this case,combination of multiple vascular materials to reconstruct the hepatic outflow tract is an optional procedure for ELRA in treatment of end-stage HAE.Strict preoperative evaluation,skillful vascular anastomosis technique,and postoperative anticoagulation are important measures to maintain patency of postoperative reconstruction vessel.